Improving Compliance with a Nurse-Driven Protocol for Unfractionated Heparin Infusions in Patients with Venous Thromboembolism.

BACKGROUND: Unfractionated heparin (UFH) is a high-risk medication that can cause bleeding and/or thrombotic complications if not managed appropriately. Between January and July 2019, our institution experienced a high number of patient safety events related to UFH infusion for the treatment of venous thromboembolism (VTE). PURPOSE: The aim of this quality improvement (QI) initiative was to prevent these safety events by improving compliance with our institution's nurse-driven VTE UFH infusion protocol. METHODS: Baseline data for patients on the VTE UFH protocol were collected to identify improvement opportunities. Compliance with eight standards of care related to the VTE UFH infusion protocol was measured. Time to first therapeutic activated partial thromboplastin time (aPTT) was recorded to assess the benefit of improved compliance. INTERVENTIONS: Institutional policy updates were made to clarify the management of UFH infusions and documentation in the electronic health record. A multidisciplinary workgroup implemented order set changes, nursing communication orders, UFH infusion reports, and a nursing education module to promote compliance with the protocol. RESULTS: The overall rate of compliance with the VTE UFH infusion protocol increased from 79.4% at baseline to 85.2% following implementation of the QI initiative, and the median time to first therapeutic aPTT decreased from 831.5 minutes to 808 minutes over the same period. CONCLUSIONS: A multidisciplinary initiative to address improvement opportunities in a nurse-driven UFH protocol for VTE treatment increased compliance with the protocol and decreased the time to first therapeutic aPTT.

Prevalência dos fatores de risco para trombose venosa profunda em pacientes cirúrgicos em unidade de terapia intensiva / Prevalence of risk factors for deep venous thrombosis in surgical patients in intensive care unit

Objetivo: Avaliar a prevalência dos fatores de risco e medidas de prevenção para trombose venosa profunda de pacientes cirúrgicos em Unidade de Terapia Intensiva. Métodos: Estudo transversal, conduzido em 2019, com utilização da escala de Caprini para classificação de cada paciente quanto ao risco para trombose venosa profunda, e análise das intervenções adotadas. Resultados: Foram avaliados 68 pacientes. Os fatores de risco mais prevalentes foram procedimento cirúrgico de grande porte (96%) e restrição ao leito (90%). O risco para tromboembolismo venoso foi alto (62/91%), moderado (5/7%) e baixo (1/2%). A mobilização de membros foi aplicada a todos os pacientes, deambulação precoce foi realizada em 62% e 56% foram submetidos à profilaxia medicamentosa. Conclusão: A alta prevalência dos fatores de risco para trombose venosa profunda em pacientes cirúrgicos e a baixa aplicabilidade de medidas preventivas demonstram a importância da implementação de programas de educação continuada e medidas de monitoramento desses eventos.

Objective: To assess the prevalence of the risk factors and preventive measures for deep venous thrombosis in surgical patients in the Intensive Care Unit. Methods: Cross-sectional study held in 2019 using the Caprini scale to classify each patient regarding their risk for deep venous thrombosis, and analysis of the actions taken. Results: A total of 68 patients were evaluated. The most prevalent risk factors were being submitted to major surgical procedures (96%) and bed restriction (90%). The risk for venous thromboembolism was high (62/91%), moderate (5/7%), and low (1/2%). Limb mobilization was applied on all patients; early ambulation was performed in 62%; and 56% were submitted to drug prophylaxis. Conclusion: The high prevalence of risk factors for deep vein thrombosis in surgical patients and the low applicability of preventive measures show the importance of implementing continuing education programs and measures to monitor such events.

Riesgo de tromboembolismo venoso e implementación de medidas preventivas / Risk of venous thromboembolism and implementation of preventive measures

OBJETIVO: Identificar la frecuencia de los factores de riesgo del tromboembolismo venoso en pacientes hospitalizados y el uso de medidas preventivas adoptadas por los profesionales de la salud. MÉTODO: Estudio descriptivo, transversal y retrospectivo que incluye registros médicos de 369 pacientes adultos hospitalizados en un hospital universitario en São Paulo, Brasil, durante al menos 48 h, del 2015 al 2017. Se investigaron datos sociodemográficos, factores de riesgo clínicos para el tromboembolismo venoso, contraindicación para profilaxis química, implementación de profilaxis química y mecánica y ocurrencia de la enfermedad. Se calculó el uso de medidas preventivas siguiendo las directivas de la Sociedad Brasileña de Medicina Clínica y el riesgo de tromboembolismo venoso según la escala de predicción de PADUA (alto riesgo ≥ 4 y bajo riesgo < 4). RESULTADOS: La prevalencia de tromboembolismo venoso fue del 7,3% (n = 27). Todos los pacientes tenían al menos un factor de riesgo de tromboembolismo venoso, siendo más prevalentes la movilidad reducida (74,2%), el cáncer activo (70,7%), la infección (27,1%), la cirugía reciente (21,6%) y la edad ≥ 70 años (20,0%). Se implementó la profilaxis química en el 70,3% de los pacientes de alto riesgo sin contraindicación y la profilaxis mecánica se aplicó solo en uno de los casos con indicación. CONCLUSIONES: Todos los pacientes tenían al menos un factor de riesgo de tromboembolismo venoso; sin embargo, hubo una baja tasa de implementación de medidas preventivas por los profesionales de la salud. Por lo tanto, existe la necesidad de múltiples intervenciones, incluida la educación durante la admisión y la educación permanente de enfermeros en relación con los riesgos y la prevención, los sistemas de alerta y la auditoría de resultados

OBJECTIVE: To identify the frequency of risk factors for venous thromboembolism in hospitalized medical patients and the use preventive measures by healthcare professionals. METHOD: A descriptive, cross-sectional, retrospective study including medical charts of 369 adult patients hospitalized in the Medical sector of a university hospital in São Paulo, Brazil, for at least 48h from 2015 to 2017. Sociodemographic data, clinical risk factors for venous thromboembolism, contraindication and implementation of chemical prophylaxis, and the occurrence of the disease were investigated. The use of preventive measures was calculated by following the guidelines of the Brazilian Society of Clinical Medicine and the risk of venous thromboembolism according to the Padua Prediction Score (high risk ≥ 4 and low risk < 4). RESULTS: The prevalence of venous thromboembolism was 7.3% (n = 27). All patients had at least one risk factor for venous thromboembolism, the most prevalent being reduced mobility (74.2%), active cancer (70.7%), infection (27.1%), recent surgery (21.6%) and age ≥70 years (20.0%). Chemical prophylaxis was implemented in 70.3% of high-risk patients without contraindication and mechanical prophylaxis was applied in only one of the cases with an indication. CONCLUSIONS: All patients had at least one risk factor for venous thromboembolism. However, there was a low rate of implementation of preventive measures by health care professionals. Therefore, there is a need for multiple interventions, including admission and permanent education of nurses regarding risk and prevention, warning systems and outcomes audit

Perioperative Management of the Direct-Acting Oral Anticoagulants.

Since the 1950s, warfarin has been the most commonly prescribed anticoagulant in the prevention of stroke-related thromboembolism. Beginning in 2008, direct-acting oral anticoagulants (DOACs) began to replace warfarin. Although the DOACs had a greater safety profile, approved reversal agentsfor use in emergent/excessive hemorrhage did not exist. This course reviews the perioperative management of the DOACs.

Nurses' objective knowledge regarding venous thromboembolism prophylaxis: A national survey study.

Venous thromboembolism (VTE) is a common vascular disorder with high mortality and morbidity. Clinical nurses are a pivotal group that can serve as first-line health care providers. Lack of knowledge about VTE is an important barrier to effective nursing performance. This study aimed to determine nurses' knowledge of VTE prophylaxis through a nationwide survey across China, to understand gaps between current knowledge, and guidelines, and to help improve clinical nursing.The survey included 5 topics with 68 items on VTE, including basic knowledge, risk assessment, basic prophylaxis, physical prophylaxis, and pharmacological prophylaxis.The survey was distributed to 106 AAA-grade hospitals throughout China; 5218 valid questionnaires were submitted for analysis. There were 5097 women and 121 men respondents, with average age 30.29 ±â€Š8.60 years. The average rate of correct responses regarding VTE knowledge was 59.90 ±â€Š15.63%; 77.81% of subjects answered more than half of the survey items correctly. Better knowledge about thromboprophylaxis was observed among nurses who were more highly educated, more experienced, had received continuing education, intensive care unit (ICU), and lead nurses. Correct response rates were 68.39 ±â€Š17.03%, 60.35 ±â€Š21.01%, 75.51 ±â€Š22.85%, 41.72 ±â€Š17.47%, and 46.01 ±â€Š21.22% for basic knowledge, risk assessment, basic prophylaxis, physical prophylaxis, and pharmacological prophylaxis, respectively.Respondents showed satisfactory results regarding basic prophylaxis, basic knowledge, and risk assessment for VTE; respondents had poorer knowledge regarding physical and pharmacological prophylaxis. Better mastery of knowledge about thromboprophylaxis was observed among nurses who were more highly educated, more experienced, had received continuous education, ICU, and lead nurses.This study suggested that nurse trainers should develop comprehensive educational programs that focus on low correct rate aspects. Higher-level continuous education could improve nurses' knowledge of thromboprophylaxis.

Evaluation of a nurse-led intervention to improve adherence to recommended guidelines for prevention of venous thromboembolism for hip and knee arthroplasty patients: A quasi-experimental study.

AIMS AND OBJECTIVES: To measure adherence to a nurse-led evidence-based venous thromboembolism prevention programme (intervention) compared to usual care in hip and knee arthroplasty patients and associated clinical outcomes. BACKGROUND: Venous thromboembolism morbidity and mortality of hospitalised patients is a major concern for health professionals. Venous thromboembolism prevention guidelines have been developed; however, adherence to guidelines is variable. PARTICIPANTS: There were 410 potential participants who were adult patients that were booked for elective hip or knee arthroplasty at the two study sites during a 2-year period (2011-2013). Of these, 27 did not meet the inclusion criteria, and the remainder were eligible for inclusion in the study (intervention site n = 196 and control site n = 187, total population n = 383). METHODS: This study adopted a quasi-experimental design, using an intervention and control study site, conducted in two private hospitals in a regional area in Australia. RESULTS: The intervention group had a mean compliance score of 11.09, higher than the control group score of 7.19. This is equivalent to a compliance rate of 85% and 55%, respectively, and indicates that adherence at the study site was significantly higher. Patient adherence and outcomes in the postdischarge period were not significantly different between the study sites. CONCLUSION: This study demonstrated a nurse-led intervention achieved high adherence with translating evidence-based guidelines into routine patient care for hip and knee arthroplasty patients. Nurses can be critical to implementing clinical practice guidelines and adopting preventive programmes in acute care to improve patient outcomes and reduce postoperative venous thromboembolism in arthroplasty patients. RELEVANCE TO CLINICAL PRACTICE: This research demonstrates the capacity of nurses to lead the translation of evidence-based practice guidelines for prevention of venous thromboembolism into routine patient care.

Cuidados de Enfermagem na prevenção do tromboembolismo venoso: revisão integrativa / Nursing care in the prevention of venous thromboembolism: an integrative review

Este estudo buscou identificar na literatura científica quais os cuidados de enfermagem na prevenção do Tromboembolismo Venoso (TEV) em pacientes hospitalizados. Trata-se de uma revisão integrativa da literatura realizada nas bases de dados Public/Publish Medline (PUBMED) e Biblioteca Virtual em Saúde (BVS). Incluíram-se estudos em inglês, espanhol e português, publicados entre 2006-2016, que apresentassem ações de Enfermagem na prevenção do TEV nos pacientes hospitalizados, para a localização dos estudos utilizou-se o cruzamento dos termos "cuidados de enfermagem", "prevenção" e "tromboembolismo venoso". Predominaram os cuidados de enfermagem na prevenção do TEV categorizados em "implementação da avaliação do risco de TEV", "intervenções mecânicas e físicas" e "ensino ao paciente sobre TEV". Esses achados podem contribuir para sistematização da assistência de enfermagem pela ampliação e direcionamento das possibilidades de cuidados, além de favorecer autonomia do enfermeiro, subsidiar pesquisas de validação e reforçar a implementação de Enfermagem Vascular como área de especialidade.

This study sought to identify in the scientific literature the nursing care provided for the prevention of venous thromboembolism (VTE) in hospitalized patients. It is an integrative review of the literature conducted in the Public/Publish Medline (PUBMED) and Virtual Health Library (VHL) databases. The studies included in this review were in English, Spanish, and Portuguese and published between 2006 and 2016. They addressed nursing care in the prevention of VTE in hospitalized patients. The studies were located by cross-referencing the terms "nursing care", "prevention" and "venous thromboembolism. The predominating topics were nursing care in the prevention of VTE, categorized under "implementing VTE risk assessment", "mechanical and physical interventions", and "educating patients on VTE". These findings may contribute to the systematization of nursing care by expanding and directing care possibilities, favoring nurses' autonomy, and supporting research to validate and reinforce vascular nursing as a speciality area.

Prevention, diagnosis and treatment of venous thromboembolism.

Venous thromboembolism (VTE) occurs more frequently in older people. For those nursing older people in a variety of settings, knowledge of VTE prevention, diagnosis and treatment is essential. This article discusses simple, practical measures that can be used to reduce the risk of VTE, including good hydration and promotion of mobilisation. It also discusses how a VTE forms, the signs and symptoms, and the methods used to diagnose and treat VTE. In recent years new drugs have been licensed to treat patients with VTE called direct oral anticoagulants. This article explores recent evidence and important considerations for their use in treatment of VTE.

Clinical nurses' knowledge and practice of venous thromboembolism risk assessment and prevention in South Korea: a cross-sectional survey.

AIMS AND OBJECTIVES: To examine Korean registered nurses' level of perceived knowledge and practice of venous thromboembolism risk assessment as well as prevention, self-efficacy in venous thromboembolism care and actual knowledge of venous thromboembolism. BACKGROUND: For hospitalised patients, venous thromboembolism is a preventable clinical disorder. Caring for venous thromboembolism patients requires coordination across multiple providers and settings. Clinical nurses can play a major role in improving venous thromboembolism prevention care, assessing venous thromboembolism risks and providing appropriate prophylactic measures to those who are at risk for venous thromboembolism. DESIGN: A cross-sectional descriptive study. METHODS: Anonymous paper-based surveys were conducted for a convenience sample of registered nurses' (n = 452) from two university-affiliated hospitals in South Korea. RESULTS: The majority of participants indicated that their overall self-rated venous thromboembolism knowledge was 'fair', while only 2·4% rated it as 'very good' or 'excellent'. The overall mean score of the venous thromboembolism knowledge questions was 50·9 (±13·0) of a possible score of 100. The mean score of self-efficacy in practising venous thromboembolism prevention/prophylaxis was 3·0 (based on a one to five Likert scale). The self-reported venous thromboembolism assessment performance on patients varied among clinical units. Only 9·3% of participants reported having received in-service venous thromboembolism education from their hospital. CONCLUSIONS: The findings showed that overall venous thromboembolism knowledge and self-efficacy in venous thromboembolism prevention practices of Korean registered nurses' were not highly rated. Korean nurses demonstrated a lack of knowledge about venous thromboembolism, particularly in the areas of venous thromboembolism prophylaxis measures and venous thromboembolism diagnosis methods. RELEVANCE TO CLINICAL PRACTICE: Focused education on venous thromboembolism prevention and risk assessment should be considered a component of continuing education for Korean nurses.

Venous Thromboembolism Prophylaxis in Plastic Surgery: A Literature Review.

Venous thromboembolism (VTE) is a major health concern because it increases morbidity and mortality after a surgical procedure. A number of well-defined, evidence-based guidelines are available delineating suitable use of prophylaxis to prevent deep vein thrombosis and pulmonary embolism. Despite the available literature, there are clear gaps between recommendations and clinical practice, affecting the incidence of VTE. Plastic surgeons underuse the substantiated literature and risk stratification tools that are available to decrease the incidence of VTE in the office-based surgical setting because of fear of bleeding or hematoma complications postoperatively. Venous thromboembolism creates an economic burden on both the patient and the healthcare system. The intent of this literature review is to determine existing VTE risk using assessment models available to aid in the implementation of protocols for VTE prevention, specifically for high-risk cosmetic surgical patients in office-based settings.

Point-of-care D-dimer testing in emergency departments.

Overcrowding and prolonged patient stays in emergency departments (EDs) affect patients' experiences and outcomes, and increase healthcare costs. One way of addressing these problems is through using point-of-care blood tests, laboratory testing undertaken near patient locations with rapidly available results. D-dimer tests are used to exclude venous thromboembolism (VTE), a common presentation in EDs, in low-risk patients. However, data on the effects of point-of-care D-dimer testing in EDs and other urgent care settings are scarce. This article reports the results of a literature review that examined the benefits to patients of point-of-care D-dimer testing in terms of reduced turnaround times (time to results), and time to diagnosis, discharge or referral. It also considers the benefits to organisations in relation to reduced ED crowding and increased cost effectiveness. The review concludes that undertaking point-of-care D-dimer tests, combined with pre-test probability scores, can be a quick and safe way of ruling out VTE and improving patients' experience.

Venous Thromboembolism: New Concepts in Perioperative Management.

Venous thromboembolism (VTE) is a serious pathophysiologic condition that is a major cause of morbidity and mortality, especially during the perioperative period. A collective term, VTE is used to describe a blood clot that develops inside the vasculature and results in a deep vein thrombosis (DVT) and/or a pulmonary embolism (PE). Deep vein thrombosis and PE are the third leading cause of cardiovascular mortality, superseded only by myocardial infarction and stroke. Patients who receive treatment for acute PE are 4 times more likely to die of a recurrent VTE within the next year. In hospitalized patients who have had surgery, the incidence of VTE and PE is estimated to be 100 times more prevalent than in the general population. The Joint Commission has established Surgical Care Improvement Project measures to address prophylactic interventions to minimize the incidence of VTE. This journal course will review the current approaches to pharmacologic and nonpharmacologic prevention and management of VTE during the perioperative period. Identification and treatment of deep vein thrombosis and acute PE are also described.

Common characteristics of patients diagnosed with upper-extremity venous thromboembolism during hospitalization: a descriptive study.

PURPOSE: The aim of this study was to explore the common characteristics of patients diagnosed with upper-extremity venous thromboembolism (UEVTE) during hospitalization. DESIGN: This was a retrospective chart review. SETTING: This study was performed at a Midwest multisite hospital of 5 acute-care hospitals and 2051 beds. SAMPLE: The sample was composed of 777 hospitalized adult patients who had a positive upper-extremity venous Doppler from July 2008 to July 2009. RESULTS: Patients were adults with a mean age of 66.6 (SD, 17.0) years and mean hospital stay of 15.7 (SD, 12.4) days. When assessing the arm clots, 398 patients (51.2%) had a right arm clot, 317 patients (40.8%) had a left arm clot, and 62 patients (8.0%) had clots in both arms. Patients were primarily admitted with medical conditions, and more than one-half were overweight or obese (59.2%). Nearly 50% of patients were at the highest venous thromboembolism (VTE) risk upon admission (n = 362), were tobacco users (n = 379), and had surgeries or invasive procedures performed prior to upper-extremity venous Doppler (n = 395). In 58.6% of the patients, chemoprophylaxis through intravenous anticoagulation therapy was administered during the first 3 days of admission. In patients with an intravenous catheter in an arm, UEVTE was likely to occur in the same arm (right and left arm, P < .001). IMPLICATIONS: Nurses caring for patients with characteristics commonly found in cases of UEVTE should regularly monitor the arms of their patients and communicate findings in shift reports to heighten awareness of UEVTE risk. In addition, patients with medical diagnoses that prevent use of early anticoagulation for VTE prophylaxis such as gastrointestinal bleed, hematologic disorders, trauma, and hemorrhagic strokes should be frequently assessed for UEVTE. Learning the characteristics of patients who had UEVTE during their hospitalization and the role of early and late anticoagulation in the development of UEVTE would advance nurse assessment and lead to novel interventions and future research.

Proactivity in VTE prevention: a concept analysis.

Venous thromboembolism (VTE) prevention is an international patient safety issue. The author has observed gaps in prescription and provision of VTE prophylaxis, and that the attitude to VTE is often reactive rather than proactive. This concept analysis aims to explore proactivity and apply it to VTE prevention to address this. Ten databases were searched (1992-2012) using the keywords proactive, proactivity, nurse, nursing, VTE/venous thromboembolism, prevent/prevention/preventing, behaviour, DVT/PE (deep vein thrombosis, pulmonary embolism). The Walker and Avant (2010) method of concept analysis identified the defining attributes as personal initiative, taking charge and feedback-seeking behaviour. Antecedents and consequences have been identified, and empirical referents are demonstrated. Defining proactivity in VTE prevention has the potential to increase prescription and, crucially, provision of prophylaxis, thereby improving patient care, reducing avoidable harm and improving the patient experience.

Implementing evidence-based practice using an interprofessional team approach: part two.

The complexity inherent in the inpatient oncology population requires effective interprofessional collaboration and integrated evidence-based practice (EBP), drawing from each of the disciplines to achieve desired outcomes. Each member of the team lends a strength and expertise that, when combined, often results in outcomes greater than the sum of its parts (Hall & Weaver, 2001; Petri, 2010; Pullon & Fry, 2005). EBP promotes the use of research to solve issues raised in day-to-day nursing practice. This article provides an overview and summary of an evidence-based project to increase compliance of sequential compression devices (SCDs) in gynecologic oncology and urology patients on a post-surgical inpatient unit using the Plan, Do, Study, Act (PDSA) model for continuous quality improvement (CQI) (Institute for Innovation and Improvement, 2013).

Implementing evidence-based practice using an interprofessional team approach.

Translational research has been defined as "bench-to-bedside" research or "laboratory-to-clinical" research. Benefits to this type of research are that it fast tracks biomedical advances to improve the quality of care and life for patients with cancer (Callard, Rose, & Wykes, 2011). The challenge, however, is translating the research findings to the bedside in a timely fashion. Burns and Foley (2005) described an estimated 20-year delay in getting research findings translated to care delivery.