National Patient Safety Goal 3E:Anticoagulation-

Nursing Education

Objectives

• List requirements for meeting standards for the National Patient Safety Goal 3E- Anticoagulation

• Identify risk factors for VTE development in hospitalized patients

• List 3 symptoms of DVT/PE development

• List the 3 patient risk groups for VTE development and 2 appropriate interventions for each risk group

Purpose of National Patient Safety Goals (NPSG):

• Promote specific improvements in patient safety

• Highlight problem areas in health care

• Describe evidence-based solutions

• Focus on system-wide solutions

National Patient Safety Goals

• Goals and Requirements are developed by experts from various fields

• Approved by the Joint Commission's Board in June 2007

• New Goals may be added each year or goals may be continued for more than one year (ex. Med-Rec)

National Patient Safety Goal 3E: Anticoagulation

• Reduce the likelihood of patient harm with the use of anticoagulation (AC) therapy

• Rationale: Anticoagulation therapy is a high risk treatment (due to complexity with dosing, patient compliance with treatment, & monitoring)

Risks with Anticoagulant Therapy

• Anticoagulation medications are listed as one of the top 5 drug classes for patient safety incidents¹

• Reported meds involved in harmful events² include : Heparin, Warfarin, Enoxaparin

• Heparin errors are usually attributed to the non-use of programmable infusion pumps and non-standardized IV concentration of Heparin drips³

1. Cousins D et al. 20062. USP MedMarx data, 20053. Fanikos J. et al. 2004

National Patient Safety Goal 3E: Nuts & Bolts

• Goal applies to the use of heparin, low molecular weight heparins, warfarin and other anticoagulants

• One year phase-in period for all hospitals with full implementation by January 1, 2009

National Patient Safety Goal 3E: Nuts & Bolts

• Requirement for all JCAHO accredited institutions:

– Implement a defined anticoagulation program

– Use ONLY oral Unit Dose products & pre-mixed IV’s

– Warfarin is dispensed for each individual patient with established monitoring

– Use approved protocols for the initiation & maintenance of AC therapy

National Patient Safety Goal 3E: Nuts & Bolts

• Requirement for all JCAHO accredited institutions:

– With the use of Warfarin – baseline/current INR is available for all patients for therapy adjustment

– Dietary services is notified of all pt’s receiving warfarin- food/drug interaction education

– Heparin IV is delivered by a programmable IV pump (MedNet safety pump- in drug library)

– Policy addresses baseline & ongoing lab tests for Heparin/LMWH

National Patient Safety Goal 3E: Nuts & Bolts

• Requirement for all JCAHO accredited institutions:

– Provide education on anticoagulation therapy for all providers, staff, patients, and families

– Pt./family education covers specific areas: follow-up, dietary restrictions, monitoring, complications, and food & drug interactions

– Evaluation of Anticoagulation safety practices

National Patient Safety Goal 3E: Surveying and Scoring

• Joint Commission will evaluate actual performance with standards of the “Goal”

• All requirements must be implemented

• Facility will be found either “Compliant or Not Compliant”

• Failure to comply will result in a “Requirement for Improvement (RFI)”

Venous Thromboembolism (VTE): Prevention and

Anticoagulation Management

The Problem…..

• 2 million Americans will be afflicted with deep vein thrombosis (DVT) each year

• As many as 600,000 will subsequently develop a pulmonary embolism (PE)

• In about 300,000 people the PE may prove to be fatal

• Third most common cause of hospital-related deaths in the U.S.

The most common preventable cause of hospital death

Post-Test Questions

$$$ Economic burden of VTE $$$

• Cost of care related to VTE (cases of DVT and PE together) in the U.S. each year is estimated at 1.5 billion

• Post-op thromboembolic complications add an average of $18,300 to the total hospital costs for each patient in which they happen

Risk Factors for VTE development

– Decreased mobility

– Age (especially >75)

– Personal history of DVT/PE or clotting disorder

– Surgery- LE joint replacement open abdominal, urologic, or gynecologic procedure

– Inflammatory conditions

– Current malignancy

– Estrogen therapy or pregnancy

– History of MI, CHF, COPD, or other respiratory failure

– Stroke < 1 month

– Admission to the ICU

– Sepsis

Venous Thromboembolism Prophylaxis, June 2007, ICSI

Causes for VTE development• Venous stasis- immobility

• Vein injury- surgery, IV therapy, phlebotomy

• Increased coagulation- cancer, inflammatory conditions or infectious process

Virchow’s Triad

Bed Rest!! … a DVT/ PE Red Flag!!!

BEDREST

Signs and symptoms of DVT or PE

• Pain, cramps or heaviness in affected extremity

• Parathesias- unexplained numbness or tingling

• Redness and edema of affected extremity

• Tenderness and pain in calf upon palpation

• Shortness of breath

• Chest heaviness (without cardiac explanation)

• Sense of “impending doom”

DVT Prophylaxis: 3 Patient Groups

Low risk

Highest risk

Moderate/High risk

• Patient Group:– Age <60– Minor surgical procedure– Medical patient on bedrest– Pregnant patient or patient on oral contraceptives or

hormone replacement

• Recommendations for prophylaxis:– Early ambulation- this means up walking in hallway 2-

3 times per day– SCD’s while in bed

Low risk

• Patient Group:– Age >60

– Central venous access

– History of previous malignancy

– History of medical risk factors CHF, COPD, inflammatory bowel disease

– Medical patient with additional risk factors (CHF, COPD, Sepsis, MI)

– Major surgery planned with additional risk factors

• Recommendations:– Early ambulation- this means up walking in hallway 2-3 times per day

– SCD’s while in bed

– Enoxaparin 40mg subQ every day start 12-24 hrs. after surgery

– If orthopedic patient- follow orthopedic anticoagulation protocol

Moderate/High risk

• Patient Group:– Age >75– Elective hip or knee surgery– Active cancer– Hip, pelvis or leg fracture (<1 month)– Stroke (<1 month)– Admission to ICU– Personal hx. of DVT, PE or clotting disorder

• Recommendations:– Early ambulation- this means up walking in hallway 2-3 times per

day– SCD’s while in bed– Enoxaparin 40mg subQ every day start 12-24 hrs. after surgery– If orthopedic patient- follow orthopedic anticoagulation protocol

Very High Risk

Medical Condition Risk DVT

Condition Risk of DVT

General Medical 10%-26%

MI 17%-34%

Stroke 11%-75%

CHF 20%-40%

Medical ICU 35%-42%

Chest 2005; 128;958-969

Prevention techniques

• Risk assessment tools- – Providers to risk stratify patients into risk

categories based on current diagnosis and previous medical history (VTE Order Set PO 1190)

• Early ambulation

• Medication prophylaxis if indicated based on patient’s VTE risk level

Venous Thromboembolism Prophylaxis, June 2007, ICSI

Contraindications to drug therapy

• Active, significant bleeding

• Extreme thrombocytopenia (<50,000)

• History of heparin induced thrombocytopenia (HIT)

• Uncontrolled hypertension (SBP >200, DBP >120)

• Patient with bacterial endocarditis

• Patient with active hepatitis or hepatic insufficiency

Venous Thromboembolism Prophylaxis, June 2007, ICSI

New HCD DVT/PE Assessment screens

• New DVT/PE assessment screens have been built in HCD- will replace “Homan’s assessment” under muskuloskeletal body system

• This assessment is under the “FLOWSHEET” tab in HCD

• The DVT/PE assessment will be completed with all nursing assessments

New HCD DVT/PE Assessment screens

• The DVT/PE assessment includes:– Calf assessment for pain, redness, warmth,

tenderness or swelling– Respiratory signs & symptoms of SOB or

difficulty breathing– Includes area for documentation of “MD

NOTIFICATION” if patient has any of the above present

New HCD DVT/PE Assessment Screens

New HCD DVT/PE Assessment screens

New HCD DVT/PE Assessment screens

New HCD DVT/PE Education screens

• New DVT/PE Education screens have been built in HCD (requirement to meet NPSG 3E standards)

• Documentation is under the “EDUCATION” tab in HCD

• The DVT/PE education will be completed and documented at least once during the hospitalization (requirement to meet NPSG 3E standards)

• Discharge RN must verify that DVT/PE education has been documented on the patient

• Enoxaparin and Coumadin Patient Education Written materials have been updated and will no longer require for nursing to document on these

New HCD DVT/PE Education screens

• For Bethesda only- Nursing will continue to document on the brown border education flowsheet

• The DVT/PE education includes:

– Patient education on diagnosis of DVT/PE or preventative information

– Documentation of consult to Dietician for additional drug/food interaction education (checking this tab will not automatically place order for consult- the consult must be manually entered)

– Patient/family education on Sx. of PE/DVT, medications, medication purpose, food/drug interactions, drug monitoring, and Lovenox demo

– Written or video education on coumadin and/or Lovenox

New HCD DVT/PE Education screens

New HCD DVT/PE Education screens

New HCD DVT/PE Education screens

New HCD DVT/PE Education screens

New HCD DVT/PE Education screens

HealthEast’s work on VTE Prevention

& Anticoagulant Management

• Aims (What are we trying to accomplish?)

– Reduce the incidence of DVT and PE in hospitalized patients by 50% in one year.

– Reduce readmissions within 31 days for DVT and PE by 50% in one year.

– Reduce patient harm associated with the use of anticoagulant therapy by 50% in one year.

HealthEast’s work on VTE Prevention

& Anticoagulant Management

• Measures (How will we know that a change is an improvement?)

– Hospital Acquired DVT per 1000 Discharges

– Hospital Acquired PE per 1000 Discharges

– Readmissions within 31 Days with DVT per 1000 Discharges

– Readmissions within 31 Days with PE per 1000 Discharges

– Patient harm associated with anticoagulant therapy as measured by the IHI Adverse Drug Event Trigger Tool

DVT Prevention

• Clinical Goals:

– Adult patients (18 & older) are assessed for VTE (DVT & PE) risk within 24 hours of admission

– Appropriate pharmacological and/or mechanical prophylaxis begins within 24 hrs of admission

– All patients receive education regarding VTE signs & symptoms, preventive methods

– All patients begin early and frequent ambulation

Venous Thromboembolism Prophylaxis, June 2007, ICSI

DVT Prevention

• Clinical Goals:

– All adult medical/surgical patients with moderate-high or very high VTE risk receive anticoagulation prophylaxis unless contraindicated

– Reduce the risk of complications from pharmacologic prophylaxis.

Venous Thromboembolism Prophylaxis, June 2007, ICSI

DVT Prevention

• Clinical Goals:

– Appropriate pharmacological and/or mechanical prophylaxis begins within 24 hrs of admission

– Mechanical prophylaxis is used when pharmacologic prophylaxis is contraindicated

– Appropriate precautions for patients receiving spinal or epidural anesthesia are implemented

Venous Thromboembolism Prophylaxis, June 2007, ICSI

Future steps……

• Development of a VTE Dashboard with all system measures for each site

• Creation of a VTE Collaborative Practice Committee with participation by all site leads

• Continue assessing progress with VTE work at each site

• Yearly nursing, pharmacy and provider education (requirement for NPSG 3E)

NPSG 3E: Anticoagulation- References

For more information, see the Joint Commission Website:

www.jointcommission.org

1. Cousins D et al. 2006. Risk assessment of anticoagulation therapy. National Patient Safety Agency. United Kingdom

2. USP MedMarx data, 2005

3. Fanikos J. et al. Medication errors associated with anticoagulant therapy in the hospital. Am J Cardiol. 2004; 94: 532-5.

4. ICSI Venous Thromboembolism Prophylaxis Fourth Edition-June 2007

5. Chest 2005; 128;958-969

6. Santell JP, Hicks RW, Cousins DD. MEDMARX Data Report:  A Chart-book of 2000-2004 Findings from  Intensive Care Units and Radiological Services.  Rockville, MD: USP Center for the Advancement of Patient Safety; 2005

Post-Test Questions

1. Which of the following are requirements for meeting the NPSG 3E standards?

a. Yearly nursing, pharmacy and provider education

b. Warfarin dosing for all patients will only be managed by pharmacy

c. Defined hospital anticoagulation management program

d. Dietary notification of all patient’s receiving warfarin

e. Answers A, C, D

2. Which are risk factors for VTE development?

a. decreased mobility, obesity, and sepsis

b. Decreased mobility, joint, surgery, and history of DVT/PE

c. decreased mobility, age >40, and history of CHF

d. Cancer, age >40, and pregnancy

3. Which are symptoms of DVT/PE development?

a. SOB and anxiety

b. Chest heaviness (without cardiac explanation) and bruising of extremity

c. Tenderness/pain upon palpation of calf and SOB

d. Redness/edema of extremity and high INR

4. What are the risk factors for the “Very High” Patient group?

a. age >60, active cancer, and history of CHF

b. age >60, central venous access, and major abdominal surgery

c. age >75, bedrest, and minor surgical procedure

d. age >75, active cancer and admission to ICU

5. What must be documented on discharge for DVT/PE patient education?a. diagnosis or preventative information, sx. Of

DVT/PE, medications, and food/drug interactionsb. diagnosis or preventative education, activity,

diet, and food/drug interactionsc. Home monitoring, food/drug interactions and

follow-up appointmentsd. Food/drug interactions, outpatient therapy, and

medications