Preventing deep venous thromboses (DVTs) and pulmonary emboli (PEs) is one of the constant challenges facing nurses specializing in critical care.
Lisa M. Soltis, MSN, APRN, CCRN-CSC, CCNS, cardiovascular/critical care clinical nurse specialist at Wake Med Health and Hospitals, Raleigh, NC, described the two-pronged approach her organization has taken to prevent DVTs and PEs over the past year.
"One group was evaluating some adverse drug events and non-therapeutic results with patients on anticoagulation therapy, so we decided to look at our medication regimens for DVT prevention," she said. "The second work group developed a prophylaxis advisor with risk stratification of patient circumstances."
The Wake Med risk stratification incorporated factors such as the reason for admission to the hospital, age, obesity, immobility, central lines, and a history of stroke, PE or DVT. "We also created a list of absolute contraindications to prophylaxis, such as severe hemorrhage or trauma with spinal cord injury," Soltis added. "We have a protocol for our med/surg patients with these factors built in."
Soltis worked with pharmacists and colleagues from other disciplines to identify knowledge and skill deficits that put patients at risk for clots.
"[We found] we were missing some of the circumstances that led to PEs," she noted. "We learned that we had great anticoagulation resources for patients, but not so much for our nurses."
Nurse educators delivered targeted education for bedside staff and provided teaching tools around dosing for prevention versus treatment of PE.
"We had grand rounds sessions that provided information about prophylaxis and some misconceptions about prophylaxis," said Soltis. "We conducted audits that showed our physicians were writing good orders for prophylaxis, but there were some issues with compliance and timeliness."
The interdisciplinary collaboration paid off.
"I've enjoyed the partnership with pharmacy over the past 12 months of the project," said Soltis. "We're seeing very positive outcomes, with a decreased incidence of both DVTs and PEs, as well as much more therapeutic dosing ranges."
Regina Cannon-Drake, MA, RN, a patient educator at Hospital for Special Surgery (HSS) in Manhattan, NY, described the proactive regimen used for patients scheduled for elective total hip or knee replacement.
"As part of our preop education program, we discuss complications like DVTs and PEs, and describe what we expect them to do postoperatively to lower their risk for those problems," she said. "We explain that the patients need to perform lower leg exercises and we'll be getting them up and moving around very soon after surgery to promote good circulation. We also review the use of mechanical compression devices (foot or calf pumps), and discuss anticoagulants that they'll be taking."
At Kaiser Permanente San Francisco, staff is well aware of the value of basic nursing interventions centered on early and continuing mobility.
"We educate patients prior to surgery how important activity is not only in the immediate postop phase, but also at home," said Katy Kennedy, MSN, RN, director of nursing education. "Physical therapy works with patients beginning the day of surgery. We also focus on getting those patients who are not surgical but are bedbound moving as much as possible to maintain their level of functionality and prevent complications."
Kaiser's electronic medical record provides plenty of support for bedside nurses.
"We have a section not only for the plan of care, but for patient education as well," said clinical adult services director Bridget Williams, MSN, RN. "All postop orders are individualized in terms of mechanical and/or pharmacological interventions. Sequential compression devices are pre-checked in the order sets. Documentation occurs on both the MAR and the nursing flow sheet. Discharge orders and information from physicians, nurses and pharmacists are incorporated in the printed discharge planning document that's given to patients."