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Best practice guidelines for Australia and New Zealand on the prevention of venous thromboembolism: Issues and implications for nurses
Jessica Schluter
Safe Medication Practice Unit, Queensland Health, Brisbane QLD
Hayden Scotter
Patient Safety Centre, Queensland Health, Brisbane QLD
Wendy Chaboyer
Director, Research Centre for Clinical and Community Practice Innovation (RCCCPI), Griffith University, Nerang QLD; Adjunct Professor Patient Safety Centre, Queensland Health, Brisbane QLD
Article Text
We have been invited to comment on the recently released best practice guidelines for Australia and New Zealand on the prevention of venous thromboembolism (Australia & New Zealand Working Party on the Prevention of Venous Thromboembolism - ANZWPPVT 2007). In this editorial we first provide a short overview of venous thromboembolism (VTE) and then we discuss issues surrounding implementation of these guidelines, focusing on current work in Queensland. We conclude by suggesting that, in addition to educating individual clinicians on the guidelines, a human factors engineering approach can be useful in change behaviours, such clinicians' practices surrounding VTE prophylaxis.
VTE is comprised of deep vein thrombosis (DVT) and pulmonary embolism (PE). VTE occurs in nearly 30,000 Australians annually and has been identified as a priority area for improving patient safety (National Institute of Clinical Studies 2003). It is now a significant problem for both medical and surgical patients and can lead to serious illness, poor quality of life and even death.VTE events not only extend hospital length of stay but also increase hospital costs associated with anticoagulant therapy.
There are a number of risk factors associated with VTE, including: ischaemic stroke; active cancer; decompensated heart failure; acute on chronic lung disease; acute on chronic inflammatory disease; hip/knee arthroplasty; major trauma; and hip fracture surgery or any major surgery (greater than 45 minutes duration) conducted on a patient over the age of 40 years.
Most hospitalised patients have one or more risk factors for VTE. Importantly, these factors are generally considered cumulative (ANZWPPVT 2007). Additional risk factors include immobility, use of oestrogen preparations, pregnancy or puerperium, a strong family history of VTE and obesity.
Current studies indicate that DVT occurs in over 50% of some categories of hospitalised patients if prophylaxis is not used. This has been found to occur in several categories including stroke (56%), elective hip replacement (51%) and multiple trauma (50%). However, due to the silent nature of DVT, many of these events are asymptomatic. The long-term sequelae of DVT are often chronic venous insufficiency (CVI), which leads to post-thrombotic syndrome (PTS) in up to 60% of patients who develop a DVT. PTS is often characterised by chronic pain, oedema, cellulitis and venous ulceration. Approximately 25% of all venous ulcers can be attributed to DVT and may cost the Australian Health Care system over $200 million annually (ANZWPPVT 2007).
PE, the second VTE condition, is one of the single most preventable causes of hospital deaths, and accounts for approximately 10% of all deaths in hospital (ANZWPPVT 2007). Non-fatal PE occurs in approximately 20 per 100 000 people per year in comparison to 50 per 100 000 people per year for fatal PE. Interestingly, up to 75% of fatal PE that occur in hospital are medical patients.
As the fourth edition of the VTE prophylaxis guidelines outline, VTE prophylaxis should be considered for every hospitalised patient. Currently recommended prophylactic methods are cost effective in patients at moderate and high risk of VTE due to the high cost of diagnosis and treatment of VTE in these patients. Effective VTE prophylaxis and treatment should also reduce the costs of managing the post-thrombotic syndrome and its consequences, especially chronic venous leg ulcers associated with PTS.
It is well recognised that there are also risks associated with anticoagulant medication use. In Queensland, the Health Quality and Complaints Commission (HQCC) developed a set of seven surgical standards that focus on what health service users should receive with respect to the quality of health care (HQCC 2007). One of these standards requires all surgical patients to be reviewed and have a documented risk assessment for VTE and any patients with a moderate to high risk of VTE should receive an appropriate prophylactic intervention if not contraindicated. While this standard applies only to surgical patients, given the magnitude of problems associated with VTE and its high incidence in medical patients, it is likely that this standard will be extended to include medical patients.
With the problems associated with VTE and the HQCC standards in mind, a number of sites, both in Queensland and interstate, have independently developed forms and decision support tools that aid the risk assessment, prescribing and administration of VTE prophylaxis. These tools have been implemented in an attempt to improve the systematic assessment and documentation of patients' VTE risk status and to improve the use and documentation of appropriate prophylaxis in patients at risk of VTE. The majority of these risk assessment tools have been developed to complement the best practice guidelines released by the ANZWPPVT (2007). These recommendations guide clinicians through risk assessment of both medical and surgical patients whilst also taking into account anticoagulant and mechanical contraindications to VTE prophylaxis.
The ANZWPPVT comprise of a group of experts who have developed guidelines to assist in identifying and treating patients at risk of developing VTE. The expert group included surgeons, haematologists, vascular physicians, medical physicians and general practitioners. The guidelines are based on recommendations from the International Union of Angiology (IUA) and American College of Chest Physicians (ACCP) and are the collective views of an expert group skilled in thrombosis management and reflective of their analysis of the obtainable evidence. The guidelines have been adapted to suit Australian and New Zealand conditions.
The use of the best practice guidelines is fairly straightforward. Information is provided with regards to both mechanical and anticoagulant prophylaxis. While anticoagulant dosage recommendations have been provided, it is suggested that clinicians refer to hospital protocols and individual patient situations to select the appropriate agent. Duration of prophylaxis is also considered. The general recommendation regarding high-risk surgical patients is at least ten days, with the exception of patients undergoing knee replacement, hip replacement or hip fracture. These patient groups require extended prophylaxis of up to 35 days. Medical patients are recommended to receive prophylaxis until resolution of their medical illness.
Risk stratification within the guidelines is also relatively uncomplicated. Surgical patients are divided into two groups; recommendations for prophylaxis are group dependent. Patients undergoing hip or knee arthroplasty or major trauma patients are at high risk of developing a VTE. These patients are recommended to receive low molecular weight heparin (LMWH) or fondaparinux combined with an intermittent pneumatic compression device (IPC) with or without the use of graduated compression stockings (GCS). Patients undergoing hip fracture surgery or any other surgery where there is a history of VTE or active cancer are recommended to receive LMWH or low dose unfractionated heparin (LDUFH) or fondaparinux combined with IPC with or without the use of GCS. Similarly, patients aged over 40 years undergoing major surgery (intra-abdominal surgery or surgery greater than 45 minutes duration) are recommended to receive LMWH or LDUFH combined with IPC with or without the use of GCS. The recommendation for all other surgical patients is dependent on any additional VTE risk factors such as, but not limited to, immobility, thrombophilia, obesity or a strong family history of VTE.
Risk stratification also considers medical patients. Patients affected by an acute stroke with paralysis of a lower limb, history of VTE, active cancer, decompensated heart failure, acute on chronic lung disease, acute on chronic inflammatory disease or aged over 60 years are all at high risk of developing a VTE. These patients are recommended to receive LMWH or LDUFH until their medical illness is resolved. Medical patients who have none of the features listed above are not considered at risk. However, as suggested above for surgical patients, additional risk factors should be considered for prophylaxis.
In response to the ANZWPPVT Best Practice Guidelines and HQCC standards, Queensland Health's Safe Medication Practice Unit (SMPU) proposes to standardise VTE risk assessment recording on the national inpatient medication chart (NIMC). It also plans to collect evidence of improvements in care to inform national changes to the NIMC. The SMPU was established in January 2005 as a continuation of the Queensland Health Medication Management Services (QHMMS) and the Quality Improvement and Enhancement Program-Quality Use of Medicines (QIEP-QUM) Program Area (see www.health.qld.gov.au/qhcss/). It is now part of Medication Services Queensland, Clinical and Statewide Services and supports Districts and Area Health Services within Queensland Health to address adverse drug events resulting in patient harm by improving medication related practices. The SMPU is a multidisciplinary team of pharmacists, nursing and medical officers who focus on improving medication related services in four main areas: high-risk medications and systems, electronic medication management, pharmaceutical review and medication continuum.
Standardisation of VTE risk assessment, in addition to reduction of patient harm, would allow for national standardisation of training of medical, nursing and pharmacy staff on VTE risk assessment. The proposed changes to the NIMC could then be captured by clinical coding to facilitate reporting requirements for the HQCC surgical standard. Currently, there is no sound evidence on whether the inclusion of a VTE risk assessment on the NIMC would improve VTE prophylaxis rate. As a result, the changes are being trialled in three Queensland Health facilities to collect evidence to inform these changes. The facilities participating in the trial include a large, tertiary teaching hospital, a smaller district hospital and a rural hospital. The importance of determining the effects of standardised VTE risk assessment across all types of facilities, both metropolitan and rural, is crucial if national changes are to be made to the NIMC.
A major difficulty in implementing the guidelines is engaging staff to physically complete risk assessment forms. There are a number of issues surrounding risk assessment. The main problem associated with VTE risk assessment is ownership; determining which clinician is best placed to conduct the risk assessment and action the outcomes of the assessment. It is well known that nursing staff are more than capable of completing patient risk assessments; one only has to consider the myriad of risk assessment tools that nursing staff complete on a daily basis. These include falls risk assessment, pressure ulcer risk assessment, discharge risk assessment and nutrition risk assessment, to name just a few. One common aspect of each of these is the ability of the nurse completing the assessment to implement interventions based on the results of the respective risk assessment. For example, if a patient is assessed to be at high risk of developing pressure ulcers, nursing interventions such as use of an air mattress and regular pressure relief can be implemented by nursing staff without the need for further consultation from the multidisciplinary team.
This then raises the issue with VTE risk assessment. Whilst nursing staff could be trained to undertake a VTE risk assessment, they cannot act upon it as the various actions require medical orders. That is, the VTE guidelines are medical guidelines to help doctors identify what forms of prophylaxis they will order. While some hospital facilities allow nursing staff to implement mechanical prophylaxis, such as GCS, a medical officer must prescribe anticoagulant medications. Therefore, the SMPU advocates for the VTE risk assessment to be completed by a medical officer.
Given the VTE best practice guidelines have been developed by medical practitioners for medical practitioners, it makes sense that these health professionals should complete VTE risk assessment. However, getting ‘buy-in' from medical staff with regards to best practice guidelines is often fraught with frustration due to the perceived limitations associated with ‘guidelines'. Some are of the belief that clinical decision-making and an individual approach to patient care is removed when protocols or guidelines are introduced.
Whilst aversion to the introduction of guidelines can be associated with perceived limitations, this is often associated with negative attitudes towards change. Change, when it affects the way people work, is often the most concerning in organisations. So, when change is associated with altering the way medical officers risk assess and treat their patients, there are always going to be challenges and barriers that need to be overcome. One avenue towards improving the uptake of change is through educating staff on how the change will benefit patients, most of which are fairly substantial with regards to VTE. Motivating and inspiring medical staff to view VTE guidelines as just that, guidelines not law and highlighting how they can ultimately benefit both clinicians and patients is by far the best way to approach the introduction of standardised VTE risk assessment.
A second approach is to underpin the requirement to perform a VTE risk assessment by human factors engineering. This approach will make it easy for clinicians to ‘do the right thing' and hard for them to ‘do the wrong thing'. It is true that no amount of study, practice, experience or motivation will ‘error proof' a clinician. Even the most intelligent, experienced and well-intentioned clinicians are error prone; this is part of the human condition. Human factors engineering helps us recognise this, and put systems in place that help to prevent our errors. For example, simple cognitive aids such as ‘forcing functions' for computer data entry can ensure key data must be entered before proceeding or colour codes on vital sign records can be used to remind nurses that certain blood pressure safety limits have been reached.
In healthcare, we are only now starting to understand that the high quality performance of tasks is determined by both individual factors and system design factors. There is now well established evidence that human factors training actually reduces and prevents aviation accidents (Diehl 1991). However, we in healthcare have been slow to take the opportunities for learning offered by other safety-critical industries. The simple form of training in communication and an understanding of good system design and resilience, whilst not the single answer, is worth considering as one of a range of solutions aimed at reducing preventable harm (Leape 1994).The field of human factors can teach us much in healthcare and it is now an important and practical adjunct to many hospital quality initiatives. According to the Department of Veterans Affairs - designers of the current Root Cause Analysis programme in Australia - Human Factors Engineering training equips investigating personnel to use a systems-oriented approach during adverse event analysis (Gosbee & Anderson 2003).
With the risk of VTE about 135 times greater in hospitalised patients than those in the community, the importance of risk assessment is apparent. While, there are a number of tools available to risk assess patients for VTE, the uptake of these is limited despite their endorsement by international consensus conferences and other expert working parties. The development of a VTE risk assessment tool and pre-printed prophylactic treatment options onto the NIMC is currently being trailed in three hospitals in Queensland. Placing the responsibility on nursing staff to complete these risk assessments is futile due to inability of nurses to implement actions associated with the VTE risk. Encouraging medical staff to complete the VTE risk assessment appears to be the way forward, but overcoming the perceived barriers imposed by VTE guidelines is the first hurdle. Human factors engineering offers one way to assist clinicians in implementing guidelines, such as those for VTE.
References
Australia & New Zealand Working Party on the Management and Prevention of Venous Thromboembolism (2007) Prevention of Venous Thromboembolism: Best Practice Guidelines for Australia & New Zealand 4th edn, Health Education and Management Innovations.
Diehl A (1991) 'Does Cockpit Management Training Reduce Aircrew Error?' Presented at the 22nd International Seminar International Society of Air Safety Investigators, Canberra Australia, November 1991.
Gosbee J and Anderson T (2003) Human factors engineering design demonstrations can enlighten your RCA team. Quality and Safety in Health Care 12: 119 121.
Leape LL (1994) Error in Medicine. Journal of the American Medical Association 272: 1851-7.
National Institute of Clinical Studies (NICS) (2003) Evidence-Practice Gaps Report Vol 1, National Institute of Clinical Studies, Canberra.
Quality of Health Services – Duty of Provider (2007) Health Quality and Complaints Commission Version 1.
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