VTE Prophylaxis in Hospitalized Cancer Patients

VTE Prophylaxis in Hospitalized Cancer Patients A Literature Review Karen Davis, RN, BSN, OCN Loyola University Chicago

VTE Prophylaxis in Hospitalized Cancer Patients

Abstract Venous thromboembolisms are a leading cause of death in the United States, but they are also the most preventable cause of inpatient mortality. Evidence-based practice has proven that mechanical and pharmacological VTE prophylaxis greatly decreases the formation of VTEs in hospitalized patients. Even though the evidence has shown that proper VTE risk-assessment screening tools and prophylaxis significantly decrease the amount of hospitalized acquired VTE, numerous hospitals do not have a risk-assessment tool or VTE prophylaxis protocol. Development of a universal VTE risk-assessment screening tool and prophylaxis protocol will prevent even more hospital acquired VTEs.

Keywords: VTE, prevention, prophylaxis, cancer

VTE Prophylaxis in Hospitalized Cancer Patients

Introduction There is an estimated 300,000 people in the United States who die each year from a venous thromboembolism or VTE (Brown, 2012). Over $15.5 billion is spent diagnosing and treating VTEs in the United States health care system (Schiro, 2011). The risk of a hospitalized patient forming a VTE is 10-20% (Galanter et al, 2010). VTEs are one of the most preventable causes of hospitalized patient mortality, it has been shown that if high-risk patients were to receive proper VTE prophylaxis over 100,000 lives would be saved a year in the United States. Studies have found that only about 60% of high-risk patients actually receive the proper VTE prophylaxis (Brown, 2012). Patients with a malignancy diagnosis are at an even greater risk for developing a VTE than other hospitalized patients. This is due to malignancy being able to affect all three areas of Virchows Triad. Virchows Triad is the fundamental causes of VTE. It consists of circulatory stasis, endothelial injury and hypercoagulable states. Malignancy affects the circulatory stasis by a patient being on excessive bed rest or compression on the vessels from the tumor mass. Endothelial damage is caused be indwelling catheters, administration of chemotherapy and direct tumor invasion. Finally, tumors produce procoagulants and inflammatory cytokines that activate the coagulation cascade and produce a hypercoagulable state (Haines, 2010). VTE prophylaxis is incredibly important to the nursing area of practice. Oncology patients are at a greater risk for developing a VTE and dying from it than

VTE Prophylaxis in Hospitalized Cancer Patients their cancer diagnosis. Studies have found that there is proven mechanical and pharmacological prophylaxis to prevent the development of a VTE, however numerous hospitals are not using a screening tool and/or proper VTE prophylaxis. PICOT Question P: Hospitalized patients with a malignancy diagnosis. I: Implementation of a VTE assessment and protocol. C: The usual care for patients before the implementation of new VTE prophylaxis protocol. O: Decrease in development of VTE and death from VTE. T: Data collection over a twelve month time period.

Synthesized Review and Critique of the Scientific Evidence The Agency for Healthcare Research and Quality (AHRQ) has ranked appropriate VTE prophylaxis as the most important safety practice with the greatest impact on patient care and The Joint Commission has placed VTE as a core performance measure that hospitals are now required to report on. Due to the importance of VTE prevention, Medicare no longer reimburses for VTEs acquired during a hospital stay or within 30 days of hospital stay. Despite VTE being a required reportable performance measure and AHRQ ranking VTE prophylaxis as the most important safety practice with the greatest impact on patient care, many hospitals do not have protocols/guidelines on VTE prophylaxis, or have a screening tool to determine at-risk patients. Studies have shown that only 16-33% of at-risk patients actually receive VTE prophylaxis (Douketis, 2008).

VTE Prophylaxis in Hospitalized Cancer Patients Studies have shown that there are several factors that may limit adherence to VTE prevention guidelines. Clinicians may have a decreased awareness of VTE risk factors and how frequently they may occur, as well as the belief that VTE is not a problem with patients in their practice. The studies have also found that there is reluctance to use pharmaceutical prophylaxis due to concerns for bleeding complications. Finally, insufficient clinician knowledge about recommended standards for VTE prevention (Schiro, 2011). Multiple research studies have shown what the proven mechanical and

pharmacological VTE prophylaxis are, but numerous hospitals are still not applying the recommended guidelines. It is unclear why these hospitals are not using a VTE risk-assessment tool or implementing the proper VTE prophylaxis. Proper education is needed for both clinicians and RNs in proper use and importance of VTE prophylaxis. A universal VTE risk-assessment tool needs to be developed for use in hospitals as well as a universal VTE prophylaxis protocol.

Pilot Research Project Design: A pilot research project using pre and posttest data collection will be conducted on the oncology unit at Lutheran General. A review of medical charts of patients admitted to the unit with a diagnosis of malignancy over a period of 6 months. After identifying what areas of VTE prophylaxis are lacking, a VTE protocol will be developed for use on the unit. Research would focus on use of VTE prophylaxis during hospital stay, frequency of VTE prophylaxis being ordered by clinicians and amount of hospital acquired VTEs. After the protocol is developed,

VTE Prophylaxis in Hospitalized Cancer Patients education will be provided to the clinicians and RNs on the unit about the VTE protocol. After protocol has been in practice for 6 months, there will be a review of medical charts again.

Sampling: Sample population will be patients over the age of 18 admitted to the oncology unit with a diagnosis of malignancy. The sample size would be all patients during a 6 month time period. By looking at all patients with a malignancy over a 6 month time trends in the use of mechanical and pharmacological VTE prophylaxis will be shown. Also the frequency of VTE development will be shown. Inclusion criteria are: over the age of 18, diagnosis of malignancy and admission to the oncology unit. Exclusion criteria are: no diagnosis of malignancy, history of VTE, HIT or a known clotting disorder, completely bedridden and admission to hospice. Methods: Data will be collected from patients medical charts. Data will be both reliable and valid. Education will be provided to data collectors on what to look for in medical chart. Data being collected will be: Use of VTE prophylaxis and what type, whether or not any VTE prophylaxis was ordered for the patient, if patient showed any signs/symptoms of VTE and if any VTEs were diagnosed during hospitalization. Proposed data analysis: A descriptive analysis will be used for all data analysis complied. A frequency distribution will be used for each area of data collected and a chi-square analysis will be used after both pre and post data has been collected. Human Subject Issues: Before the study can be conducted, permission for deidentified patient data needs to be granted from the IRB board. The pilot research study does not involve direct patient care so the researchers do not need to receive consent from the patients. Since medical charts will be reviewed, all identifying

VTE Prophylaxis in Hospitalized Cancer Patients patient data will be excluded prior to review. All identifying patient data will be excluded from data analysis results. Study Limitations: The development of a VTE protocol that will be easy and

appropriate for clinicians and RNs to follow. There may also be limitations in trying to find the time to educate clinicians and RNs on new VTE protocol, as well as getting the clinicians and RNs to attend the education sessions. Finally, a major study limitation will be compliance of the VTE protocol.

Summary VTE is a leading cause of death in the United States, and it can be easily prevented. AHRQ and The Joint Commission have required VTE to be reportable data. Even though numerous studies have been conducted and there is evidence proving the importance of VTE prophylaxis, many hospitals are not following recommended guidelines or do not have any protocols in place. Much education needs to be done for proper use of mechanical and pharmacological prophylaxis. After a universal VTE risk-assessment screening tool and prophylaxis protocol has been developed the information can be disseminated to other hospitals through nursing or medical conferences, the article can be published in American Journal of Clinical Oncology and Clinical Journal of Oncology Nursing.

VTE Prophylaxis in Hospitalized Cancer Patients References Brown, A. (2012). Preventing venous thromboembolism in hospitalized patients

with cancer: Improving compliance with clinical practice guidelines. American Journal of Healthy-System Pharmacy, 69, 469-481.

Douketis, J. (2008). Prevention of venous thromboembolism in hospitalized medical patients: addressing some practical questions. Current Opinion on Pulmonary Medicine, 14, 381-388.

Haines, S. (2010). Improving the quality of care for patients at risk for venous thromboembolism. American Journal of Health-System Pharmacy, 67, S3-8

Galanter, W., Thambi, M., Rosencranz, H., Lambert, B. (2010). Effects of clinical decision support on venous thromboembolism risk assessment, prophylaxis, and prevention at a university teaching hospital. American Journal of HealthSystem Pharmacy, 67, 1265-1273.

Kaczorowski, K., Pattillo, M. (2011). The underutilization of venous thromboembolism prophylaxis in medical patients. Critical Care Nursing, 34(2), 134-141.

VTE Prophylaxis in Hospitalized Cancer Patients Long, J. (2009). Venous thromboembolism: Pharmacological and

nonpharmacological interventions. Journal of Cardiovascular Nursing, 24(65), S8-13.

Schiro, T., Sakowski, J., Romanelli, R., Jukes, T., Newman, J., Hudnut, A., Leonard, T. (2011). Improving adherence to best-practice guidelines for venous thromboembolism risk assessment and prevention. American Journal of Health-System Pharmacy, 68, 2184-2189.