Guidelines Aim to Reduce Post-op Venous Thromboembolism

New Orleans—Venous thromboembolism is by no means a new condition, with modern study beginning in the middle of the 19th century by doctors such as Rudolf Virchow; nor is it an uncommon one, with hundreds of thousands of Americans affected annually. But even with the medical advancements of the 21st century, mortality statistics are startling high, especially for in-hospital VTE, where patients are afflicted while under the watchful eye of a medical team.

Even though most risks and preventive treatments are already known—like using blood-thinning medications to reduce the risk for clotting in high-risk patients—medical professionals and organizations are being spurred to action, investigating new standards of care and protocols for treatment to reduce the alarming statistics. Just last year, the Association of periOperative Registered Nurses (AORN) conducted a reassessment of VTE standards of care, which is done every five years. When the expert panel began to review the literature, experts like Amber Wood, MSN, RN, a senior perioperative practice specialist at AORN and lead author of the guidelines, were unsettled.

“It really struck me, the severity,” Ms. Wood said. “It’s something our patients are dying from. There’s a huge gap and a huge opportunity for us to improve quality and patient care.”

Most recent estimates from the CDC show that 60,000 to 100,000 people die from VTE every year, with sudden death being the first symptom in one-fourth of all annual cases. Of all the causes of VTE, one-third of cases develop after a patient has had surgery. Within hospital-associated VTE, the Agency for Healthcare Research and Quality estimates that 70% could be prevented, and less than half of patients received standard of care treatment to prevent VTE.

For AORN, a team of 15 experts from a variety of backgrounds, from surgeons to a quality system improvement specialist, and of course, perioperative nurses, spent months combing through more than 300 articles on VTE, rating them based on evidence provided. After they were evaluated by two separate reviewers and fashioned into the expanded guidelines, the report was open for a month-long public comment period, leading to another review by the researchers. The guidelines were released early this year.

Early Prevention Is Key

In the first half, the guidelines recommend the use of a “clinical decision support system,” which can alert within an electronic health record when the patient is at risk for VTE or has not received prophylaxis, Ms. Wood said. Studies have shown those reminders can lead to “improved compliance” with standards of care, as well as “reduction in VTE in surgical patients,” she said.

Within the mechanical prophylaxis, the guidelines now recommend using intermittent pneumatic compression or stockings, which are used to various extents throughout American hospitals. But, more than just saying “do this,” the guidelines suggest how nurses should go about doing so. “People had long been asking us when do we put it on the patient. It’s been prescribed, but when do you start?” Ms. Wood recounted. The AORN guidelines now say to start before anesthesia, along with making other research-based recommendations (Table). The guidelines also note contraindications to watch for during mechanical prophylaxis and when implementing any pharmaceutical prophylaxis prescribed by a doctor.

Table. New VTE Prophylaxis Guidelines From AORN
Prophylaxis	New Guidelines
Mechanical	Apply prior to anesthesia for greatest benefit
Pneumatic compression	Use sterile sleeves Alternate use between legs during bilateral surgeries Use MRI-safe machines during imaging Use portable machine options to increase patient compliance and track wear time to know patient compliance
Stockings	Use thigh-length stockings generally (shown to be more beneficial in stroke patients) Use knee length if the risk for skin injury is high, or the patient might roll down the stocking Measure each leg separately, as using too large a size can reduce benefits, or too small, can cause negative effects in itself Avoid using elastic bandages as an alternative if no size options are available. They do not have the graduated pressure designed in the stockings and can cause blood pooling
Pharmaceutical	Follow prescribing guidelines, but be aware of contraindications for medications

Hospital-Specific Procedures

When Jacobi Medical Center, in New York City, decided to implement a new trial protocol to reduce its observed-to-expected ratio of VTE, the medical staff found this bleed-to-clot continuum was not only important for patient health, but it caused some staff members to be averse to pharmaceutical prophylaxis in the first place. They were skeptical, the researchers said. “They had a different mindset from years ago,” said Pamela O. Turner, MSN, RN, the network director of nursing in perioperative service and procedural areas at Jacobi.

To assuage concerns, but more importantly to provide the best patient care, Ms. Turner and her colleague Maria Castaldi, MD, an associate professor of surgery at Albert Einstein College of Medicine, in New York City, and director of the Breast Health Center at Jacobi Medical Center, designed a study using a Caprini VTE risk assessment scale to identify only the highest-risk patients for pharmaceuticals, with ample educational materials (in Spanish and English) and follow-up support for all patients, including multiple check-in phone calls. The results were presented as a poster at the 2018 AORN Global Surgical Conference & Expo (poster 100).

The new protocol increased patient and staff satisfaction. “Surgeon satisfaction numbers really went up, to 83%,” Ms. Turner said, and of surveyed patients, “99% said safety was a top priority” for the hospital. Most importantly, within Jacobi’s general surgery department, observed to expected VTEs fell. They “increased [good] outcomes and decreased incidence,” she said.

Whether the patient requires pharmaceutical prophylaxis or one of the various other methods of prevention, new protocols designed to keep the responsibility on the team of medical professionals are working to reduce VTE incidence. An inclusive approach, with different mixes of options, can provide a team with many tools for combating the high incidence of hospital-associated VTE. With increasingly complex surgeries, it takes a village. “Collaborative support certainly makes a big different in a patient’s life,” Ms. Turner said. “Team engagement was critical to our success.”