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Hospital Harm: Venous Thromboembolism

Venous Thromboembolism (VTE) is the third most common cause of vascular mortality worldwide and comprises deep-vein thrombosis (DVT) and pulmonary embolism (PE) (Nicholson, et al., 2020). DVT occurs when an abnormal blood clot forms inside a vein deep in the leg. DVT may cause leg pain and/or swelling but is often clinically silent. PE occurs when all or part of a DVT breaks away from its site in a vein and travels through the venous system to lodge in the lungs. PE may cause chest pain, shortness of breath, tachycardia, hemoptysis, or pre-syncope but is often clinically silent. In clinical practice, about two-thirds of VTE episodes manifest as DVT and one-third as PE with or without DVT (Nicholson, et al., 2020).  

Topics
  • Patient safety
  • Hospital harm
Audience

  • Community organization

  • Healthcare leader

  • Person with lived/living experience

Goal

To prevent VTE in hospitalized adult and obstetrical patients by implementing strategies which increase the use of evidence-based thromboprophylaxis.

Overview

Healthcare Excellence Canada has developed this Hospital Harm Improvement Resource – a compilation of resources to support patient safety and improvement efforts.

Venous Thromboembolism (VTE) is the third most common cause of vascular mortality worldwide and comprises deep-vein thrombosis (DVT) and pulmonary embolism (PE) (Nicholson, et al., 2020). DVT occurs when an abnormal blood clot forms inside a vein deep in the leg. DVT may cause leg pain and/or swelling but is often clinically silent. PE occurs when all or part of a DVT breaks away from its site in a vein and travels through the venous system to lodge in the lungs. PE may cause chest pain, shortness of breath, tachycardia, hemoptysis, or pre-syncope but is often clinically silent. In clinical practice, about two-thirds of VTE episodes manifest as DVT and one-third as PE with or without DVT (Nicholson, et al., 2020).

About 50 per cent of all VTE events occur because of a current or recent hospital admission for surgery or acute medical illness. Hospital-acquired VTE is preventable, with interventions including anticoagulants and mechanical measures, including compression stockings and intermittent pneumatic compression (Schünemann et al., 2018). In addition, VTE remains an important cause of maternal morbidity and mortality in Canada with an overall incidence of DVT and PE of 12.1 per 10,000 and 5.4 per 10,000 pregnancies, respectively. VTE occurs at a rate of 4.3 per 10,000 pregnancies postpartum (Chan et al., 2014).

Risk Factors

Risk factors for VTE can be subdivided into factors that promote venous stasis, factors that promote blood hypercoagulability, and factors causing endothelial injury or inflammation. A clear understanding of the risk factors for VTE is vital to identify patients at risk of VTE who would benefit from thromboprophylaxis. An individual patient's risk of VTE depends on intrinsic, patient-specific factors (such as genetic risk factors, age, or body mass index) and acquired risk due to the unique context or situation (such as hospitalization, surgery, cancer, or pregnancy). Risk factors are also frequently categorized by "transient vs. persistent" and "major vs. minor" (Nicholson et al., 2020; Chan et al., 2014).

Importance to Patients and Families

Hospital-acquired VTE (blood clots) is preventable (Schünemann et al., 2018).

One of the most important things you can do to prevent blood clots is to know if you are at risk. Some risk factors are hospitalization, surgery, pregnancy, or cancer. Other things you can do to reduce your risks and protect yourself from life-threatening blood clots include:

  • Recognize the signs and symptoms of blood clots (DVT: swelling, pain, skin warm to the touch, redness; PE: difficulty breathing, chest pain, coughing, blood in sputum, rapid or irregular pulse).

  • Tell your doctor if you have risk factors for blood clots.

  • Before any surgery, talk with your doctor about blood clots.

  • Tell your doctor or nurse if you have any symptoms of a blood clot.

  • Mobilize as recommended by your health care provider.

  • Don't smoke or quit smoking

Patient Story

How a Drawing Saved My Life: Lori's Story

In August 2014, I was overwhelmed with joy after delivering my baby boy, Jack. He was perfect, the delivery was pretty easy, and I was ready to go home. During a brief moment of quiet during his nap, I perused through the endless literature provided by the hospital. A hand drawing of a leg, with a red mark and arrow pointing to the calf describing deep vein thrombosis (DVT) struck me. I had a weird Charley horse in my leg, right in the same spot, but I thought it was no big deal. I mentioned it to the nurse, and we decided it was harmless. I went home with my bundle of joy. (Stop the Clot, nd).

Maury Lieberman's story

Maury Lieberman, National Blood Clot Alliance (NBCA) Board member, discusses his experience with cancer and blood clots: (Stop the Clot, 2015) Video

Clinical and System Reviews, Incident Analyses

Given the broad range of potential causes of VTE, in addition to recommendations listed above, we recommend conducting clinical and system reviews to identify latent causes and determine appropriate recommendations.

Occurrences of harm are often complex with many contributing factors. Organizations need to:

  1. Measure and monitor the types and frequency of these occurrences.

  2. Use appropriate analytical methods to understand the contributing factors.

  3. Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.

  4. Have mechanisms in place to mitigate consequences of harm when it occurs.

Measures

Vital to quality improvement is measurement, and this applies specifically to implementation of interventions. The chosen measures will help to determine whether an impact is being made (primary outcome), whether the intervention is actually being carried out (process measures), and whether any unintended consequences ensue (balancing measures). In selecting your measures, consider the following:

You may use different measures or modify the measures described below to make them more appropriate and/or useful to your particular setting. However, be aware that modifying measures may limit the comparability of your results to others.

Evaluate your choice of measures in terms of the usefulness of the final results and the resources required to obtain them; try to maximize the former while minimizing the latter.

Whenever possible, use measures you are already collecting for other programs.

Try to include both process and outcome measures in your measurement scheme.

Discharge Abstract Database

Discharge Abstract Database (DAD) Codes included in this clinical category: A06: Venous Thromboembolism

Concept: Embolism, thrombosis, phlebitis or thrombophlebitis of the pulmonary vein or other veins (excluding superficial veins) identified during a hospital stay.

Success Stories

Getting patients on board with VTE prophylaxis

A bundle to educate patients about venous thromboembolism (VTE) included a 10-minute video of patients' stories and in-person support from a nurse educator.

Where: The Johns Hopkins Hospital, a 1,000-bed academic medical center in Baltimore.

The issue: Administering venous thromboembolism (VTE) prophylaxis as prescribed.

Background: Hospitalists know the importance of medications for VTE prophylaxis, but 12.7 per cent of prescribed doses were not administered in a study of 75 patients at Johns Hopkins Hospital, published in March 2018 by the American Journal of Health-System Pharmacy. Because the most commonly cited reason for non-administration was patient refusal, the Johns Hopkins VTE Collaborative decided to tackle the problem with patient education.

"Our first step was to ask patients what they wanted to learn," said Elliott R. Haut, MD, PhD, vice chair of quality, safety, and service in the department of surgery at Johns Hopkins Medicine. After collecting patient input, the research group developed a patient education bundle composed of a two-page form about blood-clot prevention, a 10-minute video of patients' stories (shown on a hospital tablet, the TV, or a patient's personal device), and in-person support from a nurse educator... (Frost, 2019)

References

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