DVT In Nursing

ABSTRACT

There is an ever growing introduction of new anticoagulants i.e. blood thinning medications into the health care market. Due to the associated risk of DVT prophylaxis with concurrent anti-coagulation therapy, it is imperative that detailed medication reconciliation is completed pre and post hospital admission/discharge or special procedures to prevent complications of increased bleeding. Factors influencing these risks include; multiple dosing providers, poor patient compliance, and adverse concurrent anticoagulant use. Improved nursing research has been initiated to improve awareness and the incidence of adverse affects on patient populations.

Deep Vein Thrombosis (DVT) is the collection of blood within the deep veins of

the body. This collection of blood disrupts the current flow through the venous circulation and leads to the lodging of clots. These clots affect areas such as organs; often time the lungs, and other circulatory pathways, causing the lack of perfusion distal to the clot. According to the CDC approximately 60-100,000 Americans die from DVT complications per year, and around 900,000 are thought to be affected. In an effort to minimize the risk of DVT occurrence, DVT prophylaxis protocols have been initiated when patients come into the health care setting. Prophylaxis includes pneumatic compression devices (PCD’s), ambulation of patients when possible, and medication.
Medication reconciliation is vital to the continuation of therapeutic goals of the patient.

Proper health and medication history/reconciliation is important pre-admission, during, and discharge from the hospital setting. Ziaeian et. al. conducted a study on the medication accuracy and patient understanding of intended medication changes at discharge. This article concluded that “Medication reconciliation and patient understanding are inadequate in older patients post discharge. Errors and misunderstandings are particularly common in medications unrelated to the primary diagnosis. Efforts to improve medication reconciliation and patient understanding should not be disease specific, but should be focused on the whole patient”. The responsibility to educate patients is shared among various disciplines. At discharge, nurses play a vital role in medication reconciliation with the transition of patients back into the home or post hospital care setting. A major observed preventative risk with DVT prophylaxis is multiple dosing providers, poor patient compliance, and adverse concurrent

anticoagulant.
Polypharmacy is very prevalent in the geriatric community. Multiple dosing providers can lead to various adverse outcomes and poor medication compliance. An example of the risk associated with multiple dosing providers is anticoagulant use. Poor medication history and lack of communication congruency of heath personnel can lead to severe symptoms or even death of the patient. In the article “Anticoagulant PolyPharmacy” pharmacist Zarowoitz list several recommendations to assist in preventing a severe interaction with patients needing blood thinners. “1. Medication reconciliation upon transition to new care environment and between physician prescribers is recommended to identify and prevent potential medication errors caused by omission, duplication, or discontinuation of medication. 2. The elderly are at increased risk of significant bleeding when treated with antiplatelet or anticoagulant monotherapy. Therefore, risk should be mitigated by initiating the lowest effective dose for the shortest possible duration”.
When obtaining a medication history, one of the major questions patients are asked: “Are you currently taking any blood thinners or anticoagulants?” Patient often time answer no to these questions because of forgetfulness or not understanding the meaning or uses of medications. After review of medication list in the computer system and you see documented daily aspirin or Coumadin. The patient often reply is “Oh yeah, I take that too”. Understanding the seriousness of DVT prophylaxis with concurrent anticoagulant use is extremely important in post surgical patients as well as those who require anti-aggregate therapy use. “Adverse drug events after hospital discharge are common and often serious. These events may result from provider errors or patient misunderstanding (Ziaeian et. al)”. Doctor’s offices and health care facilities have implemented printable list to carry from practitioner to practitioner to ensure the continuity of medication profiles.
Another important factor is poor patient compliance. There responsibility of safe DVT prophylaxis in concurrent with anticoagulation medication does not rest solely on the health care provider. Patients themselves also participate is an importance role. Compliance issues range from missing dose, doubling doses, not obtaining prophylactic medication in a timely fashion, therapeutic level checks, and also diet modification. Diet modification is very important. Anticoagulants such as Coumadin or Lovenox require certain foods to be avoided in order to maintain a therapeutic blood level of coagulation. “A better understanding of patients’ functioning level and health utilization factors may help to develop and target interventions for high risk patients and reduce complications from suboptimal therapy and poor warfarin management due to non-compliance (Seliverstov, 2011).” Encouraging ownership is effective in the ability of patients to sustain responsibility in their care. Patients have greater outcomes when engage to participation in their care. Also, providing information to patients at a school age literacy levels helps to ensure the information attempting to be conveyed is received without missing elements.
Adverse concurrent anticoagulant medication use is among the top risk factors for increased bleeding in patients receiving DVT prophylaxis. Patients should continuously be instructed on the Signs and symptoms of increase bleeding with the additional of new anticoagulant therapy, throughout the process and cessation of the medication therapies. These adverse symptoms include blood in urine (hematuria), bleeding of the gums, teeth or ears, as well as severe adverse hemorrhagic reaction. “Before administering an anticoagulant, coagulation test values must be checked. If they are abnormal, the physician must be notified. Normal ranges prior to anticoagulation therapy are (Skidmore-Roth, 2007).
Platelets 150,000-400,000/mm3
Or 150-400 x 109/L
Activated partial thromboplastin time (APTT) 30-40 sec.
Partial thromboplastin time (PTT) 60-70 sec.
Prothrombin time (PT) 11.0-12.5 sec.

The above coagulation test, are not entirely indicative of therapeutic dosage levels of all medications.

Some DVT prophylaxis therapeutic levels cannot be measured immediately, timing varies according by medication. Education also needs to focus on patients stopping and restarting of blood thinning medications pre/post discharge. Discontinuation or holding of medications pre surgery has to be closely monitored post op. Some diseases processes require blood clotting times to be at a certain therapeutic level. Postsurgical procedures routinely have standard DVT prophylaxis. A mistake within the medication reconciliation is that patients are ordered DVT prophlaxis without addressing the previous anticoagulation medication pre-hospital admission, and when the patient goes home to resume medications. They continue to take medications as previously with the additional discharge medication. This error isn’t often found until the next doctors’ office visit, home care nurse visit, or complications arise where the patient has to return back to the health care facility for sever and life threatening emergency. Safe practices policy and procedures have been put in place to ensure such adverse occurrences are prevented from happening. Some of these practices include: “The following basic principals can be used to reduce errors when using fibrinolytics and related drugs (Jennings,

2008).”
1. Standardize
2. Simplify
3. Improved access to information
4. Restrict access to high alert drugs
Standardizing the approach in managing patient medications across the health care discipline enables all providers to have one uniform approach in medication evaluations. It also simplifies the reconciliation process to add and delete medications at once, and after the patient health care visit, each time the medication list can be updated and or modified. With the recent push towards electronic medical records individuals can now access their records and notify providers of errors in information. This gives the patient also additional responsibility in their care. Another way to manager adverse reactions to coagulation and DVT prophylaxis therapy is to have restrictions for high alert drugs. This acts as a fail safe for hospital administered drugs as well as those reconciled at discharge.

In conclusion, the risk factors associated with DVT prophylaxis and concurrent anticoagulant use are very severe. It is the responsibility for all health professionals to reconcile medications on an as needed basis, those who prescribe; those who deliver medications as Pharmacist, and nurses administer these medications. As mention previously, this should be done before administering, ordering, and dispensing any anticoagulant products. Patients provide a key role in the compliance, information providing, and management of their medication in the home setting. Our ability to standardize this process will help to decrease the occurrence of adverse medication errors with acute and prolong DVT prophylaxis. Much research is available, but there is a need for specific additional studies to be completed as it narrows to specific disease processes and how anticoagulant therapies are managed.

References

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Reducing anticoagulant medication adverse events and avoidable patient harm. The Joint
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5. Skidmore-Roth, L. (2007). Mosby's 2007 nursing drug reference. Philadelphia: Mosby.
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Medication Changes on Hospital Discharge. JGIM. (2012).

7. Zarowitz, Barbara. Anticoagulant Polypharmacy. Geriatric Nursing, Volume 32, Number 3.

Medication Changes on Hospital Discharge. JGIM. (2012).