Evidence-based Practice for Venous Thromboembolism

VENOUS THROMBOEMBOLISM

 What is evidence-based practice (EBP) and why is it important in the healthcare field?  EBP is research that is conducted on specific practices that pertain to patient care with the anticipation of integrating the new and updated findings in to the healthcare setting.  EBP studies are important to allow for evolvement to keep up with the changing times.  Although, it may take years for the implementations of EBP research to be put into effect, the results have proven to be beneficial not only for patients but for the healthcare facility as well, saving the establishment from incurring costs on unfortunate, preventable outcomes.  Prophylaxis for venous thromboembolism (VTE) is a prime example of one of the practices that was brought about by EBP research.

 A VTE is a blood clot that originates in a vein, usually in the lower extremities.  Risk factors for developing a VTE are: surgery, cancer, immobilization, hospitalization, and women who are pregnant or on oral contraceptives or hormone therapy.  A patient has the potential of developing one of two types of VTE: deep vein thrombosis (DVT) or pulmonary embolism (PE).  The difference between a DVT and a PE is a DVT is a clot in a deep vein and a PE is a clot that has broken free from a vein wall and travels to the lungs and partially or completely blocks of the blood supply.  According to the American Heart Association (2017), VTEs are the third leading vascular diagnosis after a heart attack and stroke, affecting between 3000,000 to 600,000 Americans each year.  Because VTEs are serious and life-threatening, but most significantly preventable, EBP guidelines were developed.  Some mechanical and pharmacological implementations that a patient may encounter are: placement of sequential compression devices (SCDs) on the lower extremities that mimic the movement of walking, wearing compression stockings (available in various lengths), and the administration of an anticoagulant (Heparin, Lovenox, Coumadin). 

In order for the patient to receive the benefits of VTE prophylaxis treatment there first has to be an order placed; however, not all health care providers are initiating the EBPs of the VTE protocol.  In 2007, believing that the prevention of VTE was an underused protocol, Lloyd et. al (2012) conducted a 3 month survey amongst Canadian health care workers in an attempt to understand why prophylaxis of VTE was underutilized.  The results showed that health care workers found the following as potential barriers to implementation: concerns of bleeding, lack of indications, contraindications of DVT prophylaxis, patient discomfort from injections, and lack of time to consider DVT prophylaxis in every patient.  From this study, two “novel barriers were identified: misperception of DVT prophylaxis underutilization, and confusion about roles and responsibilities in the area” (Lloyd et. al, 2012). 

  Safety in health care requires a commitment to continuing education.  Every member of the interdisciplinary team must be aware of new guidelines for diagnostic or preventative measures that have been established by the health care facility.  Zieler et. al (2008) recognized a need in the community for appropriate VTE education, which in turn spawned the creation of the “VTE Safety Toolkit”. The intention of the toolkit was to enlighten not only providers but patients and the public as well.  Although, the toolkit originated in 2008 it can still provide useful information that can be utilized in today’s age such as patient education materials and strategies for providers to use for continuity of care.  There are 10 components to the toolkit that are evidence-based guidelines for preventing, diagnosing, treating, and educating patients and providers about VTE. “The components are as follows:

• VTE prophylaxis guidelines.
• VTE risk assessment tool.
• DVT diagnostic algorithm.
• PE diagnostic algorithm.
• HIT (heparin-induced thrombocytopenia) assessment.
• VTE treatment pathway.
• DVT outpatient treatment order set.
• Vascular laboratory requisition.
• Neural-axial anesthesia guidelines.
• Patient education (prevention and treatment) pamphlets.”

(Zieler et. al, 2008)

  It is important to understand that VTE is a medication issue that requires a coordination of care among an array of individuals during diagnosis, prophylaxis, or treatment so the implementation of another tool to help bridge the gap on education is welcomed addition.

 With the advent of electronic medical record (EMR) systems, providers are now able to determine if a patient is a high risk for VTE development based on the electronic entry of their assessment, therefore the patient can now be screened simultaneously to see if they are a candidate for needing a VTE protocol order with no additional work needed.  With a VTE prevention protocol in place, “it provides specific, sequential steps for patient care delivered by nurses and other health care professionals” (Tietze & Gurley, 2014).  There is a clear structure that should be followed.  In the health care field, many times the main focus is to address the patient’s acute medical issue, neglecting to see the importance of prophylactic VTE prevention.  By adhering to the VTE protocol, nurses are providing total care that is in the best interest of the patient. 

Health care providers should strive to deliver quality care with an emphasis on patient safety.  After all that is why many health care providers made a conscious decision to join the medical field.  With the nursing staff acting as a patient advocate, the patient is then given an opportunity to focus on their recovery rather than have to worry about developing any complications such as a VTE, morbidity, or mortality. 

References

• American Heart Associations. (2017). What is Venous Thromboembolism (VTE)?. Retrieved from https://www.heart.org/en/health-topics/venous-thromboembolism/what-is-venous-thromboembolism-vte.
• Lloyd, N.S., Douketis, J.D, Cheng, J., Schünemann, H.J., Cook, D.J., Thabane, L., Pai, M., Spencer, F.A., & Haynes R.B.  Thromboprophylaxis: Survey on Barriers. J. Hosp. Med 2012;1;28-34. doi:10.1002/jhm.929
• Tietze, M., & Gurley, J. (2014). VTE Prevention: Development of an Institutional Protocol and the Nurse’s Role. MEDSURG Nursing, 23(5), 331-333.
• Zierler BK, Wittkowsky A, Peterson G, et al. Venous Thromboembolism Safety Toolkit: A Systems Approach to Patient Safety. In: Henriksen K, Battles JB, Keyes MA, et al., editors. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools). Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Aug. Available from: https://www.ncbi.nlm.nih.gov/books/NBK43659/