Gallup Indian Medical Center



Gallup Service Unit

Policy & Procedure Statement

Subject: VTE Risk Assessment and Prevention Policy Latest Revision: 5/2011

Organizational Level: GSU.CLI.11A.VTERiskAssessmentandPrevention Next Review: 5/2014

I. POLICY

The aim of this policy is to ensure that all adult patients (18 years and older) admitted to Gallup Service Unit (GSU) are formally assessed and appropriate measures are taken to reduce the likelihood of developing a venous throboembolism (VTE). Either a deep vein thrombosis (DVT) or pulmonary embolism (PE) can be called a VTE. As per a Call to Action by the Surgeon General in 2008, VTEs are the number one preventable hospital death nationwide. Also, per the Agency for Healthcare Research and Quality (AHRQ) "Thromboprophylaxis is the number one patient safety practice to prioritize among the nearly 70 practices reviewed.”

II. PROCEDURE

A) PURPOSE

The purpose of this policy is to ensure that all adult (18 years and older) hospitalized patients are appropriately assessed for risk of VTE and treated appropriately according to their risk stratification through the patient’s stay at GSU.

B) PROTOCOL UTILIZATION

Per The Joint Commission (TJC) Standards every adult hospitalized patient needs to be assessed for VTE Risk and appropriately prophylaxed within 24 hours of admission. Furthermore, if the patient is contraindicated for VTE Prophylaxis, this must also be documented within 24 hours.

Adult patients who are treated as an inpatient need to be assessed for VTE risk:

1. within 24 hours of full admission

2. after change in level of care and

3. after leaving surgery ward (post-op).

Documentation of assessment and prophylaxis orders will be contained on the VTE Prophylaxis Protocol. Once a patient’s VTE risk has been assessed and documented on the VTE Prophylaxis protocol, it need not be reassessed until the patient experiences a change in level of care or undergoes surgery.

Applicability: This policy applies to all staff with clinical responsibility for an individual stay in the hospital VTE risk assessment, prevention and treatment including admitting and hospitalist physicians.

Physician responsibility: The attending physician will assess the patient for VTE risk level upon admission, transfer or post-op (low, moderate or high) and prescribe corresponding VTE prophylaxis. Both actions will be documented on GSU’s DVT/PE/VTE RISK LEVEL & PROPHYLAXIS ORDER (Protocol) which is signed by the physician. If the patient has a valid contraindication to chemical VTE prophylaxis, the contraindication must be documented on the protocol and the physician can choose to use sequential compression devices (SCDs) unless the patient is also contraindicated for SCDs (which also needs to be documented by the physician).

Nurse responsibility: If a patient has not been assessed for VTE risk and prescribed VTE prophylaxis within 14 hours of admission. Nurses are encouraged to remind physicians to fill out the form, in order to comply with TJC standards of having every patient assessed and documentation of that assessment within 24 hours. Completing this form will rely on the nursing notes for assessment and documentation of ambulation, and empowers nurses to remind physicians if protocol has not been filled out within TJC time limits.

Ward Clerk: The ward clerk is responsible for photocopying (or using the carbon copy) the original order and placing the copy into the pharmacy bin for pharmacy to pick up. The ward clerk will also enter the labs that are automatically ordered with pharmacologic VTE prophylaxis. (Labs will be baseline platelet count and platelets Q72 hours afterwards.)

Pharmacist responsibility: Fulfillment of the medication orders will allow for pharmacist adjustment based on renal function or other contraindication with notification of the physician.

The manner in which each step is carried out will likely be different upon conversion to electronic health records (EHR) and will addressed upon conversion.

C) IMPLEMENTATION, MONITORING AND EVALUATION

This policy will be implemented, monitored and evaluated in line with the Policy on Procedural Documents.

VTE assessment and prevention is included with in the Quality Initiative mandatory yearly training program.

The VTE Committee will supervise audits of compliance within this policy. The key performance indicators for which are:

- Percentage of patients receiving appropriate prophylaxis (target 100%)

- Percentage of patient risk assessed and documented (target 100%)

- Number of VTE events during or within 28 days of hospital admission (target less than national average)

- Number of bleeding events during a patient stay potentially caused by pharmacologic VTE prophylaxis

The VTE Task Force will be comprised of, but is not limited to:

- a pharmacist

- clinical supervisory nurse

- a physician champion from each department (Ortho, Surgery, Family Medicine/Internal Medicine, OB/GYN and Hospitalist) and

- Quality Initiative Manager

The goal of this task force is to effectively implement, facilitate and monitor inpatient hospital VTE prophylaxis.

D) GUIDELINES

Prevention of VTE is outlined by 2008 (8th Edition) Evidence-Based Clinical Practice Guidelines American College of Chest Physicians Prevention of Venous Thromboembolism (ACCP VTE Prophylaxis Guidelines). The ACCP VTE Prophylaxis Guidelines address institutional policy and are acceptable guidelines per CMS, TJC and AHRQ. The VTE Policy, Procedure and Protocols will be based on these guidelines.

E) REFERENCES

1. Geerts WH, Bergqvist D, Pineo GF, Heit JA et al (2008) Prevention of venous thromboembolism: ACCP evidence-based clinical practice guidelines (8th edition). Chest 133(Suppl 6):381S-453S.

2. Maynard GA et al. Optimizing prevention of hospital-acquired venous thromboembolism (VTE): prospective validation of a VTE risk assessment model. J Hosp Med. 2010;5:10-8.

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