DVT Prophylaxis and
Pulmonary Embolism
Karen Ruffin RN, MSN Ed.
Frequency in the US
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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
Percentage if at risk for
Development of a VTE
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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
Feied, C.F. & Handler, J.A., (2008)
(48%).
Mortality and Morbidity
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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
Mortality and Morbidity
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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.
Virchow’s Triad
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Vessel Damage
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Vascular Constriction
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Blood Viscosity
Vessel Damage
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Endothelial cells allow blood to flow with
ease through vessels.
Factor VIII or Willibrand’s Factor
Conditions/lifestyles that damage vessel
walls:
– Past VTE
– Smoking
– High Cholesterol
– Varicose Veins
- Pressure Ulcers
- Cellulites
Vascular Constriction
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Trauma
Surgery
Insertion of central line
Varicose Veins
Restricted Mobility
Sepsis
Induction
MI
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HF
Stroke
Any external force that cause damage to the
vascular system can cause slow blood flow
Blood Viscosity
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Dehydrating
Birth Control Pills
High estrogen states
– Pregnancy
– Postpartum
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Cancer
Sepsis
Blood transfusions
Obesity
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IBS
Hematologic Disorders
Elevated Blood Sugar
Platelet Aggregation
Physiology of Clotting
What is the difference
between a thrombus and
an emboli?
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A thrombus is a clot that is stationary and
a emboli is a thrombus that has broken
off and is traveling.
Most Common Cause of a
PE
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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).
What is a Pulmonary
Embolism (PE)?
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Occlusion of a portion of the
pulmonary vascular bed by an
embolism. They can be a:
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Thrombus (Blood Clot)
Tissue Fragment
Lipids (Fat)
Air Bubble
Pathophysiology
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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
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▪ 10% of the time left lung
▪ Lower lobes are 4 times
more often upper lobes.
Pathophysiology
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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.
Risk Factors for DVT and
PE
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Previous episode of
thromboembolism
Prolonged immobility
Cancer
Obesity
Pregnancy
Oral estrogen
Fever
Atrial fibrillation
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CHF, Shock
Varicose veins
Over 60 y/o
Hematologic disorders
Trauma
Central Lines
Dehydration
Hypovolemia
Surgical Patients
Prophylaxis Strategies
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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)
Understanding the Different
Recommendation Categories
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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)
General Patient
Population
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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)
What about patients w/ a
PICC line??????
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We are a seeing
and increased
incidence of DVT in
patients with PICC
lines.
How can we assess
for it?
Clinical Manifestation of
PE
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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.
Applying the Nursing
Process
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Assessment
Diagnosis
Planning
Intervention
Evaluation
Assessment and
Symptoms
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Homon’s sign
H&P
Cough
Sudden onset of
SOB
Agitation
Lightheadness
Fainting
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Dizziness
Sweating
Anxiety
Rapid Breathing
Tachycardia
Air Hunger
What are your nursing
diagnosis going to
be???
Tell me your long and short term
goals.
Diagnostics
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Arterial Blood Gases
EKG
Echocardiogram
Chest x-ray
VQ scan
Spiral CT scan
Pulmonary
Angiogram
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Pt, ptt, INR
D-DImer
Split Fibrinogen
MRA
WHAT ARE YOUR
INTERVENTIONS FOR YOUR
STATED GOALS?
Remember to always have:
Assessment
Action
Psychosocial
Education
For every goal!
Treatment
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Supportive
Filters
Anticoagulants/Thrombolytics
– Heparin
– Coumadin
– Streptokinase
– Retavase
– TPA
SO WHAT WILL WE
EVALUATE AND WHY?
Cost of Prevention vs.
Treatment????
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Sequential
stockings- $10 day
Heparin subqpennies a day
Lovenox subq $15 a
day
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V/Q scan- $1500
ICU bed $9000 day
Arterial Angiogram$3200
Many other realted
cost?????
Prevention is KEY
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Intermittent Pneumatic Stockings
– SCD
– Teds
– Early Ambulation
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Low Dose Anticoagulation
– Heprin
– Lovenox
– Arixtra
So, what does all of this
mean to us?
Assessment and
Documentation
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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
Why are all those steps
important????
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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
Why are all those steps
important????
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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.
So what does that mean
to the bedside nurse?
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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.
The Power of Suggestion!!
Don’t ever underestimate
it!!!!!!!
Case Studies
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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
Case Study
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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.
Case Study
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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.
-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.
Now we will do an Evolve
case study!