Venous Thromboembolisms (VTE)

This guide outlines the steps that managers can follow to prevent venous thromboembolisms (VTE):

To support your staff in maintaining safe practices associated with preventing Venous Thromboembolisms:

1. Develop protocols for the appropriate use of mechanical and pharmacological prophylactic measures.
2. Ensure adequate training of frontline staff.
   1. Ensure adequate VTE prevention competencies and skills for frontline staff.
3. Ensure that DVT and VTE prevention protocols are embedded into clinical workflows.
4. Take steps to ensure that patients, regardless of low or high risk, do not develop VTE.
5. Report VTE prevention measures and compliance monthly.
6. Determine and report number of instances where guidelines were missed and reinforce the necessity of reporting this data with staff.
7. Measure and report the proportion of patients who are prescribed risk-appropriate VTE prophylaxis.
8. Measure and report the proportion of non-administered doses of prescribed VTE prophylaxis.
9. Determine and report the number of patients who received no VTE prophylaxis prior to the day before the date of the first positive VTE diagnostic test.
10. Measure and report the proportion of hospitalized patients with a documented VTE risk assessment completed.
11. Note trends in areas with low compliance and high VTE incidence.
    1. Routinely reassess outcomes.
12. Reassess VTE/DVT risk daily.
13. Organize patient education resources to ensure ease of access for frontline staff.
14. Ensure proper documentation of VTE prophylaxis measures in patient record.
15. Ensure there are enough staff to effectively manage necessary preventive care.
16. Eliminate barriers to making rapid changes to documentation templates and order sets.
17. Debrief team on a regular basis to solicit feedback about barriers to sustained compliance. Adjust the plan quickly and nimbly as needed.
18. Reduce all prophylaxis options to preferred options to simplify processes and reduce confusion.
19. Fully investigate any instances of a patient developing DVT/VTE to assess potential failures in prevention.
20. If VTE rates indicate room for improvement, initiate a performance improvement project.
21. Ensure frontline involvement in VTE improvement activities. Maintain their engagement and remove barriers to progress.
    1. Gather the right project team.
       1. Be sure to involve the right people on the team. You’ll want two teams: an oversight team that is broad in scope, has 10-15 members, and includes the executive sponsor to validate outcomes, remove barriers, and facilitate spread. The actual multidisciplinary project team consists of 5-7 representatives who are most impacted by the process. Whether a discipline should be on the advisory team or the project team depends upon the needs of the organization. Patients and family members should be involved in all improvement projects, as there are many ways they can contribute to safer care.
       2. Recommended VTE improvement team:
          • Physicians
          • Nurses
          • Physical and occupational therapists
          • Residents
          • Pharmacists
          • Information technology (program/build within EHR)
          • Data analyst (pull/analyze data from EHR)
       3. Understand what is currently happening and why.
          1. Reviewing objective data and trends is a good place to start to understand the current state, and teams should spend a good amount of time analyzing data (and validating the sources), but the most important action here is to go to the point of care and observe. Even if team members work in the area daily, examining existing processes from every angle is generally an eye-opening experience. The team should ask questions of the frontline during the observations that allow them to understand each step in the process and identify the people, supplies, or other resources needed to improve patient outcomes.
       4. Prioritize the gaps to be addressed and develop an action plan.
          1. Consider the cost effectiveness, time required, potential outcomes, and realistic possibilities of addressing each gap identified. Determine which are a priority for the organization to focus on. Be sure that the advisory team supports moving forward with the project plan so they can continue to remove barriers. Design an experiment to be trialed in one small area for a short period of time and create an action plan for implementation.
       5. Evaluate outcomes, celebrate wins, and adjust the plan when necessary.
    2. Ensure that an after-discharge plan exists in your department.
    3. Report number of DVTs and VTEs monthly with staff.
       1. Share successes of zero events with staff.
       2. Hold staff accountable for providing standardized care and reward success.
    4. The action plan should include the following:
       1. Assess the ability of the culture to change and adopt appropriate strategies.
       2. Revise policies and procedures.
       3. Redesign forms and electronic record pages.
       4. Clarify patient and family education sources and content.
       5. Create a plan for changing documentation forms and systems.
       6. Develop the communication plan.
       7. Design the education plan.
       8. Clarify how and when people will be held accountable.

Metrics to consider assessing in VTE prevention:

1. Total numbers of VTEs
2. Risk score use
3. Pharmacological prophylaxis ordered
4. Pharmacological prophylaxis missed doses
5. Patient refusal of pharmacological prophylaxis
6. Mechanical prophylaxis ordered
7. Patient refusal of mechanical prophylaxis
8. VTE prophylaxis continuation post-discharge
9. Mechanical prophylaxis in pre-op areas
10. Percent of patients who have a documented VTE risk assessment within 24 hours of admission
11. Percent of patients with mechanical prophylaxis ordered versus those who actually have compression devices in place
12. VTE patients receiving unfractionated heparin with dosages/platelet count monitoring by protocol
13. Surgical patients who received appropriate VTE prophylaxis within 24 hours post-surgery
14. Patients readmitted due to VTE
15. Number of patients diagnosed with confirmed VTE during hospitalization (not present at admission) who did not receive VTE prophylaxis between hospital admission and the day before date of the first positive VTE diagnostic test