questions

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DVT Prevention:

What Works Best?

SHINE BELL, RN, LACEY KEITH, LPN, AMBER MCGRAW, RN, REGAN WENTZ, RN.

FACULTY CONSULT: JAMIE MORRIS, MS RN

OU College of Nursing: Degree Completion

Evidence-Based Practice Symposium

Friday, April 26. 2019

Objective

To analyze and critique current research

regarding the most effective means of

DVT prophylaxis.

PICO Question

For Deep Vein Thrombosis (DVT) prophylaxis, which intervention, mechanical, pharmacological or combination, best decreases DVT occurrence in the acute care setting?

 Population: Patients in the Acute Care Setting

 Intervention: DVT Prophylaxis

 Comparison: Mechanical vs Pharmacological vs Combination

 Outcome: Decrease of DVT occurrence

What is the Problem?

 No current standardized practice guideline for DVT

prevention.

 DVT prophylaxis is not implemented correctly in all patients

for whom it is ordered.

 There is currently no consensus regarding the preferred

pharmacological therapeutic agent.

Why is this a Problem?

 As many as 70% of healthcare-associated blood clots are preventable, yet

fewer than half of hospitalized patients receive appropriate preventive

treatment (CDC, 2018).

 Almost all patients admitted to the hospital are at risk for developing a DVT

(Sachdeva, 2018).

 DVT is the single most important preventable cause of morbidity and

mortality in many surgical specialties (Chibbaro, 2018).

 Without prophylaxis, DVT occurs in 40–60 percent of postoperative cases in

the 7–14 days following surgery (AHRQ, 2012).

Literature Review

 Database Search: PubMed, CINAHL, Ovid, Joanna

Briggs

 Key terms included: Deep Vein Thrombosis, prophylaxis,

mechanical, pharmacological, DVT best practice, DVT

acute care setting.

 Articles used are between the years 2012-2018

Literature Review & Conclusions

 Bala et al (2017) A large database analysis asking (1) What are the differences in VTE incidence in primary TKA after administration of aspirin, warfarin, enoxaparin, or factor Xa inhibitors? (2) What are the differences in bleeding risk among these four agents? (3) How has use of these agents changed with time? Concluded that utilization trends for these agents are not well-studied.

 Beitland et al (2015) A systematic review with meta-analysis and trial sequential analysis of randomized controlled trials (RCTs) comparing pharmacological thromboprophylaxis with low molecular weight heparin (LMWH) versus unfractionated heparin (UFH) in ICU patients. Concluded a need for future trials.

 Chibbaro et al (2018) A prospective comparative study analyzing results from two separate prophylaxis protocols implemented in a European neurosurgical center to assess the safety and efficacy of prevention. Concluded that mechanical devices are non-negligible support in the prophylaxis of clinically symptomatic DVT.

Literature Review & Conclusions

 O'Brien et al (2018)

A two-stage sequential multi method design study aimed at developing a clinical

tool to guide nurses’ assessment of postoperative patients at risk for DVT. Concluded

that due to multiple limitations, there is no identified gold standard in clinical

assessment for the detection of early DVT. Further research needs to be conducted

for both screening and assessment of DVT.

 Park et al (2016)

Comprehensive Meta-Analysis comparing the efficacies and safety profiles of UFH,

LMWH, mechanical prophylaxis and no prophylaxis. Study did observe a significant

reduction of DVT risk with pharmacologic prophylaxis compared to the control

group. Concluded that the choice of best thromboprophylaxis technique still needs

further investigation.

Literature Review & Conclusions

 Sachdeva et al (2018) A Cochrane Database Systemic Review to evaluate the effectiveness and safety of graduated compression stockings in preventing DVT in various groups of hospitalized patients. Concluded that the occurrence of problems with wearing GCS was poorly reported in the included studies.

 Snyder et al. (2017) A prospective, randomized control trial examining whether there is a difference in DVT occurrence using aspirin-based prophylaxis with or without extended use of mechanical compression device (MCD) therapy. Conclusion: This study did not establish the best prevention protocol.

 Pharmacological plus mechanical prophylaxis reduced the risk of DVT by 52 percent when compared with pharmacological prophylaxis alone (AHRQ, 2012).

Types of Prophylaxis

Pharmacological  Oral antiplatelet agents (Aspirin)

 Injectable low-molecular-weight heparins (Lovenox)

 Injectable unfractionated heparin

 Injectable or oral factor Xa inhibitors

 Injectable or oral direct thrombin inhibitors

 Oral vitamin K antagonists

Mechanical

 Graduated compression (TED hose)

 Intermittent pneumatic compression

(SCD machine)

 Venous foot pump

Pros and Cons

Mechanical Interventions:  Types: graduated compression stockings

and intermittent pneumatic compression.

 Pro: More cost effective, no drug interactions

 Con: can cause the spread of nosocomial infections, dislodge pre- formed DVT that can result in fatal PE. little evidence is available to guide clinicians in the efficacy of mechanical thromboprophylaxis.

Pharmaceutical Interventions  Types: aspirin, unfractionated heparin,

low molecular weight heparins, vitamin k antagonists and fondaparinux

 Pro: pharmacological thromboprophylaxis could be a more effective, equally safe, and less expensive measure for the prevention of VTE.

 Con: The choice of best thromboprophylaxis technique still needs further investigations.

STOPDVTs

(O'Brien, 2018)

Kotter’s Model of Change

(Kotter, 2018.)

Recommendations for Change

 Nurses play a critical role in the detection of early DVT in postoperative patients

as they conduct frequent patient assessments, follow patients through their

inpatient journey and have the ability to prompt initial investigation of potential

cases and escalation of care (O'Brien, 2018).

 The need for additional education for the nurses staff. Increase knowledge to

incorporate the DVT assessment as a daily standard. Implement a rounding tool to

assist with early detection.

 Provide patient with educational handouts regarding DVT prevention upon admission

and discharge.

 The need for increased compliance is to prevent patients from developing

complications which can be avoided.

Evaluation of Effectiveness

 Due to a lack of evidence and the need for further studies, no implications

for practice can be made regarding the greater effectiveness of

pharmacological, mechanical, or combination prophylaxis.

 The reason for the lack of a gold standard is due to the complexity of DVT,

its risk factors and the constant change in medication and health status of

an individual in the acute care setting.

Suggestions for Further Study & New

Research Question

 Additional research needs to be completed in the preferred

pharmacological prophylactic agent and in the combination of

pharmacological and mechanical prophylaxis.

 Further studies on how to increase compliance of mechanical prophylaxis

in the acute care setting are needed.

 Further research studies need to be conducted in North America to

contribute to the development of a standardized DVT protocol in the

acute care setting.

 Development of increased communication and accountability of

interdisciplinary staff regarding implementation of mechanical prophylaxis.

Questions?

References

 AHRQ. (April, 2012). Methods Guide for Effectiveness and Comparative Effectiveness Reviews. Retrieved from www.effectivehealthcare.ahrq.gov/ehc/ products/60/318/MethodsGuide_Prepublication-Draft_20120409.pdf.

 Bala, A., Huddleston, J.I., Goodman, S.B., Maloney, W.J., Amanatullah, D.F. (2017). Venous thromboembolism prophylaxis after tka: Aspirin, warfarin, enoxaparin, or factor xa inhibitors? Clinical Orthopaedics and Related Research., 475 (9), 2205-2213. https://doi.org/doi:10.1007/s11999-017-5394-6

 Beitland, S., Sandven, I., Kjaervik, L., Sandset, P. M., Sunde, K., & Eken, T. (2015). Thromboprophylaxis with low molecular weight heparin versus unfractionated heparin in intensive care patients: a systematic review with meta-analysis and trial sequential analysis. Intensive Care Medicine., 41(7), 1209-19. https://doi.org/doi: 10.1007/s00134-015- 3840-z

 Centers for Disease Control and Prevention (CDC). (2018, August 29). Fact sheets about blood clots | CDC. Retrieved March 8, 2019, from https://www.cdc.gov/ncbddd/dvt/materials/factsheets.html

 Chibbaro, S., Cebula, H., Todeschi, J., Fricia, M., Vigouroux, D., Abid, H., ... Pop, R. (2018). Evolution of prophylaxis protocols for venous thromboembolism in neurosurgery: Results from a prospective comparative study on low-molecular-weight heparin, elastic stockings, and intermittent pneumatic compression devices. World Neurosurgery, 109, E510-e516. https://doi.org/doi:10.1016/j.wneu.2017.10.012

 O’Brien, A., Redley, B., Wood, B., Botti, M., & Hutchinson, A. F. (2018). STOPDVTs: Development and testing of a clinical assessment tool to guide nursing assessment of postoperative patients for deep vein thrombosis. Journal of Clinical Nursing, 27(9-10), 1803-1811.https://doi.org/https://doi.org/10.1111/jocn.14329

 Park, J., Lee, J.M., J.S., &Cho, Y. (2016). Pharmacological and mechanical thromboprophylaxis in critically ill patients: A network meta-analysis of 12 trials. Journal of Korean Medical Science, 31(11), 1828-1837. https://doi.org/doi: 10.3346/jkms.2016.31.11.1828

 Sachdeva, A., Dalton, M., & Lees, T. (2018). Graduated compression stockings for prevention of deep vein thrombosis. Cochrane Database of Systemic Reviews, 12, CD001484. https://doi.org/doi:10.1002/14651858.CD001484.pub3

 Snyder, M. A., Sympson, A. N., Scheuerman, C. M., Gregg, J. L., & Hussain, L. R. (2017). Efficacy in deep vein thrombosis prevention with extended mechanical compression device therapy and prophylactic aspirin following total knee arthroplasty: A randomized control trial. The Journal of Arthroplasty, 32(5), 1478- 1482. https://doi.org/10.1016/j.arth.2016.12.027