Venous thromboembolism (VTE) as a factor that facilitates deaths in patients

Studies have pointed out cases of venous thromboembolism (VTE) acquired during the hospital stay as a critical factor that facilitates preventable deaths among in-patients. Notably, it is estimated that incidences of deep vein thrombosis (DVT) and venous thromboembolic (VTE) manifest at the rate of 117 cases per 100,000 people in the general population (Stewart et al. 2006). It is essential to note that deep vein thrombosis (DVT) and venous thromboembolism (VTE) tend to be among the common conditions affecting hospitalized patients, with a majority of them exhibiting one or multiple risk factors for the onset pf deep venous thrombosis. In the absence of both pharmacological and mechanical prophylaxis, it is estimated that 40-60% of hospitalized patients would, at some point, develop the condition. US Department of Health and Human Services (2008) estimates that approximately 100,000-180,000 annual deaths occur in the US alone as a result of pulmonary embolism. However, Piazza et al. (2012) indicate that venous thromboembolism (VTE) affects only 2 in every 100 acutely ill patients. Further, it underlines that with the appropriate implementation of the universal thromboprophylaxis protocols, 60% of venous thromboembolism (VTE) incidences would be mitigated (Cornwell III et al. 2002).

Relatively, the number of patients afflicted with chronic conditions emanating from venous thrombosis i.e., thromboembolic pulmonary hypertension, recurrent venous thromboembolism, post-thrombotic syndrome as well as VTE-related deaths would also be minimized by 60% (Stewart et al. 2006). Notably, despite extensive documentation of expert guidelines and best practices on the prevention of venous thromboembolism (VTE), underutilization of thromboprophylaxis on hospitalized patients remain problematic in the US and across the world in general (Cornwell III et al. 2002). Quality improvement programs that leverage on computerized decision support tend to enhance thromboprophylaxis prescription among hospitalized patients. However, while the initiatives aimed at enhancing the efficacy of thromboprophylaxis prescriptions are vital in mitigating the onset of venous thromboembolism (VTE), they often do not necessarily imply that the hospitalized patients receive adequate/effective mechanical or pharmacological prophylactic measures (Piazza et al. 2012). The paper examines inefficiencies in the administration of active prophylaxis orders in this case sequential compression devices (SCD) at the University of Mississippi Medical Center’s 5 North Orthopedic/Trauma Unit as well as formulate quality improvements initiatives on the same.

The use of sequential compression devices (SCD) is a standard prophylactic modality against deep vein thromboembolism in hospitals primarily due to its ease of use in addition to the safety profile attached to its administration going by results from various clinical trials. However, the issue of inconsistent compliance to physician orders on sequential compression devices administration remains a problematic aspect in nursing, an aspect that not only reduced the quality of care but also predisposes patients from unnecessary conditions (Stewart et al. 2006). It is critical to note that when it comes to the application of sequential compression devices, compliance is not limited to the presence of the equipment in the room but its proper application. That implies, the sequential compression device ought to be on the patient at all times when in a non-ambulatory state, switched on at the same time appropriately connected to a functional pump (Piazza et al. 2012).

Sample data from the University of Mississippi Medical center 5 North orthopedic/trauma unit depicts revelations of non-compliance, a reflection of poor nursing care. Non-compliance on the part of the nurses involved a lack of fulfillment in physician orders in that despite the existence of an active prophylaxis order. The nurses failed to ensure the patients in question had their sleeves on an in a working condition. Data for this metric indicated an upward trajectory in the three months of January to March with 3.4%, 7.7%, and 11.1%, respectively. The indicator for this particular metric implies reduction. However, from the data, it is apparent that over the three months on review, the figures have been on an upward trajectory, thus depicting diminished nursing care.

Conversely, the rates of patient refusal to venous thromboembolism prophylaxis were relatively high, with an average of 20.8%. It implies one out of five patients that physicians ordered for the administration of sequential compression devices declined the intervention. While patients have the autonomy to decline any form of treatment, the nurses are bound to provide relevant information on the essentiality of the intervention to the patient’s wellbeing.

Therefore, the high rates of refusals witnesses in the 5 North Orthopedic/trauma unit depict a fundamental failure on the part of nurses. Notably, in educating their patients on the importance of sequential compression devices as a prophylactic modality against deep vein thromboembolism. Notably, hospitalized patients tend to depict one or multiple risk factors to deep vein thromboembolism, an aspect that predisposes them to various venous thromboembolic events. Ideally, the Joint Commission and Centers for Medicaid and Medicare regard thromboembolism prophylaxis as a core measure for patients aged above 18 years and with the hospitalization of at least 48 hours (Murray et al. 2017). Additionally, in varied applications, mechanical venous thromboembolism prophylaxis has demonstrated the potential to reduce venous thromboembolic events by up to 60% while retaining a safety profile on the part of patients. These indicators depict the importance of full compliance of physician orders, particularly concerning the administration of sequential compression devices.

Non-compliance to physician orders concerning venous thromboembolism prophylaxis tends to be a problematic aspect across nursing care. However, interventions from both healthcare institutions and individual nursing units have played an integral role in reversing the trend. Periodic education among the nursing personnel, coupled with a routine audit on sequential compression device compliance undertaken by both nurses and physicians, has proved successful in numerous healthcare settings (Piazza et al. 2012). However, a majority of healthcare institutions that register high compliance rates to (SCD) physician orders tend to have instituted nursing cultures that emphasize on the use of sequential compression devices with absolute compliance as a standard of care. In that regard, for the University of Mississippi Medical Center to enhance its compliance rate from the current average of 73.4%, proper administration of SCD ought to be incorporated as a standard of care in the institution.

Contrary to common practice, some institutions are increasingly implementing mandatory documentation of SCD use as a modality of facilitating accountability for compliance with physician orders. In the case of the University of Mississippi Medical Center, in an average of 7.4% of situations, sequential compression devices were not either on the patient or in the room altogether. It implies the physician orders were not fulfilled an aspect that not only epic poor nursing care but also diminishes positive health outcomes on the part of the patient. In light of such compliance loopholes, some nursing units have incorporated the utilization of sequential compression devices in the nursing checklist as well as the signoffs between shifts to flag out non-adherence. The report indicates significant levels of patient refusal to SCD as a prophylactic modality against venous thromboembolism. Surprisingly, in January 2020, 5 North Orthopedic/trauma unit recorded 29.8% patient refusal to the administration of sequential compression devices while hospitalized. The average patient refusal rate for the three months stood at 20.8%, still a modest figure considering that the clients were on active prophylaxis orders. Patient education initiatives have proved to significantly enhance patients’ comprehension of the rationale for the administration of SCD, an aspect that, in turn, fostered medication adherence by approximately 5% (Maynard, 2016).

That notwithstanding, standard nursing response to the patient refusal of SCD administration through structured one-on-one sessions is essential in reducing such incidents. Standardization ensures the client is made aware of the potential complications resulting from lack of venous thromboembolism prophylaxis, individualized VTE risk factors as well as forwarding patient refusal feedback to the prescribing physician (Maynard, 2016). Numerous nursing units have reported enhanced success rates using this intervention. Additionally, a majority incorporated an assessment of appropriate SCD administration through daily ward rounds by multidiscipline teams, including timely feedback on patient refusal rates.

After an in-depth analysis of VTE Redcap Metrics on SCD sleeves for 5 North Orthopedic/Trauma unit, it revealed significant levels of non-compliance to physician orders and high levels of patient refusals. In that regard, the unit will embark on quality improvement initiatives meant to address the underlying issues. Targeted interventions focused on fostering enhance compliance on SCD compliance, documentation as well as patient education all meant to facilitate compliance documentation and overall patient care. Some of the proposed quality improvement initiatives include; periodic nursing education on universal SCD administration best practices, routine audits on SCD compliance, and fostering a nursing environment at the unit where the use of SCD with absolute compliance is a standard of care. That notwithstanding, incorporation of SCD use in the nursing checklist, targeted patient education initiatives as well as standard nursing response and documentation of patient refusals to SCD administration. Ideally, these initiatives seek to revamp the implementation of SCD administration by introducing enhanced accountability, all aimed at facilitating positive outcomes on the part of the patients that, in turn, minimize in-hospital DVT incidences. With these initiatives in place, it is expected that the level of appropriate SCD administration will increase from the current 73.4% to approximately 80%, on the other hand, incidences of patient refusals will drop by roughly 5% from the current average.

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