Deep Vein Thrombosis (DVT)

1. Deep Vein Thrombosis (DVT) Education for Nurses

2. Objectives • Identify risk factors for the development of Deep Vein Thrombosis (DVT) • Describe the nurse’s role in DVT prevention • Discuss the process for DVT prophylaxis at LVH

3. Did You Know? • Up to 2 million people in the United States suffer from DVT every year. • Approximately 600,000 experience pulmonary embolism (PE). • Venous Thromboembolism (VTE) is the term commonly used to describe both DVT and PE. 1 1 • Hirsh, Hoak. Circulation. 1996;93:2212-2245.

4. Did You Know? For up to 200,000 of those with PE, the blood clot in the lung proves fatal – killing more people than AIDS and breast cancer combined. 2-6 • Bick. Drugs. 2000;60:575-595. • Kim, Spandorfer. Emerg Med Clin North Am. 2001;19:839-859. • Anderson et al. Arch Intern Med. 1991;151:933-938. • Centers for Disease Control. Available at: http://www.cdc.gov. • American Cancer Society. Available at: http://www.cancer.org.

5. Oh, I just saw Mrs. Smith in the ER last week with the flu. I wonder why she was admitted with DVT!!

6. Risk Factors for DVT Medical conditions, such as: Coronary Artery Disease • Heart Failure • Exacerbation of COPD or other severe respiratory disease • Acute MI • Trauma/Burns • Sepsis • Inflammatory bowel disease • Lupus • Stroke

7. Risk Factors for DVT 7,8 • Illness or injury that causes prolonged immobility • Age > 40 • Pregnancy, birth control pills and hormone replacement therapy • Cancer and its treatment • Major surgery (ex: abdomen, pelvis, hip facture, knee fracture, hip or knee replacement) • Surgery time > 30 minutes • Obesity • Indwelling vascular devices • Previous DVT or PE • Geerts et al. Chest. 2001;119(suppl):132S-175S. • National Experts’ Consensus Panel for Clinical Excellence in Thrombosis Management. Available at: http://www.thrombosis-consult.com.

8. I wonder if Mrs. Smith was at risk for DVT?

9. Was Mrs. Smith at Risk for DVT? • 47 years old • She is recuperating from surgery (abdominal hysterectomy) one month ago. • She was just in the emergency dept. with flu-like symptoms; has spent the last 3 days in bed. • She has a history of Lupus. Yes! She certainly had several risk factors. The more risk factors a patient has, the greater the risk for DVT.

10. Could Mrs. Smith’s DVT have been prevented? • Evidenced based CHEST Guidelines recommend: • Identifying hospitalized patients that are at high risk for developing DVT • Implementing interventions to prevent DVT

11. Let’s review the important interventions for the prevention of DVT: • Ambulation early and often (simplest and most cost effective means to reduce risk of DVT) • Intermittent External Compression Devices: • Also called sequential compression devices or SCDs • They increase rate/velocity of venous blood and reduce pooling in the peripheral veins • Compression should begin pre-operatively and be continued until the patient is fully ambulatory • Anticoagulant Medication Therapy

12. Medication for DVT Prevention Chest Guidelines recommend Enoxaparinfor the prevention of DVT.

13. Medication for DVT Prevention • Enoxaparin: • Also known by the trade name Lovenox • Always administered subcutaneously • Usual dose is 40mg per day for medically ill patients • If Creatinine Clearance is <30ml/min, adjusted dose is 30mg per day

14. Medication for DVT Prevention • Enoxaparin: • Also known by the trade name Lovenox • Always administered subcutaneously • Usual dose is 40mg per day for medically ill patients • If Creatinine Clearance is <30ml/min, adjusted dose is 30mg per day

15. What’s happening at Lehigh Valley Hospital? • We are focusing on DVT prophylaxis for all in-patient admissions. • The following screen will be attached to all admission order screens in Last Word. • Requires the physician to place the order for the appropriate DVT prophylaxis

16. Physician Order

17. Physician Order (continued) If DVT prophylaxis is NOT indicated…. the reason must be identified.

18. Physician Order (continued) Reasons why prophylaxis may not be indicated include: • Patient is fully ambulatory and is expected to be hospitalized for less than 24 hours • The patient declines DVT prophylaxis • The patient is fully anticoagulated

19. Physician Order (continued) • The following screens show: • How the order will appear on the patient’s active order list • The detail screen for the order

20. Physician Order (continued)

21. Physician Order (continued)

22. Diagnosing DVT • Clinical diagnosis of DVT is unreliable because classic symptoms (pain, swelling, tenderness, and warmth) may not be present. • Therefore it is important for ALL healthcare professionals to collaborate in the identification of high risk patients and implement prophylaxis.

23. Patient Education It is important that our patients are included in the plan for prevention of DVT.

24. Patient Education • Education material available to our patients includes: • Patient education video “DVT Prevention” available on CCTV • Written material: • Learn More About Deep Vein Thrombosis • Learn More About Pulmonary Emboli

25. Remember • Major risk factors for DVT include: heart failure, severe respiratory disease and sepsis. • All patients’ DVT risk factors are identified on admission. • If an acutely ill hospitalized patient has a major risk factor for DVT or is confined to bed and has one or more additional risk factors, then prophylaxis is recommended.

26. Congratulations You have completed the DVT learning module. If you need more information: Contact your unit Patient Care Specialist (PCS)