UAB Synopsis, Vol. 25, No. 8, April 10, 2006
“Seventy-five to 80% of hospitalized patients are appropriate candidates for DVT prophylaxis,” says James Lyman, MD.
“Deep vein thrombosis (DVT) is the fourth leading cause of stroke in the United States. and a critically important issue in University Hospital’s highly subspecialized and academic environment,” says Dr. Lyman, medical director of UAB’s Hospitalist Service and DVT project director. “Clinically silent and hard to diagnose, DVT occurs in 1 in 100 hospitalized patients, and is the leading cause of preventable hospital deaths.”
Based on evidence that prophylaxis significantly reduces adverse patient outcomes and overall costs, the American College of Chest Physicians recommends formal hospital strategies to address
prevention of thromboembolic complications.
Project Design
Nationwide, hospitals without a DVT prophylaxis protocol successfully prophylax only 30% of their patients. In December 2004, Dr. Lyman designed and presented the DVT Prophylaxis Project to the hospital’s Performance Improvement Core Advisory Team (PICAT), which provides clinical oversight by prioritizing and directing quality improvement (QI) initiatives.
PICAT-sponsored projects must have high clinical risk, high or increasing variable costs, high volume, high or increasing length of stay, low patient satisfaction, an impact on a strategic imperative, and a physician champion. “The DVT project certainly fits PICAT criteria,” hospital QI Coordinator Debbie Soniat, RN, explains. “The incidence of DVT drives up cost, increases length of hospital stay, and has a negative impact on patient outcomes.”
Incidence
The actual incidence of DVT and pulmonary embolism (PE) is difficult to accurately pin down.
“Much of the literature focuses on the incidence of confirmed DVT where patients have been diagnosed through imaging studies or autopsy,” Dr. Lyman says. “We need more studies on the incidence of DVT and PE and more awareness of the need for prophylactic measures.”
According to the American Heart Association, some 2 million people in the United States annually are affected by DVT. At the same time, 74% of Americans have little or no awareness of the condition, according to the American Public Health Association. DVT-associated hospital costs nationwide are estimated at $340 million annually.
Practice Guidelines
Clinical risk factors are increased age, previous episodes of DVT/PE, obesity, cardiac dysfunction, and estrogen use. “Inherited conditions also can make blood more likely to clot,” Dr. Lyman says. Other risk factors include:
• Prolonged bed rest (immobility)
• Comorbidities
• Major injuries or paralysis
• Surgery, especially lasting more than 30 minutes or involving the leg joints or pelvis
• Rheumatologic disease
• Trauma and burns
• Cancer and chemotherapy
• Nephrotic syndrome
• Pregnancy and childbirth; hormonal changes increase coagulability and the fetus exerts pressure on pelvic veins. Pregnancy- related DVT is highest just after childbirth
• Hypercoagulable states; resistance to activated protein C (factor V Leiden),
antithrombin III deficiency, protein C and protein S deficiencies, and
antiphospholipid syndrome.
Hospital Joins National Campaign
UAB is a leader in the nationwide effort to treat DVT. “It is imperative that UAB staff remain alert to the possibility of DVT,” Soniat explains.
The hospital now routinely conducts preoperative DVT risk assessments, which take into account patients’ personal risk factors and the type of surgery involved. “Two or more risk factors qualify patients for immediate DVT prophylaxis,” Dr. Lyman continues. “We also have enhanced the education of physicians and nurses and implemented a nurse-screening system with subsequent physician communication via verbal exchanges or chart notes. Also, our computerized order entry system has been adapted to track outcomes.”
Prophylactic measures include anticoagulant medicines, compression stockings, and an intermittent compression pump —a mechanical device that automatically squeezes the feet and lower legs, promoting the circulation of blood in the first few days after surgery.
Dr. Lyman concludes “We must also educate our patients about DVT and PE so they are aware of their risk factors and can recognize symptoms. University Hospital’s new processes, strategic use of data, and educational opportunities are delivering a breakthrough in patient safety.”
For more information, visit www.dvt.net or www.preventdvt.org.