Preventing VTE in
Surgical Patients
Today’s Topics
• The common sense science of VTE prevention
• Brief history of VTE prevention techniques
• High yield methods of preventing VTEs in
surgical patients
• A glance at the reporting requirements for VTE
• Understanding your needs: A series of polls
Why Are We Focusing In
Surgery?
Common Sense Science:
Venous Thromboembolism (VTE)
• When blood clots form in the vein and form a
mass
• Two types:
– Deep Vein Thrombosis (DVT): occurs in leg
veins (clot that forms in the deep veins of the
body)
– Pulmonary Embolism – occurs when a clot
detaches from the vessel and travels to the
lungs and lodges within the pulmonary
arteries
• DVT + PE = VTE
Common Sense Science
Continued
• ~ 300,000-600,000 Americans develop VTE
each year
• 60,000-100,000 die each year from VTE
• Annual cost of care is estimated at $1.5
billion
• About two-thirds of all VTE events are related
to hospitalization
• 40% or more of hospital associated VTE is
preventable through prophylaxis
U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism: 2008. Office of the
Surgeon General and the National Heart, Lung, and Blood Institute of the National Institutes of Health; 2008. Available at:
http://accpstorage.org/chest08/bestOF/SurgeonGeneralsReport.pdf. Accessed July 31, 2009.
Venous Thromboembolism:
A Brief History
Rudolf Carl Virchow
1821-1902
Virchow’s Triad
Stasis of blood flow
(blood slows down)
Injury to the vein
State of the body
(Hypercoagulability)
VTE Main Risk Factors
• Increasing age
(risk rises steadily from age
40)
• Prolonged/restricted mobility
• Cancer and cancer therapy
• Cardiac problems
• Systemic lupus
erythematous
• Infection
• Microalbuminuria associated
with ESRD
• Stroke
• Nephrotic syndrome
•
•
•
•
•
•
•
•
•
Trauma
Inflammatory bowel syndrome
Atherscelerosis
History of DVT or PE
Inherited or acquired
predisposition to clotting
Obesity
Pregnancy and postpartum
period
Oral contraceptive or hormone
replacement with estrogen
Varicose veins
The Greatest Risks for VTE
• The trauma of surgery itself
• Prolonged/restricted mobility
• Length of the surgical procedure
The Most Important Question
to Ask
“Is this patient going to be
in bed for a long time?”
Surgical Patients at Risk for
VTE
Risk Level
Highest
High
Moderate
Low
Patient Population
• Undergoing hip or knee surgery
• With multiple risk factors
• With major trauma
• Older than 60 years
• Patents ages 40-60 years with additional risk factors
• Additional risk factors undergoing minor surgery
• 40-60 years with no additional risk factors
• Younger than 40 years with no additional risk factors
undergoing minor surgery
Prophylaxis Options
Pharmacological Options
• Low-dose unfractionated
heparin (LDUH)
• Low molecular weight
heparin (LMWH) or
Factor Xa Antagonist
• Warfarin
• Oral Factor Xa Inhibitor
(Rivaroxaban)
NonPharmacological/Mechanical
Options
• Intermittent pneumatic
compression (IPC)
• Graduated compression
stockings (GCS)
• Venous foot pump (VFP)
Preventing VTE Is Complicated
(Slide 1 of 3)
Hight, Henrietta. Venous Thromboembolism & Prophylaxis in the Surgical Patient. FMQI.
http://www.hsag.com/App_Resources/Documents/FMQAI_SCIP_VTE_LearningModule.pdf. 27 June 2013
Preventing VTE Is Complicated
(Slide 2 of 3)
Hight, Henrietta. Venous Thromboembolism & Prophylaxis in the Surgical Patient. FMQI. http://www.hsag.com/App_Resources/Documents/FMQAI_SCIP_VTE_LearningModule.pdf. 27 June 2013
Preventing VTE Is Complicated
(Slide 3 of 3)
Hight, Henrietta. Venous Thromboembolism & Prophylaxis in the Surgical Patient. FMQI.
http://www.hsag.com/App_Resources/Documents/FMQAI_SCIP_VTE_LearningModule.pdf. 27 June 2013
Sample Order Set
Sample order sets
are available at:
http://www.fmqai.com/library/at
tachmentlibrary/VTERiskAssessmentToo
ls.pdf
Work within a Specialty
Surgical Care Improvement
Project (SCIP) Measures
VTE Measure 1:
Surgery patients with
recommended venous
thromboembolism
(VTE) prophylaxis
ordered anytime from
hospital arrival to 24
hours after Anesthesia
End Time.
VTE Measure 2:
Surgery patients who
received appropriate
venous
thromboembolism
(VTE) prophylaxis
within 24 hours prior to
Anesthesia Start Time
to 24 hours after
Anesthesia End Time.
Centers for Medicare & Medicaid Services (CMS). The Joint Commission. Specifications Manual for National Hospital Inpatient Quality Measures. Version 3.1a.
Revised November 6, 2009; 135-177 [SCIP-VTE 1-1 – SCIP-VTE 2-23]. QualityNet Web site. Available at:
http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier4&cid=1228749003528. Accessed March 8, 2010.
Joint Commission Measures
VTE-1
Venous Thromboembolism
Prophylaxis
• The number of patients who received VTE prophylaxis or have documentation why no VTE
prophylaxis was given the day of or the day after hospital admission or surgery end date for
surgeries that start the day of or the day after hospital admission
VTE-2
Intensive Care Unit VTE
• The number of patients who received VTE prophylaxis or have documentation why no VTE
prophylaxis was given the day of or the day after the initial admission (or transfer) to the
Intensive Care Unit (ICU) or surgery end date for surgeries that start the day of or the day
after ICU admission (or transfer).
VTE-3
VTE Patients with Anticoagulation
Overlap Therapy
• The number of patients diagnosed with confirmed VTE who received an overlap of parenteral
(intravenous [IV] or subcutaneous [subcu]) anticoagulation and warfarin therapy,
VTE-4
VTE Patients Receiving Unfractionated
Heparin with Dosages/Platelet Count
Monitored by Protocol or Nomogram
• The number of patients diagnosed with confirmed VTE who received intravenous (IV) UFH
therapy dosages AND had their platelet counts monitored using defined parameters such as a
nomogram or protocol.
VTE-5
Venous Thromboembolism
Warfarin Therapy Discharge
Instructions
VTE-6
Hospital Acquired PotentiallyPreventable Venous
Thromboembolism
• The number of patients diagnosed with confirmed VTE that are discharged to home, home
care, court/law enforcement or home on hospice care on warfarin with written discharge
instructions that address all four criteria: compliance issues, dietary advice, follow-up
monitoring, and information about the potential for adverse drug reactions/interactions.
• The number of patients diagnosed with confirmed VTE during hospitalization (not present at
admission) who did not receive VTE prophylaxis between hospital admission and the day
before the VTE diagnostic testing order date.
Poll 1: Realistically, how often do you think
that patients receiving surgery in your
facility receive treatment that fulfills some
of the guidelines that we talked about?
•
•
•
•
Never
Sometimes
Most of the time
Always
Poll 2: Additional resources from the
SCHA to help us further refine our
VTE prophylaxis efforts would be
helpful?
• Yes
• No
Poll 3:
What do you see as the biggest
barrier to more consistent use
of VTE guidelines?
(Open-ended question)
Take Home Messages
• Preventing VTE is complicated and requires
interventions across the entire system of care
• Creating guidelines/order sets by specialty is helpful
• The hospital association would like to learn more
about your experiences with VTE please send an
email to Lorri Gibbons at lgibbons@scha.org with:
– any successes that you have had
– if you have any suggestions for future topics to help
further your work in this area
Questions
Office Hours:
Wednesday 2:00-3:00
Resources
Website:
www.safesurgery2015.org
Email:
safesurgery2015@hsph.harvard.edu