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Helping Canadian Hospitals Meet Accreditation Requirements For VTE Prophylaxis
- 1. Helping Canadian Hospitals Meet Accreditation Requirements For VTE Prophylaxis
- 2. Deep vein thrombosis (DVT) forms in a vein of the leg. • Characterized by pain, swelling or tenderness of the leg, sometimes with redness and warmth Deep Vein Thrombosis
- 3. Pulmonary Embolism Pulmonary embolism (PE) occurs when the blood clot breaks loose and travels to the lungs • Characterized by shortness of breath, sharp rib/chest pain and occasionally by hemoptysis, light-headedness, or collapse
- 4. Symptoms and Signs of DVT • Leg pain (90%) • Tenderness (85%) • Ankle edema (76%) • Calf swelling (42%) • Dilated veins (33%) • Dusky discoloration (30%) • Warmth • Redness DVT cannot be reliably diagnosed on the basis of history and physical exam, even in high-risk patients. Symptomatic DVT Most hospitalized patients with DVT will have NO SYMPTOMS or SIGNS!
- 5. Risk of VTE in Hospitalized Patients Geerts WT, et al. Chest 2008;358:381S-453S. Patient Group DVT Prevalence (%) Medical Patients 10-20 General Surgery 15-40 Major Gynecologic Surgery 15-40 Major Urologic Surgery 15-40 Neurosurgery 15-40 Stroke 20-50 Hip and Knee Arthroplasty, Hip Fracture Surgery 40-60 Major Trauma 40-80 Spinal Cord Injury 60-80 Critical Care Patients 10-80
- 6. Pulmonary Embolism Hospital Risk •Accounts for 10% of hospital deaths •In the UK, PE following DVT causes between 25,000 and 32,000 deaths each year1 International, cross- sectional audit of 35,000 inpatients at risk for VTE found:2 •only 59% of surgical patients and 40% of medical patients received recommended prophylaxis. 1. UK House of Commons Health Committee. HC 99. Published on 8 March 2005. 2. Cohen AT, et al. Lancet 2008;371:387-394.
- 7. Characterization of VTE events In the Worcester County, Mass VTE Study •60-70% of VTE events were considered to be provoked by: • Recent hospitalization (within 3 months) • Surgery • Trauma/fracture • Pregnancy 1. Spencer FA, et al. Arch Intern Med 2007;167:1471-5. 2. Spencer FA, et al. J Thromb Thrombolysis 2009;28:401-9. Risk for VTE increases with the number of risk factors and persists after hospital discharge.
- 9. Adapted from: Greer IA. Bailliere’s Clin Obstet Gynaecol 1997;11:403-30. The risk of DVT and PE is increased by several factors, including: Factors intrinsic to the patient Factors related to underlying disease or medical condition Factors introduced by medical or surgical treatment • Age • Obesity • Immobility • History of thrombosis • Thrombophilia • Varicose veins • Venous insufficiency • Pregnancy • Trauma • Heart failure/MI • Malignancy • Concomitant medication • Chemotherapy • Orthopaedic surgery • Major surgery • Caesarean section
- 10. 1. VTE is common in hospital patients 2. VTE is fatal (acutely and long-term) 3. VTE is preventable (safely and inexpensively) 4. Preventing VTE is the standard of care for almost all hospital patients in 2011 Slide courtesy of Dr. William Geerts. Rationale for Thromboprophylaxis
- 11. Adverse Consequences of VTE $Slide courtesy of Dr. William Geerts.
- 13. Key steps to ensure compliance with ROP: 1.Development of written policy/guideline 2.Identifies clients at risk & provides VTE prophylaxis 3.Establishes measures of success, uses information to make improvements 4.Provides information to health professionals (on risks & prevention measures)
- 14. 1. Hospital commitment; committee, leadership 2. Follow the ACCP guidelines 3. Written hospital policy on prophylaxis 4. Keep it simple and standardize it 5. Use order sets, computer order entry 6. Make prophylaxis decision mandatory 7. Involve everyone – MD, RN, pharm, patients 8. Audit and feedback to improve best practices 8 steps: Slide courtesy of Dr. William Geerts. Local Strategies to Improve Thromboprophylaxis Success
- 15. Every in-patient w/o contraindication should be on VTE prophylaxis
- 16. Audrey’s Story Following a one week wait for surgery and the successful removal of a benign tumour – Audrey developed a PE. We are scared and worried about our surgery or primary reason for being in the hospital as it is. We rely on you to make us aware of any possible complications. For me, the blood clot was far scarier and worse than my brain tumour and operation. This experience with the blood clot has impacted my life. It was the scariest and worst experience I have ever had and it has left me fearful and anxious. “My plea to healthcare professionals: make sure you get people’s attention, and make sure they fully understand their risks and what can be done to prevent a blood clot.”
- 17. • Written hospital policy on VTE prophylaxis • Opt-out policy for all medical and surgical in- hospital patients • VTE prophylaxis embedded in hospital order sets Policy ensures prophylaxis is considered resulting in lower rates of VTE in hospital setting Hospital Commitment for VTE Prophylaxis should include:
- 18. • Simplicity = single choice • LMWH advantages over UFH: • once a day administration • lower rates of heparin induced thrombocytopenia • availability in prefilled syringes Written hospital policy on prophylaxis - Simplicity LMWH: low molecular weight heparin; UFH: unfractionated heparin
- 19. • Due to differences in LMWH molecule size and charge, longer chained and more charged LMWHs like tinzaparin do not appear to require dose adjustments in patients with: • impaired renal function1 • renal failure2,3 • on haemodialysis2,3 • Dose reduction may be necessary with shorter chain LMWHs (i.e. enoxaparin) Use of LMWHs in Renal Impairment 1. Mahé O, et al.Thromb Haemost 2007;97:581-6. 2. PROTECT Investigators. N Engl J Med 2011;364:1305-14. 3. Nutescu EA, et al. Ann Pharmacother 2009;43:1064-83.
- 20. 1. Hospital commitment, committee, continued leadership 2. Written hospital policy on prophylaxis 3. Keep policy simple and standardize it 4. Use embedded order sets &/or computer order entry 5. Make prophylaxis decision mandatory (i.e. opt-out policy) 1. Involve everyone – MD, RN, pharm, patients 2. Audit and feedback essential to measure success and identify problems areas Implementation Slide courtesy of Dr. William Geerts.
- 21. 96% Success with Policy and Embedding Appropriate Prophylaxis* (use in General IM Patients) 9% 2003 2007 2008 2009 21% 100% 75% 50% 25% 0 60% *based on direct chart audit Quality improvement in action!Slide courtesy of Dr. William Geerts.
- 22. Vigilance is Key: Appropriate Prophylaxis* Use in General IM Patients 9% 2003 2007 2008 2009 2010 21% 100% 75% 50% 25% 0 60% 96% *based on direct chart audit We opened the champagne too soon! 72% Slide courtesy of Dr. William Geerts.
- 23. Multicomponent Toolkit for Canadian Hospitals
- 24. •Best practices in VTE prophylaxis •Clinical order set •Audit material •Health Professional education material •Patient education material The Content
- 25. • Reginald E. Smith, PharmD, ACPR, (Chair) Clinical Pharmacy Specialist, Thrombosis Clinic, BC • William Geerts, MD, FRCPC, National lead, VTE Prevention, Safer Healthcare Now! Thromboembolism Specialist; Professor of Medicine, University of Toronto, ON • Artemis Diamantouros, BScPharm, MEd, National Coordinator, VTE Prevention, Safer Healthcare Now!; KT Pharmacist, ON • Glenn Whiteway, BScPharm, PharmD, Pharmacy Clinical Manager; Adjunct Professor, Dalhousie University, NB • Mary Pederson, BScPharm, Clinical Practise Leader, AB • Patrick Robertson, BSP, PharmD, Manager Pharmacy Services, SK • William Semchuk, MSc, PharmD, FCSHP, Manager Pharmacy Services, SK • Ritesh Mistry, MD, CCFP, Hospitalist; Clinical Assistant Professor, McMaster University, ON Developed by Canadian experts
- 26. • Sylvie Desmarais, MD, FRCPC, CSPQ, Internal and Vascular Medicine Internist, QC • James Douketis, MD, FRCPC, FACP, FCCP, Professor, McMaster University, ON • Jeannine Kassis, MD, FRCPC, Hematologist; Professor of Medicine, Université de Montréal, QC • Robin McLeod, MD, FRCSC, FACP, Professor of Surgery and Health Policy, University of Toronto, ON • Otto Moodley, MD, FRCPC, Clinical Hematologist, SK Reviewed by Canadian experts
- 27. Prevention of VTE in Hospitalized Patients: Summary of Good Practice
- 28. Weight Based vs. Fixed Dosing • fixed doses of LMWH in a prefilled syringe (i.e. tinzaparin 4 500 U subcutaneously once daily) is the simplest regimen for most patients. • obese patients (>100 kg, BMI>35 kg/m2 ) require higher doses of LMWH than the non-obese • use fixed dosing for patients between 50-100 kg and adjust dosing for others Prevention of VTE in Hospitalized Patients: Summary of Good Practice
- 29. Weight Dalteparin Dose Enoxaparin Dose Tinzaparin Dose <40 kg 2 500 U SC once daily 30 mg SC once daily 3 500 U SC once daily 40-100 kg 5 000 U SC once daily 40 mg SC once daily 4 500 U SC once daily 101-150 kg 5 000 U SC BID 40 mg SC BID 10 000 U SC once daily 151-200 kg 40 U/kg SC BID 0.4 mg/kg SC BID 14 000 U SC once daily Prevention of VTE in Hospitalized Patients: Summary of Good Practice eGFR >30 mL/min In patients with impaired renal function (<30 mL/min): Dalteparin: no dose adjustment is required. Enoxaparin: a dosage adjustment is recommended since enoxaparin appears to accumulate in this patient group and may increase risk of bleeding. Tinzaparin: no dose adjustment of tinzaparin at prophylaxis doses is needed in patients with impaired renal function1 , renal failure2,3 , or on hemodialysis2,3 .
- 31. Guidelines for Prevention of VTE *Use clinical judgment to weigh the risk of venous thromboembolism versus the risk of bleeding.
- 33. Awareness
Notes de l'éditeur
- Speaker Notes: Venous Thromboembolism is the collective term for deep vein thrombosis and pulmonary embolism. It may help to refer to DVTs as vein blood clots to patients to help them differentiate between blood clots in the legs and blood clots in the brain (stroke). 50% of DVTs produce no symptoms or signs, with the first awareness of a DVT being a pulmonary embolism (PE).
- Speaker Notes: One serious risk of venous thrombosis is part of the clot breaking away and being carried by the blood to the lungs. This is known as a pulmonary embolism (PE). The clot interferes with oxygenation of blood in the lungs and can therefore be fatal.
- Speaker Notes: Approximately 50% of patients have some of the expected symptoms and signs of DVT. However, most hospitalized patients, will have no symptoms or signs. Clinical diagnosis is unreliable, thus definitive diagnosis requires a Doppler ultrasound.
- Speaker Notes: This table from the ACCP Consensus Guidelines highlights the risk for venous thromboembolic disease in patients that have not been prophylaxed. Medical patients have a prevalence of DVT in the absence of prophylaxis, of up 10% to 20%, while critical care patients have a 10% to 80% risk. It is important to note that these percentages represent asymptomatic DVTs. Surgery patients have had most of the attention with regard to VTE prophylaxis. Unlike surgery patients, the majority of prophylaxis-eligible medical patients are not receiving any prophylaxis or appropriate prophylaxis. Reference: Geerts WT, et al. Chest. 2008;358:381S-453S.
- Speaker Notes: In the UK, PE following DVT causes between 25,000 and 32,000 deaths each year, this exceeds the combined total deaths from breast cancer, AIDS and traffic accidents. References: UK House of Commons Health Committee. HC 99. Published on 8 March 2005. Cohen AT, et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet. 2008;371:387-394.
- Speaker Notes: The 2009 study examined all patients (n=1 567 patients) with a first-time VTE in Worchester County, Massachusetts from 1999 to 2003. The study also found that: 72% of patients were “community acquired” VTE 20% of all events were unprovoked 30% were thought to be related to malignancy Using an expected rate of 60% - that means that in Ontario the hospital-acquired VTE rate is about 8 000/year. References: Spencer FA, et al. Venous thromboembolism in the outpatient setting. Arch Intern Med. 2007;167:1471-5. Spencer FA, et al. Incidence rates, clinical profile, and outcomes of patients with venous thromboembolism. The Worcester VTE study. J Thromb Thrombolysis. 2009;28:401-409. Heit J, et al. Relative impact of risk factors for deep vein thrombosis and pulmonary embolism: a population-based study. Arch Intern Med. 2002;162:1245–1248. Heit J. The Epidemiology of Venous Thromboembolism in the Community. Arterioscler Thromb Vasc Biol. 2008;28: 370–372.
- Speaker Notes: “Patients without risk factors for VTE are called outpatients.” G. Maynard (2010) Epidemiological data suggest an incidence in the general population of:1 160 per 100,000 for DVT 120 per 100,000 for PE In those over age 65 this increases to:2 655 per 100,000 for DVT (4-fold increase) 255 per 100,000 for PE References: O’Shaughnessy D.F. Haemostasis and Thrombosis: Current Clinical Practice: Low-Molecular-Weight Heparins in The Prophylaxis and Treatment of Thrombo-Embolic Disease. Hematol. 2000;4:373-380. Stein PD, et al. Venous thromboembolism according to age: the impact of an aging population. Arch Intern Med. 2004;164:2260-2265.
- Speaker Notes: 60-70% of all VTE is hospital-acquired (i.e. this is a public health issue). Pulmonary embolism is the commonest preventable cause of hospital death.
- Speaker Notes: Required Organizational Practice (ROP) for VTE.
- Speaker Notes: The ROP provides key compliance tests, and more importantly key steps to ensure hospital-wide compliance.
- Speaker Notes: Remind the groups that patients at risk of VTE can look quite different.
- Speaker Notes: This is a real story. Here is more of it: I was in a hospital bed attached to an IV pole for one week waiting for my surgery. My surgery was successful, although the anesthesia left me feeling unwell. I went home to recuperate but continued to feel unwell, and had limited mobility due to an ongoing problem with my leg. Five days after I was released from hospital I could not stop coughing and I felt quite faint. Upon return to the ER it was discovered I had an enormous blood clot in my lungs- both of them. I ended up in the ICU on an anticoagulant and had to have special medication to dissolve the clot because it was so big and threatened my life. This experience with the blood clot has impacted my life. It was the scariest and worst experience I have ever had and it has left me fearful and anxious. It was a horrifying experience and one I never want to go through again, and I hope no one else has to go through either.
- Speaker Notes: Because of differences in the molecules, long chained/charged innohep and UFH can better bind to endothelial cells, be cleared by the reticulo-endothelial pathway, and are less affected/do not appear to accumulate in patients with renal impairment Tinzaparin can be safely used in patients with CrCl below 30 mL/min. References: Mahé O, et al. Tinzaparin and enoxaparin given at prophylactic dose for eight days in medical elderly patients with impaired renal function: a comparative pharmacokinetic study. Thromb Haemost. 2007;97:581-6. PROTECT Investigators. Dalteparin versus unfractionated heparin in critically ill patients. N Engl J Med. 2011;364:1305-14. Nutescu EA, et al. Low-molecular-weight heparins in renal impairment and obesity: available evidence and clinical practice recommendations across medical and surgical settings. Ann Pharmacother. 2009;43:1064-83.
- Speaker Notes: This data shows the VTE prophylaxis audit outcomes for one hospital between 2003 and 2009. It clearly demonstrates the success and improvement in VTE prophylaxis when a hospital has VTE protocols, embedded order sets, simple LMWH dosing, regular audits and staff awareness.
- Speaker Notes: This data is from the same hospital, with the addition of the audit data from 2010. It shows that despite well developed policies and systems, vigilance and continued staff awareness is key to continued success.
- Speaker Notes: The VTE Prevention Simplified Kit was developed by a group of Canadian experts to address a need in hospitals setting up protocols to meet the Accreditation Canada ROP. These experts developed tools, rather than policies or guidelines, to assist hospitals with the implementation of the VTE prophylaxis ROP. All of the material has been provided as electronic templates in order that hospitals may adapt the material to meet their own policies and procedures. The focus of this kit is on best practices in the use of tinzaparin or innohep®.
- Speaker Notes: The kit has 4 main sections: Introduction: introduction to kit and Best practices in VTE prophylaxis Tools: Clinical order set, audit material Education: healthcare professional and patient education material Other: room to add additional Clinical order sets and information in the future
- Speaker Notes: These Canadian experts developed and approved all of the material.
- Speaker Notes: These Canadian specialists reviewed and approved all of the material.
- Speaker Notes: Prophylaxis of VTE works best when there is a system-wide approach within a hospital. The best way to accomplish this is to embed orders for prophylaxis in clinical order sets, such that prophylaxis is routine and inclusive. Limiting choices for VTE prophylaxis to keep it simple. Only one or two choices are sufficient in most situations. The summary of good practice reviews all of the above and provides expert opinion. UFH:low dose unfractionated heparin LMWH: low molecular weight heparin
- Speaker Notes: There is evidence that obese patients (&gt;100 kg, BMI&gt;35 kg/ m 2 ) require higher doses of LMWH than non-obese patients. However, fixed doses of LMWH in a prefilled syringe (i.e. tinzaparin 4 500 U subcutaneously once daily) is the simplest regimen for most patients. One way to solve this issue on the clinical order set is to have a fixed dose for the most common weight ranges, with adjusted dosing for those at the weight extremes (&lt;50 or &gt;100 kg). Another consideration is that fixed dose syringes reduce costs with less wastage. They also reduce errors as patient weights and dosing do not need to be determined.
- Speaker Notes: The above dosing recommendations are those of the VTE Prevention Simplified experts. Different policies/dosing for weight categories exist in hospitals across Canada. Again, the templates supplied can be modified/ adjusted to conform with hospital policy. sc: subcutaneously 1. Mahé O, et al. Thromb Haemost. 2007;97:581-6; 2. PROTECT Investigators. N Engl J Med. 2011;364:1305-14; 3. Nutescu EA, et al. Ann Pharmacother. 2009;43:1064-83. FRAGMIN Product Monograph. Pfizer Canada Inc. January 6, 2014; LOVENOX Product Monograph. sanofi-aventis Canada Inc. December 20, 2013; INNOHEP Product Monograph. LEO Pharma Inc. February 3, 2011.
- Speakers Notes: Example of an opt-out clinical order set with prophylaxis embedded. This “box” is supplied electronically and can be embedded into any hospital order set.
- Speakers Notes: Importantly, the expert committee believes that all medical and surgical patients should receive thromboprophylaxis as they are all at risk. However, there are precautions and contraindications that may alter time of dosing or type of thromboprophylaxis.
- Speakers Notes: These contraindications are specific to innohep®. This is not a complete list. Reference: innohep® Product Monograph. Leo Pharma Inc, February 2011.
- Speaker Notes: Implementation of a VTE prophylaxis policy includes raising awareness of VTE risks amongst healthcare workers and patients. It is important that dissemination of the information be done by multiple methods to reach the greatest number of healthcare professionals. To assist with implementation this slide deck as well as a shorter version have been developed to increase staff awareness. Posters for healthcare professionals and patients have also been developed to raise awareness and keep VTE prophylaxis top of mind. Examples of how to spread the word: Grand Rounds In-service sessions Posters for medical staff rooms Patient awareness and education Please note that the audit material is reviewed in a separate slide deck.