Venous Thromboembolism Prevention

1. Venous Thromboembolism Prevention August 2010

2. Expected Practice • Assess all patients upon admission to the ICU for risk factors of venous thromboembolism (VTE) and anticipate orders for VTE prophylaxis based on risk assessment Venous Thromboembloism Prevention

3. Expected Practice • Moderate-risk patients (medically ill and postoperative patients): low dose unfractionated heparin, low-molecular-weight heparin (LMWH), or fondaparinux • High risk patients (major trauma, spinal cord injury, or orthopedic surgery): LMWH, fondaparinux, or oral vitamin K antagonist Venous Thromboembloism Prevention

4. Expected Practice • Patients with high risk for bleeding: mechanical prophylaxis • Graduated compression stockings • Intermittent pneumatic compression devices • Mechanical prophylaxis may also be anticipated in conjunction with anti-coagulant based prophylaxis regimens Venous Thromboembloism Prevention

5. Expected Practice • Review daily each patient’s current VTE risk factors including • clinical status • necessity for central venous catheter • current status of VTE prophylaxis • risk for bleeding • response to treatment. Venous Thromboembloism Prevention

6. Expected Practice • Maximize patient mobility to reduce the amount of time the patient is immobile • Ensure that mechanical prophylaxis devices are fitted properly and in use at all times Venous Thromboembloism Prevention

7. Problem Scope and Impact • Most hospitalized patients have at least one risk factor for VTE. • VTE is common and contributes to excess length of stay, excess charges, and mortality. • Primary thromboprophylaxis reduces the morbidity and mortality associated with deep vein thrombosis and pulmonary embolism. Venous Thromboembloism Prevention

8. Supporting Evidence • The majority of critical care patients have one or more risk factors leading to VTE formation • Immobilization • sedation/neuromuscular blockade • CVC’s • Surgery • sepsis • mechanical ventilation • vasopressor administration • heart failure • Stroke • Malignancy • previous VTE • renal dialysis Venous Thromboembloism Prevention

9. Supporting Evidence • Signs and symptoms of VTE are frequently silent and can lead to fatal pulmonary embolism, VTE prophylaxis is recommended for at-risk patients. Venous Thromboembloism Prevention

10. Supporting Evidence • Low dose unfractionated heparin and LMWH are efficacious in preventing VTE in moderate-risk critical care patients. • For patients at higher risk major trauma or post orthopedic surgery, LMWH has been shown to provide superior protection over low dose unfractionated heparin. • Direct thrombin inhibitors can be used in place of low molecular weight heparin or unfractionated heparin in patients with heparin induced thrombocytopenia. Venous Thromboembloism Prevention

11. Supporting Evidence • Mechanical methods of prophylaxis have been shown to reduce the risk of VTE • graduated compression stockings • intermittent compression devices • venous foot pumps • Mechanical prophylaxis is less efficacious when compared to anticoagulation based therapy. • Mechanical prophylaxis methods do not pose bleeding concerns. Venous Thromboembloism Prevention

12. Supporting Evidence • Written policies for VTE prophylaxis along with either standing ICU admission orders increase compliance with prophylaxis measures • A daily goals form, which included VTE prophylaxis, resulted in a significant improvement in increased staff understanding the patient’s daily goals for care and decreased ICU length of stay Venous Thromboembloism Prevention

13. Supporting Evidence • The presence of a CVC is a risk factor for upper extremity VTE population • Several studies identified immobility either as a co-morbidity or independent risk factor. • Compliance monitoring with intermittent pneumatic compression devices demonstrated rates of non-compliance ranging from 22% to 81% in at-risk patients Venous Thromboembloism Prevention

14. Supporting Evidence • Improperly fitted compression stockings producing a reversed pressure gradient were associated with a significantly higher incidence of VTE compared with stockings that were properly fitted Venous Thromboembloism Prevention

15. Actions for Nursing Practice • Ensure that your unit has a written policy for VTE prophylaxis that is updated regularly to reflect emerging evidentiary findings • Ensure that preprinted or computerized admission orders are available and current • Ensure that your unit has an organized process for developing and communicating patient goals (including VTE prophylaxis) to members of the multidisciplinary team Venous Thromboembloism Prevention

16. Actions for Nursing Practice • Educate and routinely evaluate all staff in the use of mechanical prophylaxis devices • Review orders of patients discharged from the ICU to ensure a continuation plan for VTE prophylaxis Venous Thromboembloism Prevention

17. Actions for Nursing Practice • Monitor • compliance with VTE prophylaxis policies • rates of VTE and pulmonary embolism • initiate quality improvement initiatives Venous Thromboembloism Prevention

18. Need More Information? For more information or further assistance, please contact a clinical practice specialist with the AACN Practice Resource Network. Email: practice@aacn.org Venous Thromboembloism Prevention