National Patient Safety Goal 3E: Anticoagulation- Nursing Education

1. National Patient Safety Goal 3E: Anticoagulation- Nursing Education

2. 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

3. 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

4. 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)

5. 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)

6. 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 • Cousins D et al. 2006 • USP MedMarx data, 2005 • Fanikos J. et al. 2004

7. 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

8. 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

9. 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

10. 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

11. 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)”

12. Venous Thromboembolism (VTE): Prevention and Anticoagulation Management

13. 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

14. Post-Test Questions

15. $$$Economic burden of VTE$$$ • 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

16. 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 Risk Factors for VTE development Venous Thromboembolism Prophylaxis, June 2007, ICSI

17. Causes for VTE development • Venous stasis- immobility • Vein injury- surgery, IV therapy, phlebotomy • Increased coagulation- cancer, inflammatory conditions or infectious process Virchow’s Triad

18. Bed Rest!! … a DVT/ PE RedFlag!!! BEDREST

19. 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”

20. DVT Prophylaxis: 3 Patient Groups Low risk Moderate/High risk Highest risk

21. Low 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

22. Moderate/High 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

23. Very 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

24. Medical Condition Risk DVT Chest 2005; 128;958-969

25. 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

26. 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

27. 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

28. 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

29. New HCD DVT/PE Assessment Screens

30. New HCD DVT/PE Assessment screens

31. New HCD DVT/PE Assessment screens

32. 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

33. 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

34. New HCD DVT/PE Education screens

35. New HCD DVT/PE Education screens

36. New HCD DVT/PE Education screens

37. New HCD DVT/PE Education screens

38. New HCD DVT/PE Education screens

39. 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.

40. 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

41. 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

42. 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

43. 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

44. 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)

45. NPSG 3E: Anticoagulation- References For more information, see the Joint Commission Website: www.jointcommission.org • Cousins D et al. 2006. Risk assessment of anticoagulation therapy. National Patient Safety Agency. United Kingdom • USP MedMarx data, 2005 • Fanikos J. et al. Medication errors associated with anticoagulant therapy in the hospital. Am J Cardiol. 2004; 94: 532-5. • ICSI Venous Thromboembolism Prophylaxis Fourth Edition-June 2007 • Chest 2005; 128;958-969 • 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

46. Post-Test Questions • Which of the following are requirements for meeting the NPSG 3E standards? • Yearly nursing, pharmacy and provider education • Warfarin dosing for all patients will only be managed by pharmacy • Defined hospital anticoagulation management program • Dietary notification of all patient’s receiving warfarin • Answers A, C, D

47. 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

48. 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

49. 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

50. 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 interactions b. diagnosis or preventative education, activity, diet, and food/drug interactions c. Home monitoring, food/drug interactions and follow-up appointments d. Food/drug interactions, outpatient therapy, and medications