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Leadership Strategy Analysis: Quality Improvement Process for DVT Prophylaxis


Brandie Zimmerman, Student and Student
Ferris State University

Running Head: LEADERSHIP STRATEGY

Leadership Strategy Analysis: Quality Improvement Process for DVT Prophylaxis


Deep vein thrombosis (DVT) is a condition that affects patients in many different
healthcare settings. DVTs are a complication that can potentially have fatal consequences for
patients. DVT along with pulmonary embolism comprise a condition known as venous
thromboembolism (VTE). The incidence of VTE is 10% to 20% in general medical patients,
20% to 50% in patients who have had a stroke, and up to 80% in critically ill patients (Smeltzer
et al., 2010, p. 874). As nursing professionals, it is our duty and responsibility to our patients to
implement interventions and coordinate with other healthcare professionals to prevent this
complication from happening. This paper will explore the clinical need for DVT prophylaxis and
will present a design for an interdisciplinary team, a design for data collection methods, will
establish desired outcomes, implement strategies for change and evaluate the quality
improvement process.
Clinical Need
In todays healthcare economy, healthcare professionals are under more pressure to
prevent this complication from happening while a patient is hospitalized. According to the
Affordable Care Act of 2010, Medicare and Medicaid will no longer provide payment for
provider preventable conditions (PPCs) including health care-acquired conditions (HCACs) and
other provider-preventable conditions (OPPCs) (Centers for Medicare and Medicaid Services ,
2014). DVTs developed after elective knee and hip replacements have been included in this nonpayment exclusion criterion. The development of DVTs related to other diagnoses and
conditions will still be reimbursed. However, the development of a DVT regardless of the reason
will result in the patients increased length of stay which will ultimately increase the cost of the
hospitalization. A recent study focused on the costs of DVTs found that patients with DVT, PE,

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or DVT and PE had higher annualized direct medical costs before the index (initial) DVT and/or
PE event (median: $7227, $6381, and $6771, respectively) than controls (median: $1045).
During and after the DVT/PE event annualized median costs rose to $17,512, $18,901, and
$25,554, respectively, compared with $680 in the control group (MacDougall et al., 2006). This
was just the cost of a DVT with one patient. These costs will add up and will increase over time
and could cause healthcare organizations to go into debt or bankruptcy.
It is not only the high cost of treatment for DVTs that makes the need for prevention so
great, but it is also the long term complications. The biggest concern after a patient develops a
DVT is the development of a pulmonary embolism (PE). This is when the blood clot that formed
in the extremity moves to the lung and blocks one or more of the blood vessels. This condition
can be fatal if it is not caught in time (Mayo Clinic Staff, 2014). Another complication that can
occur as a result of a DVT is postphlebitic syndrome. This condition is caused by the damage to
the veins during the blood clot and results in decreased blood flow to the area. Patients can
experience edema, pain, skin discoloration, and skin sores as a result of the condition.
Postphlebitic syndrome can occur years after a DVT happens. These long term complications
make it apparent that the need for prevention of a DVT is important for all patients (Mayo Clinic
Staff, 2014).
Interdisciplinary Team
Effective DVT prevention will require professionals from multiple disciplines including
nursing, physicians, and physical therapy. The physicians can identify individuals at risk for
DVTs and prescribe anticoagulation medications as necessary. They can also write orders for
compression devices and stockings used in DVT prophylaxis. Nurses can then carry out the
orders by applying the compression devices and stockings and administering anticoagulant

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medications. Nurses can also encourage early ambulation and identify patients who will need
physical therapy. Physical therapy can then assist patients who are having difficulties with
ambulation and help them to reach their full activity potential.
Data Collection
In reducing the risk of venous thromboembolism in hospital patients, data is collected to
measure the quality of this standard. A detailed flowchart provides a complex process to view
what step will add value and which is the next path to take to prevent a venous
thromboembolism incident in each individual patient. This method of data collection helps team
members to gain a shared understanding of the process and uses this knowledge to identify the
problems as well as which resources will be utilized.
The flowchart on the following page was initiated by the National Institute of Health and
Care Excellence (NICE) and displays the steps that are initiated on new admissions to identify
and prevent VTEs in patients (NICE, 2014). After decades of research, health care providers
have identified the best clinical pathway to take and which is the best solution to this potentially
deadly problem.

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Reducing the risk of venous thromboembolism


in hospital patients

Provide patients with information

Risks and possible consequences of VTE


Importance of prophylaxis and possible side effects

Patients having elective surgery

All patients that are admitted.

Assess risk of VTE and bleeding


Do not administer VTE prophylaxis if the
patient is high risk for bleeding.

Only administer VTE prophylaxis if the risk


of bleeding outweighs risk of VTE.

Choice of VTE prophylaxis


Mechanical prophylaxis (anti-embolism
stockings, sequential compression
devices)
Pharmacological

Figure 1. This is a flowchart that shows the National Institute of Health and Care Excellences
recommendations for assessing patients risk for a VTE (NICE, 2014).

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Once decision is made to prevent VTEs with either or both mechanical and
pharmacological measures, review of systems must be continued to evaluate the effectiveness of
this prophylactic treatment. Further assessment is done to determine whether therapy is to be
continued or stopped after discharge of the patient.
In improving DVT prophylaxis in hospitalized patients, between the NICE pathway and
the American College of Chest Physicians (ACCP), guidelines were established for the use of
thromboprophylaxis. These guideline developers cited the high prevalence of VTE in
hospitalized patients, the common problem of a clinically silent VTE and the associated burden
of a VTE. Compliance in following these guidelines is a vital part of a patients admission and
recurring assessment. In a study conducted by Memorial Medical Center (MMC) in Springfield,
Illinois, hospital-wide compliance in prescribing adequate pharmacologic and mechanical
prophylaxis improved from pre-intervention to post-intervention (Annamalai, 2006).
Established Outcomes
The overall goal is not so much as to have 100% of all patients on anticoagulants or
using mechanical devices for DVT prophylaxis, but to have 100% of health care providers
assessing their patients for appropriate prophylaxis. As with antibiotic administration, the keys
to preventing DVT are assessing who is at risk, when to apply the preventive measure, and
applying the appropriate measure. Implementation of a system-wide process for preventing
DVTs is a standard of care that reflects evidence-based practice in reducing the incidence of
VTEs in hospitalized patients.
Implementation Strategies
Critically ill patients, trauma patients and surgical patients are at a higher risk for DVT
development (Songwathana, Promlek & Naka, 2011). According to Songwathana, Promlek &

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Naka (2011), complications from DVTs are the third leading cause of death in critically ill and
trauma patients. The risk for DVT development can be reduced by implementing a risk
assessment and following a protocol to implement prophylactic measures for DVT prevention
(Songwathana, Promlek & Naka, 2011).
A planned change theory and linear approach to implementing VTE risk assessment
utilizes three stages of process change (Yoder-Wise, 2011, pg. 326-327). The first stage of
implementing VTE risk assessment is to provide VTE education in order to make staff aware of
the risk factors and potential impact on health and wellness for patients at risk for developing a
VTE or DVT (Yoder-Wise, 2011, pg. 327). A study conducted by Songwathana, Promlek &
Naka (2011) suggests that educating staff about the risk for DVT or VTE development could
lead to greater compliance in risk reduction methods and strategies. The second stage for
implementing VTE risk assessment is to integrate a VTE risk assessment tool into the admission
assessment. This tool will evaluate certain risk factors for DVT or VTE development such as:
critically ill, trauma, surgery, pregnancy and limited mobility patients (Songwathana, Promlek &
Naka, 2011). The third stage for implementing VTE risk assessment is to continually measure
the success of the risk assessment by conducting surveys for staff input about process change and
evaluating the implementation strategies to continually improve the process (Yoder-Wise, 2011,
pg. 327).
Evaluation
According to Yoder-Wise (2011), the process of evaluating change should be conducted
from the beginning of the change process, throughout the process and after implementation of
the change to determine the successfulness of the change that is implemented (pg.331). The
process of implementing DVT prophylaxis is best described by the PRECEDE-PROCEED

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model for health promotion (Pender, Murdaugh & Parsons, 2011, pg. 74). This model states that
health risks are related to multiple risk factors and efforts to change the risk of poor outcomes is
multidimensional and must be participatory for successful outcome to be achieved (Pender,
Murdaugh & Parsons, 2011, pg. 74). This model supports use of surveys to determine the staffs
current knowledge of VTE and DVT risk factors and potential health implications. This model
further supports staff education and early risk assessment using a risk assessment tool to evaluate
high risk factors related to DVT or VTE development. This model also supports the use of
evaluation tools designed to monitor staff follow through with preventative measures and a tool
utilized to evaluate if the strategies implemented effectively reduced the risk for developing a
VTE or DVT in high risk patients. According to Songwathana, Promlek & Naka (2011),
implementing education, interventions and conducting evaluations throughout the process could
reduce the risk of developing a DVT or VTE in high risk patients.
Conclusion
DVTs are the third leading cause of morbidity in high risk patients and are preventable
with proper education, assessment and implementation of risk reduction measures (Songwathana,
Promlek & Naka, 2011). Hospital acquired DVTs are financially costly and pose a high risk for
complications, including morbidity (MacDougall et al., 2006). This evidence suggests the
clinical need to develop an interdisciplinary team to collect data on DVT and VTE risk in order
to develop and implement strategies to decrease the risk for DVT or VTE development. DVTs
can be prevented through staff education, risk assessment, implementation of risk reducing
measures and evaluating the reduction of risk. These measures are cost effective and improve
patient outcomes. Overall, the prevention of DVTs is in the best interest for patients and
healthcare organizations.

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References
Annamalai, A. & Deckard, A. (2006). Improving DVT Prophylaxis in Hospitalized Patients: A
Quality Improvement Project. Semin Med Practice, 2006; 9:47-53. Retrieved from:
http://www.turner-white.com
Centers for Medicare and Medicaid Services. (2014). Provider preventable conditions. Retrieved
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MacDougall, D., Feliu, A., Boccuzzi, S., & Lin, J. (2006). Economic burden of deep-vein
thrombosis, pulmonary embolism, and post-thrombotic syndrome. American Journal of
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Mayo Clinic Staff. (2014). Diseases and conditions: deep vein thrombosis. Retrieved from Mayo
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National Institute for Health Care Excellence. (2014, June). Reducing the risk of venous
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