Evaluation of a nurse-led intervention to improve adherence to recommended guidelines for prevention of venous thromboembolism for hip and knee arthroplasty patients: A quasi-experimental study.

AIMS AND OBJECTIVES: To measure adherence to a nurse-led evidence-based venous thromboembolism prevention programme (intervention) compared to usual care in hip and knee arthroplasty patients and associated clinical outcomes. BACKGROUND: Venous thromboembolism morbidity and mortality of hospitalised patients is a major concern for health professionals. Venous thromboembolism prevention guidelines have been developed; however, adherence to guidelines is variable. PARTICIPANTS: There were 410 potential participants who were adult patients that were booked for elective hip or knee arthroplasty at the two study sites during a 2-year period (2011-2013). Of these, 27 did not meet the inclusion criteria, and the remainder were eligible for inclusion in the study (intervention site n = 196 and control site n = 187, total population n = 383). METHODS: This study adopted a quasi-experimental design, using an intervention and control study site, conducted in two private hospitals in a regional area in Australia. RESULTS: The intervention group had a mean compliance score of 11.09, higher than the control group score of 7.19. This is equivalent to a compliance rate of 85% and 55%, respectively, and indicates that adherence at the study site was significantly higher. Patient adherence and outcomes in the postdischarge period were not significantly different between the study sites. CONCLUSION: This study demonstrated a nurse-led intervention achieved high adherence with translating evidence-based guidelines into routine patient care for hip and knee arthroplasty patients. Nurses can be critical to implementing clinical practice guidelines and adopting preventive programmes in acute care to improve patient outcomes and reduce postoperative venous thromboembolism in arthroplasty patients. RELEVANCE TO CLINICAL PRACTICE: This research demonstrates the capacity of nurses to lead the translation of evidence-based practice guidelines for prevention of venous thromboembolism into routine patient care.

Clinical nurses' knowledge and practice of venous thromboembolism risk assessment and prevention in South Korea: a cross-sectional survey.

AIMS AND OBJECTIVES: To examine Korean registered nurses' level of perceived knowledge and practice of venous thromboembolism risk assessment as well as prevention, self-efficacy in venous thromboembolism care and actual knowledge of venous thromboembolism. BACKGROUND: For hospitalised patients, venous thromboembolism is a preventable clinical disorder. Caring for venous thromboembolism patients requires coordination across multiple providers and settings. Clinical nurses can play a major role in improving venous thromboembolism prevention care, assessing venous thromboembolism risks and providing appropriate prophylactic measures to those who are at risk for venous thromboembolism. DESIGN: A cross-sectional descriptive study. METHODS: Anonymous paper-based surveys were conducted for a convenience sample of registered nurses' (n = 452) from two university-affiliated hospitals in South Korea. RESULTS: The majority of participants indicated that their overall self-rated venous thromboembolism knowledge was 'fair', while only 2·4% rated it as 'very good' or 'excellent'. The overall mean score of the venous thromboembolism knowledge questions was 50·9 (±13·0) of a possible score of 100. The mean score of self-efficacy in practising venous thromboembolism prevention/prophylaxis was 3·0 (based on a one to five Likert scale). The self-reported venous thromboembolism assessment performance on patients varied among clinical units. Only 9·3% of participants reported having received in-service venous thromboembolism education from their hospital. CONCLUSIONS: The findings showed that overall venous thromboembolism knowledge and self-efficacy in venous thromboembolism prevention practices of Korean registered nurses' were not highly rated. Korean nurses demonstrated a lack of knowledge about venous thromboembolism, particularly in the areas of venous thromboembolism prophylaxis measures and venous thromboembolism diagnosis methods. RELEVANCE TO CLINICAL PRACTICE: Focused education on venous thromboembolism prevention and risk assessment should be considered a component of continuing education for Korean nurses.

Prevention, diagnosis and treatment of venous thromboembolism.

Venous thromboembolism (VTE) occurs more frequently in older people. For those nursing older people in a variety of settings, knowledge of VTE prevention, diagnosis and treatment is essential. This article discusses simple, practical measures that can be used to reduce the risk of VTE, including good hydration and promotion of mobilisation. It also discusses how a VTE forms, the signs and symptoms, and the methods used to diagnose and treat VTE. In recent years new drugs have been licensed to treat patients with VTE called direct oral anticoagulants. This article explores recent evidence and important considerations for their use in treatment of VTE.

Venous Thromboembolism Prophylaxis in Plastic Surgery: A Literature Review.

Venous thromboembolism (VTE) is a major health concern because it increases morbidity and mortality after a surgical procedure. A number of well-defined, evidence-based guidelines are available delineating suitable use of prophylaxis to prevent deep vein thrombosis and pulmonary embolism. Despite the available literature, there are clear gaps between recommendations and clinical practice, affecting the incidence of VTE. Plastic surgeons underuse the substantiated literature and risk stratification tools that are available to decrease the incidence of VTE in the office-based surgical setting because of fear of bleeding or hematoma complications postoperatively. Venous thromboembolism creates an economic burden on both the patient and the healthcare system. The intent of this literature review is to determine existing VTE risk using assessment models available to aid in the implementation of protocols for VTE prevention, specifically for high-risk cosmetic surgical patients in office-based settings.

Venous Thromboembolism: New Concepts in Perioperative Management.

Venous thromboembolism (VTE) is a serious pathophysiologic condition that is a major cause of morbidity and mortality, especially during the perioperative period. A collective term, VTE is used to describe a blood clot that develops inside the vasculature and results in a deep vein thrombosis (DVT) and/or a pulmonary embolism (PE). Deep vein thrombosis and PE are the third leading cause of cardiovascular mortality, superseded only by myocardial infarction and stroke. Patients who receive treatment for acute PE are 4 times more likely to die of a recurrent VTE within the next year. In hospitalized patients who have had surgery, the incidence of VTE and PE is estimated to be 100 times more prevalent than in the general population. The Joint Commission has established Surgical Care Improvement Project measures to address prophylactic interventions to minimize the incidence of VTE. This journal course will review the current approaches to pharmacologic and nonpharmacologic prevention and management of VTE during the perioperative period. Identification and treatment of deep vein thrombosis and acute PE are also described.

Proactivity in VTE prevention: a concept analysis.

Venous thromboembolism (VTE) prevention is an international patient safety issue. The author has observed gaps in prescription and provision of VTE prophylaxis, and that the attitude to VTE is often reactive rather than proactive. This concept analysis aims to explore proactivity and apply it to VTE prevention to address this. Ten databases were searched (1992-2012) using the keywords proactive, proactivity, nurse, nursing, VTE/venous thromboembolism, prevent/prevention/preventing, behaviour, DVT/PE (deep vein thrombosis, pulmonary embolism). The Walker and Avant (2010) method of concept analysis identified the defining attributes as personal initiative, taking charge and feedback-seeking behaviour. Antecedents and consequences have been identified, and empirical referents are demonstrated. Defining proactivity in VTE prevention has the potential to increase prescription and, crucially, provision of prophylaxis, thereby improving patient care, reducing avoidable harm and improving the patient experience.

Point-of-care D-dimer testing in emergency departments.

Overcrowding and prolonged patient stays in emergency departments (EDs) affect patients' experiences and outcomes, and increase healthcare costs. One way of addressing these problems is through using point-of-care blood tests, laboratory testing undertaken near patient locations with rapidly available results. D-dimer tests are used to exclude venous thromboembolism (VTE), a common presentation in EDs, in low-risk patients. However, data on the effects of point-of-care D-dimer testing in EDs and other urgent care settings are scarce. This article reports the results of a literature review that examined the benefits to patients of point-of-care D-dimer testing in terms of reduced turnaround times (time to results), and time to diagnosis, discharge or referral. It also considers the benefits to organisations in relation to reduced ED crowding and increased cost effectiveness. The review concludes that undertaking point-of-care D-dimer tests, combined with pre-test probability scores, can be a quick and safe way of ruling out VTE and improving patients' experience.

VTE Prevention: Development of an Institutional Protocol and the Nurse's Role.

Venous thromboembolism (VTE), including the combined diseases of deep vein thrombosis and pulmonary embolism, is a significant health problem that affects mortality, morbidity, and resource expenditure. Multiple guidelines have been formulated to address this condition, but broad implementation in health care is lacking. Nurses have a pivotal role in VTE prevention through increased knowledge, patient advocacy, and implementation/development of institutional VTE protocols.

Improving Compliance with a Nurse-Driven Protocol for Unfractionated Heparin Infusions in Patients with Venous Thromboembolism.

BACKGROUND: Unfractionated heparin (UFH) is a high-risk medication that can cause bleeding and/or thrombotic complications if not managed appropriately. Between January and July 2019, our institution experienced a high number of patient safety events related to UFH infusion for the treatment of venous thromboembolism (VTE). PURPOSE: The aim of this quality improvement (QI) initiative was to prevent these safety events by improving compliance with our institution's nurse-driven VTE UFH infusion protocol. METHODS: Baseline data for patients on the VTE UFH protocol were collected to identify improvement opportunities. Compliance with eight standards of care related to the VTE UFH infusion protocol was measured. Time to first therapeutic activated partial thromboplastin time (aPTT) was recorded to assess the benefit of improved compliance. INTERVENTIONS: Institutional policy updates were made to clarify the management of UFH infusions and documentation in the electronic health record. A multidisciplinary workgroup implemented order set changes, nursing communication orders, UFH infusion reports, and a nursing education module to promote compliance with the protocol. RESULTS: The overall rate of compliance with the VTE UFH infusion protocol increased from 79.4% at baseline to 85.2% following implementation of the QI initiative, and the median time to first therapeutic aPTT decreased from 831.5 minutes to 808 minutes over the same period. CONCLUSIONS: A multidisciplinary initiative to address improvement opportunities in a nurse-driven UFH protocol for VTE treatment increased compliance with the protocol and decreased the time to first therapeutic aPTT.

Venous thromboembolism (VTE) risk assessment: rural nurses' knowledge and use in a rural acute care hospital.

It is estimated that about 2000 people die as a result of venous thromboembolism (VTE) each year, with a further 30,000 being hospitalized. Prophylaxis significantly reduces VTE morbidity and mortality, and thus represents a real long-term health-care benefit. The aim of this study was twofold: (i) to assess the current level of compliance to VTE risk assessment and prophylaxis best practice guidelines within an Australian rural hospital; and (ii) to determine the effectiveness of nurse education on that compliance. VTE compliance information was obtained from auditing patient notes for a 3-month period prior to nurse education and was repeated after the education. Nurse knowledge of VTE risk assessment and prophylaxis use was also measured. Both compliance with and knowledge of best practice VTE risk assessment and prophylaxis increased following nurse education. Although the sample size was relatively small, this study has shown nurse education to be effective at increasing VTE compliance and awareness within an Australian rural hospital. This relatively inexpensive and simple intervention bears consideration and could lead to reductions in the morbidity and mortality associated with VTE, as well as reduction in associated health-care costs.

We've got it covered! Graduated compression stockings.

Hypercoagulability is a well documented feature of pregnancy and contributes to the increased incidences of venous thromboembolism (VTE) in pregnancy. Thromboembolism remains a leading cause of maternal death in the UK, though it's predicted that up to two thirds of these deaths could be prevented if appropriate thrombophylaxsis is adopted. This article aims to further midwives' knowledge in relation to thromboprophylaxsis, focusing in particular on graduated compression stockings (GCS). It aims to assist midwives in identifying those women at high risk of developing a VTE, explain the way in which compressio stockings can reduce thromboembolism and provide advice on their application and the clinical observations required.

[From bedside to evidence - and back to bedside. 5 years evidence-based guidelines in South Tyrol: methods and experiences]. / Vom Bett zur Evidenz - und wieder zurück. 5 Jahre evidenzbasierte Leitlinien in Südtirol: Vorgehen und Erfahrungen.

In South Tyrol we developed guidelines with two different methodological approaches: one relates to the autonomous development of a nursing guideline for oral care using GRADE, and the other relates to the adaptation process of the NICE guideline on the prevention of venous thromboembolism. Both methods do have advantages and disadvantages: by autonomously developing guidelines the guideline panel identifies more with the product but time and effort is much higher than adapting and amending existing (high quality) guidelines. On the other hand there are only few high quality nursing guidelines. Additionally, the experiences in South Tyrol show that nursing guidelines seem to be not really suitable for a 1:1 application into practice because nearly half of the nurses have not changed their practice - although they knew the content of the guideline. Therefore, in order to promote the implementation process multimodal strategies on different organisational levels were adopted. Amongst these was the involvement of management through the negotiations of objectives, training and active participation of staff in the development of user-friendly application tools.

Safety Express: a strategic health authority's approach.

The Safety Express programme is a national workstream within the Quality, Innovation, Productivity and Prevention (QIPP) programme that is designed to improve health outcomes and quality care, as well as reduce costs associated with the following four patient harms: pressure ulcers, falls, urinary tract infections in patients with catheters and venous thromboembolism (VTE). NHS London developed a pilot project to implement Safety Express across London. This paper presents case studies of the outcomes of the Safety Express pilot in three locations in London. Findings from the pilot showed that the proportion of patients who were harm-free from pressure ulcers, falls, urinary infections (in patients with a catheter) and new VTE compares favourably with the national average, with an overall decrease in all four.

Translating venous thromboembolism (VTE) prevention evidence into practice: a multidisciplinary evidence implementation project.

BACKGROUND: Venous thromboembolism (VTE) is an important patient safety issue resulting in significant mortality, morbidity, and health care resource expenditure. Despite the widespread availability of best practice guidelines on VTE prevention, we found that only 49% of our patients were receiving appropriate prophylaxis. AIM: To improve health care professionals' compliance with evidence-based guidelines for VTE prevention in hospitalised patients. DESIGN: A practice improvement methodology was employed to identify, diagnosis, and overcome practice problems. Pre- and post-intervention audits were used to evaluate performance measures. SETTING: The study was conducted from September 2008 until August 2009 and took place in a 250-bed acute-care private hospital in metropolitan Sydney, Australia. INTERVENTION: A change plan was developed that attempted to match organisational barriers to VTE guideline uptake with evidence-based implementation strategies. The strategies used included audit and feedback, documentation aids, staff education initiatives, collaboratively developed hospital VTE prevention policy, alert stickers, and other reminders. RESULTS: The proportion of patients receiving appropriate VTE prophylaxis increased by 19% from 49% to 68% (p= 0.02). Surgical patient prophylaxis increased by 21% from 61% to 82% (p = 0.02) while medical patient prophylaxis increased by 26% from 19% to 45% (p= 0.05). The proportion of patients with a documented VTE risk assessment increased from 0% to 35% (p < 0.001). CONCLUSIONS: The intervention resulted in a 19% overall improvement in prophylaxis rates, which is a significant achievement for any behavioural change intervention. There is, however, still a significant discrepancy between surgical and medical patient prophylaxis rates, which clearly warrants further attention.

Preventing venous thromboembolism.

Venous thromboembolism (VTE) is a significant cause of long-term disability, chronic ill health and mortality, causing about 25,000 deaths a year in hospitals in England. It is recognised as a clinical priority for the NHS by the National Quality Board, which established a VTE board to mainstream and embed VTE prevention in NHS activity by 2012 (Keogh 2011) through the national VTE programme. This article describes NHS East of England's approach to implementing the programme.

Reducing patients risk of venous thromboembolism.

As the largest professional group involved in direct clinical care, nurses have a vital role to play in venous thromboembolism prevention. This article describes the condition and its implications for patients. It discusses how nurses can reduce the risk of harm to patients through risk assessment and thromboprophylaxis, and by educating patients.

Venous thromboembolism: a chronic illness.

Deep vein thrombosis (DVT) is a common disorder frequently seen in both the inpatient and outpatient settings. DVT increases the risk of pulmonary embolism, a potentially fatal complication. These 2 conditions--DVT and pulmonary embolism--comprise venous thromboembolism (VTE), which is a major and often unrecognized cause of morbidity and mortality in hospitalized and ambulatory patients. Acquired risk factors include smoking, obesity, stasis (such as long-term travel), hypercoagulability, recent surgery, trauma, or hospitalizations. In addition, inherited or innate disorders that pose risk include increasing age and personal or family history of VTE.After a first episode of VTE, the risk for recurrent episodes of a DVT is elevated: 21.5% after a first event and 27.9% after a second. And, the risk of recurrence varies with time, with highest risk occurring during the first 6 to 12 months after the event. Death occurs in 6% of DVT cases within 1 month of diagnosis. Once a DVT occurs, the risk recurrence never resolves to zero; therefore, VTE should be considered a chronic illness rather than a short-term condition. As a key member of the healthcare team, the role a nurse practitioner is to identify patients at risk for VTE and institute appropriate preventative/treatment measures. By doing so, morbidity and mortality from this common disorder can be minimized.

Perioperative Management of the Direct-Acting Oral Anticoagulants.

Since the 1950s, warfarin has been the most commonly prescribed anticoagulant in the prevention of stroke-related thromboembolism. Beginning in 2008, direct-acting oral anticoagulants (DOACs) began to replace warfarin. Although the DOACs had a greater safety profile, approved reversal agentsfor use in emergent/excessive hemorrhage did not exist. This course reviews the perioperative management of the DOACs.