DVT Prophylaxis and Pulmonary Embolism Karen Ruffin RN, MSN

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DVT Prophylaxis and Pulmonary Embolism

• Karen Ruffin RN, MSN Ed.

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Frequency in the US

• Up to 2 million people are affected annually by
  Venous Thromboembolism(VTE).
• Of those 2 million people it is estimated that
  300,000 of them will develop and die from a
  Pulmonary Embolism (PE).
• The highest incidence of PE is with hospitalized
  patients.
• Autopsy shows that as many as 60 of patients
  dying in the hospital have had a PE, but the
  diagnosis is being missed 70 of the time.

According to Center for Disease Control (CDC),
Department of Health and Human Services, Food and
Drug Administration (FDA), The Surgeon General
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Percentage if at risk for Development of a VTE

• All hospitalized patients, depending on acuity,
  have between a 10-48 of developing a VTE
• Med-Surg patients placed on bed rest for a week
  (10-13).
• Patients in the MICU (29-33).
• Patients with Pulmonary Disease on bed rest for 3
  or more days (20-26).
• Patients in the CCU with an MI (27-33).
• Patients who are asymptomatic after a CABG (48).

Feied, C.F. Handler, J.A., (2008)
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Mortality and Morbidity

• Approximately 10 of the patients with an acute
  PE will die with in the first 60 minutes.
• 1/3 of those who live, the condition is diagnosed
  and treated.
• 2/3 of the remaining patients go undiagnosed.
• Deaths that are a result of VTE/PE were shown to
  be the most common cause of preventable hospital
  deaths
• THAT IS HUGE!

According to Center for Disease Control (CDC),
Department of Health and Human Services Food and
Drug Administration (FDA), The Surgeon General
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Mortality and Morbidity

• Race- Subtle population differences may exist,
  but the incidence is high in all racial groups.
• Sex- Women only when they are pregnant.
• Age- Although the frequency for developing a PE
  increases with age, age alone is not an
  independent risk factor. It has more to do with
  co-morbidities.

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Virchows Triad

• Vessel Damage
• Vascular Constriction
• Blood Viscosity

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Vessel Damage

• Endothelial cells allow blood to flow with ease
  through vessels.
• Factor VIII or Willibrands Factor
• Conditions/lifestyles that damage vessel walls
• Past VTE - Pressure Ulcers
• Smoking - Cellulites
• High Cholesterol
• Varicose Veins

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Vascular Constriction

• Trauma
• Surgery
• Insertion of central line
• Varicose Veins
• Restricted Mobility
• Sepsis
• Induction
• MI

• HF
• Stroke

• Any external force that cause damage to the
  vascular system can cause slow blood flow

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Blood Viscosity

• Dehydrating
• Birth Control Pills
• High estrogen states
• Pregnancy
• Postpartum
• Cancer
• Sepsis
• Blood transfusions
• Obesity

• IBS
• Hematologic Disorders
• Elevated Blood Sugar
• Platelet Aggregation

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Physiology of Clotting
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What is the difference between a thrombus and an
emboli?

• A thrombus is a clot that is stationary and a
  emboli is a thrombus that has broken off and is
  traveling.

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Most Common Cause of a PE

• 90 are thrombi dislodged from deep veins in the
  calf.
• Some originate in the pelvis, particularly in
  pregnant women.
• Fat embolus occur when long bones are broken
  (this is rare).

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What is a Pulmonary Embolism (PE)?

• Occlusion of a portion of the pulmonary vascular
  bed by an embolism. They can be a
• Thrombus (Blood Clot)
• Tissue Fragment
• Lipids (Fat)
• Air Bubble

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Pathophysiology

• Once the embolus is released into the blood
  stream they are distributed in
• 65 of the time both lungs
• 25 of the time right lung
• ? 10 of the time left lung
• ? Lower lobes are 4 times more often upper
  lobes.

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Pathophysiology

• Massive Occlusion- an embolus that occludes a
  major portion of the pulmonary circulation.
• Embolus with Infarction- An embolus that is
  large enough to cause an infarction (death) of a
  portion of lung tissue
• Embolus without Infarction- Not sever enough to
  cause permanent lung injury.
• Multiple Pulmonary Emboli- This can be chronic
  or recurrent.

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Risk Factors for DVT and PE

• Previous episode of thromboembolism
• Prolonged immobility
• Cancer
• Obesity
• Pregnancy
• Oral estrogen
• Fever
• Atrial fibrillation

• CHF, Shock
• Varicose veins
• Over 60 y/o
• Hematologic disorders
• Trauma
• Central Lines
• Dehydration
• Hypovolemia
• Surgical Patients

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Prophylaxis Strategies

• The evidence based practice guidelines published
  by the ACCP in June 2008 incorporated data
  obtained from a comprehensive literature review
  of the most recent studies available.
• The recommendations are broken up in to different
  categories from general patient populations to
  specific groups and conditions.

American College of Chest Physicians, (2008)
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Understanding the Different Recommendation
Categories

• Grade 1 Benefits outweigh risk
• Grade 2 Less certain about the magnitude of
  benefits versus risk
• Grade A High quality evidence
• Grade B Moderate quality evidence
• Grade C Low quality evidence

American College of Chest Physicians, (2008)
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General Patient Population

• Every hospital should have a formal strategy for
  addressing VTE prophylaxis (Grade 1A)
• Mechanical methods of thromboprophylaxis should
  be used primarily in patients who have a high
  risk of bleeding (Grade 1A)
• It is recommended against the use of aspirin
  alone as thromboprophylaxis for VTE for any group
  of patients (Grade 1A)

American College of Chest Physicians, (2008)
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What about patients w/ a PICC line??????

• We are a seeing and increased incidence of DVT in
  patients with PICC lines.
• How can we assess for it?

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Clinical Manifestation of PE

• Massive Occlusion- Profound shock, hypotension,
  tachycardia, pulmonary hypertension, and chest
  pain.
• Embolus with Infarction- Pleural pain, pleural
  friction rub, pleural effusion, hemoptysis,
  fever, and leukocytosis.
• Recurrent PE- Occur in individuals who have had
  a history of previous emboli.

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Applying the Nursing Process

• Assessment
• Diagnosis
• Planning
• Intervention
• Evaluation

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Assessment and Symptoms

• Homons sign
• HP
• Cough
• Sudden onset of SOB
• Agitation
• Lightheadness
• Fainting

• Dizziness
• Sweating
• Anxiety
• Rapid Breathing
• Tachycardia
• Air Hunger

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What are your nursing diagnosis going to be???

• Tell me your long and short term goals.

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Diagnostics

• Arterial Blood Gases
• EKG
• Echocardiogram
• Chest x-ray
• VQ scan
• Spiral CT scan
• Pulmonary Angiogram

• Pt, ptt, INR
• D-DImer
• Split Fibrinogen
• MRA

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What are your Interventions for your stated goals?

• Remember to always have
• Assessment
• Action
• Psychosocial
• Education
• For every goal!

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Treatment

• Supportive
• Filters
• Anticoagulants/Thrombolytics
• Heparin
• Coumadin
• Streptokinase
• Retavase
• TPA

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So what will we evaluate and why?
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Cost of Prevention vs. Treatment????

• V/Q scan- 1500
• ICU bed 9000 day
• Arterial Angiogram- 3200
• Many other realted cost?????

• Sequential stockings- 10 day
• Heparin subq- pennies a day
• Lovenox subq 15 a day

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Prevention is KEY

• Intermittent Pneumatic Stockings
• SCD
• Teds
• Early Ambulation
• Low Dose Anticoagulation
• Heprin
• Lovenox
• Arixtra

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So, what does all of this mean to us?
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Assessment and Documentation

• We must assess if a patient is at risk for the
  development of a VTE
• Document that assessment
• Communicate with the health care team that the
  patient is at risk for a VTE.
• Document that communication
• Education, Education, Education

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Why are all those steps important????

• The Joint Commission and the Centers for Medicare
  and Medicaid have implemented VTE quality
  measures for surgical patients which include the
  Surgical Care Improvement Project (SCIP 1 SCIP
  2).
• SCIP 1 evaluates if patients were identified as
  being at risk, was prophylaxis ordered
  appropriately.
• SCIP 2 examines if prophylaxis was actually
  received by patient. Surgical types include
  ortho, gyn, urological, elective spine,
  intracraneal . Appropriate prophylaxis includes
  LDUFH, Fundaparinux, LMWH, warfarin

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Why are all those steps important????

• The CMS has created guidelines on payment for
  service for healthcare providers that use
  evidence based practice to promote the best
  possible outcomes for its customers.

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• In 2005, section 5001(c) of the Deficit Reduction
  Act of 2005 (DRA) authorized the Secretary of the
  Department of Health and Human Services to select
  conditions that 
• (1) are high cost, high volume, or both (2) are
  identified through ICD-9-CM coding as
  complicating conditions (CCs) or major
  complicating conditions (MCCs) that, when present
  as secondary diagnoses on claims, result in a
  higher-paying MS-DRG and (3) are reasonably
  preventable through the application of
  evidence-based guidelines.

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So what does that mean to the bedside nurse?

• We must encourage all healthcare members to
  follow best practices as outline by creditable
  bodies such as the ACCP.
• Our role in assisting with reimbursement for care
  provided is to appropriately assess our patients
  and determine who is at risk for VTE/PE.
• Next we must communicate this information with
  the physicians.
• Once orders are receive for thromboprophylaxis we
  should ensure that treatment is delivered as soon
  as possible or within 2 to 3 hours of receiving
  the orders.

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The Power of Suggestion!! Dont ever
underestimate it!!!!!!!
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Case Studies

• 37y/o women presented to the ER 18 days s/p
  laparotomy for lyses of adhesions.
• Symptoms- CP, SOB, lightheadness, tachycardia.
• She was seen by an NP and not by an MD. CBC,
  Cardiac Enzymes, and Chem 7 ordered and were
  normal. Pt was sent home and told to follow up
  with her primary in two days.
• Pt. suffered a nonfatal PE that night. She was
  awarded 1,000,000.00

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Case Study

• Nurse was to D/C a pt. home. She noted a large
  reddened, raised, warm area on the pt. right
  ankle. The nurse documented it, but did not
  notify the physician.
• The pt. suffered a fatal PE two days later. A
  claim was filed against the nurse and was settled
  for 4,000,000.00.

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Case Study

• Pt. was admitted with a fractured right hip on
  Sat morning. Patient was started on Lovenox 30mg
  subq daily. That order was renew on Monday after
  the patient had an ORIF of the right hip. The
  order was missed for 2 days. The patient
  suffered a non-fatal PE was transferred to the
  ICU. The hospital stay was extended by 3 weeks.
  A claim was filed against several nurses and was
  settled for 1,500,000.00 and medical expenses.

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-American College of Chest Physicians, (2008).
Antithrombotic and Thrombolytic Therapy American
College Of Chest Physicians Evidence Based
Clinical Practice Guidelines. 8th Edition. Volume
133/number 6 (Suppl) pages 67s-968s.-Center for
Disease Control, (2008). Are you at risk for deep
vein thrombosis? Retrieved from
http//www.cdc.gov/Features/Thrombosis on
December 12, 2008.-Center for Medicare and
Medicaid Services, (2008). CMS improves patient
safety for Medicare and Medicaid by addressing
never events., CMS Manual System.-Feied, C.F.
Handler, J.A., (2008). Pulmonary Embolism.
Retrieved from eMedicine.com on December 12,
2008.-Galson, S.K., (2008) The Surgeon General
calls to action to prevent deep vein thrombosis.
US Department of Health and Human Services Office
of the Surgeon General. Retrieved from
http//www.surgeongeneral.gov on December 12,
2008.-National Institute for Health, (2007).
What is a Deep Vein Thrombosis? Retrieved from
http//www.nhlbi.nih.gov/health/dci/Diseases/Dvt
on December 12, 2008.-Sanofi-Aventis, (2008).
The Coalition to Prevent Deep-Vein Thrombosis.
Retrieve from, http//www.preventdvt.org on
December 12, 2008.-Sumpio, B.E., Riley, J.T,
Dardik, A. (2002). Cells in focus endothelial
cell. Department of Surgery, Yale University
School of Medicine. Retrieve from
http//www.ncbi.nlm.nih.gov on December 12, 2008.
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Now we will do an Evolve case study!