Background

A Deep Vein Thrombosis (DVT) is a patient condition where a blood clot forms in a deep vein, usually in the legs. DVT is particularly dangerous because the clot can break loose and travel through the bloodstream to the lungs: if this happens it is called a pulmonary embolism (PE), which is life-threatening. Together, DVT and PE are referred to as venous thromboembolism (VTE).

Risk factors for VTE

Patient risk factors that contribute to the occurrence of a DVT or PE include:

• prolonged immobility,

• surgery,

• certain medical conditions, and

• pregnancy.

Symptoms

DVT symptoms can vary depending on the size of the clot and its location. Sometimes, DVT may occur without any noticeable symptoms, however when symptoms do appear, they typically include:

1. Swelling usually occurs in one leg, though sometimes both can be affected and is usually in the calf or thigh.

2. Pain or tenderness may start in the calf and feel like a cramp or soreness. The pain might worsen when standing or walking.

3. Red or discolored skin over the affected area, that may have a bluish tinge.

4. Warm sensation in the affected area compared to the surrounding skin.

5. Visible veins in some cases may occur, with superficial veins becoming more visible or enlarged due to the underlying clot.

PE occurs when a clot from DVT breaks loose and travels to the lungs, blocking blood flow. This can be life-threatening, and symptoms may include:

1. Sudden shortness of breath is the most common symptom and can occur without warning, even when at rest.

2. Chest pain that may feel sharp or stabbing and can worsen with deep breaths, coughing, or bending.

3. Coughing, with some people coughing up blood or blood-streaked mucus.

4. Rapid heart rate or palpitations may be felt as the heart tries to compensate for the reduced blood flow in the lungs.

5. Lightheadedness or fainting due to a sudden drop in blood pressure, which may occur with a large PE.

6. Sweating, often described as cold and clammy skin, can be a symptom of PE.

7. Anxiety, or a sense of impending doom can sometimes accompany the physical symptoms.

Treatment and Impact

If left untreated, DVT can lead to complications such as post-thrombotic syndrome, which causes long-term pain and swelling. More importantly, there's a risk of the clot traveling to the lungs, causing a PE. A PE is a medical emergency that can lead to severe complications or death if not treated quickly. The blockage in the lungs can prevent oxygen from reaching the heart and other vital organs.

Based on four studies reporting cost data, the Agency for Healthcare Research & Quality (US) has estimated the additional cost for hospital-acquired VTE to be $17,367 (95% CI: $11,837 to $22,898). Based on nine studies, excess mortality was estimated at 0.043 (95% CI: 0.040 to 0.078) per hospital-acquired condition: this means that for every 1,000 VTE cases, there are 43 excess deaths.

A key step in-hospital VTE prevention is to ensure that patients are identified as being at risk of a VTE event and then ensure that proactive interventions are in place to reduce the risk to the patient. Intervention options include:

1. Medications: Anticoagulants or blood thinners are often prescribed to prevent clot formation, especially in high-risk patients.

2. Mechanical Methods: Compression stockings or intermittent pneumatic compression devices can help improve blood flow in the legs.

3. Early Mobilization: After surgery or long periods of inactivity, getting up and moving as soon as possible helps prevent blood clots from forming.

How is VTE proactively managed in an Accountable Care Unit with SIBR rounds?

During SIBR, the bedside nurse is required as part of step 4 of the SIBR communication protocol, i.e. during the SIBR quality-safety checklist, to report on patient's VTE risk, and to recommend the most suitable intervention options if the patient is at risk. Ideally each unit will have a nurse-driven VTE prophylaxis/prevention protocol that nurses can use to prompt their critical thinking on the best management strategy for each patient. The ACU leadership dyad, nurse & physician co-leads, should be monitoring VTE events on the unit and working with the frontline staff to optimize the treatment process.

Improvement Outcomes Reported by ACUs

A 26-bed acute medical unit at Orange Hospital in New South Wales reported a 100% percent increase in VTE prophylaxis compliance in the year following ACU & SIBR implementation.

A 35-bed hematology & bone-marrow transplant unit in Queensland reported a 50% point increase in the mean VTE prophylaxis compliance for at risk-patients in a 9-month pre- and post-implementation comparison.

References

1. https://www.ahrq.gov/hai/pfp/haccost2017-results.html#:~:text=Based%20on%20six%20studies%20reporting,CAUTI%20cases%2C%20there%20are%2036