Patient education proves best practice in DVT

Results are much better than national benchmark

About four years ago, Charleston Area Medical Center (CAMC) in Charleston, WV, implemented best practices for orthopedic patients to prevent deep-vein thrombosis (DVT) and pulmonary embolism (PE).

"We developed care maps and standardized physicians’ orders that emphasize manual as well as pharmaceutical prophylaxis, along with patient education," says Tami Currie, RN, ONC, the former orthopedic case manger, now a clinical staff nurse for trauma at CAMC.

Were the best practices effective? Very, according to a retrospective chart review from 1993, the year CAMC’s interventions were implemented.

"Prior to that we were doing prevention, of course, but we didn’t do it consistently with every patient — only the high-risk ones," Currie says. "After four years of streamlining our care and providing best practice patterns, we wanted to document how they were affecting patient outcomes."

So she and Kim Hayes, an information system specialist, teamed up to examine the charts of 1,436 patients who had total hips or knees replaced between Jan. 1, 1993, and Sept. 30, 1996, comparing DRGs 209 and 471 with ICD-9 codes for DVT/PE.

The study showed the medical center’s DVT/ PE incidence rate stayed at less than 1% during the four-year period. "We achieved reductions in length of stay and maintained the rate of DVT/PE despite an increase in the severity of illness score," says Currie. The increase in severity was due to a greater number of elderly patients, she explains. "Included in the study were patients in their 80s and 90s, who had fallen and needed a partial prosthesis." (See chart of data analysis, above.)

Although Currie wasn’t able to access the data to get a baseline of incidence before the best practices began, she uses a national benchmark from her literature reviews to measure her progress.

"We know from the literature that our likely occurrence among high-risk patients who do not receive any prophylaxis is 8.3% for DVT and 2.9% for PE," she says. The best practices implemented in 1993 had kept CAMC’s rate at 0.6% or lower for both DRGs, which means the center has saved about $604,000 through prevention, Currie says.

$3 billion problem: Silent disease

The costs of treating DVT/PE vary depending upon the type of facility, explains Jeffrey Lersch, director of marketing/vascular therapy for Kendall Healthcare Products Co., a vendor in Mansfield, MA, that supplies manual vascular compression products.

For example, the cost to a teaching institution may run $10,000 per incidence for DVT and $20,000 for PE, while those same costs could run $4,000 to $10,000 in a community hospital.

"It’s a $3 billion problem nationally," he says. "It’s often called the ‘silent disease’ because many times it isn’t diagnosed until it’s too late. That’s why prevention, rather than treatment, should be the focus."

Although Currie and Hayes worked together in 1996 to conduct the retrospective study, developing the best practices in 1992 was a collaborative effort involving orthopedic nurses, physicians, an internist, a physical therapist, an occupational therapist, a pharmacist, and a social worker.

"We gathered care maps from other institutions, talked to people at conferences, and put the information together, always asking the question, ‘What is the best way to do this?’" she says. They then developed their own care map, which has been revised twice since its implementation four years ago. (See care map excerpt, p. 126.)

The team also incorporated information from Kendall’s reference library containing protocols, case studies, and care maps from literature reviews. Among the tools developed were physician orders for each procedure that tailor care from admission to discharge, and nursing outcome flowsheets for each procedure that chart the expected progress.

Put education in care map

The extensive patient education effort is mapped by a patient education flowsheet detailing the education protocols for each procedure. (See sample of flowsheet, p. 127.) Additional education tools include patient instruction sheets for each procedure that detail for the patients what to expect following surgery; and a coumadin patient information handout. (See sample of handout, p. 128.) Additionally, the team secured 16-page patient education booklets that are given to patients to act as lifestyle guides after discharge.

Currie highlights these best practices for Healthcare Benchmarks:

1. Patient education.

"I consider this the number one best practice," says Currie. "Otherwise, patients don’t understand why they’re being asked to move, why they have foot pumps, or why their blood is being drawn everyday — and they’re not as likely to cooperate."

When patients arrive for preoperative testing, they receive comprehensive total joint education from the orthopedic nurses that includes information about mobilization as well as manual and pharmaceutical prophylaxis. The patient education flowsheet not only allows nurses to document which teaching method was used (audiovisual, demonstration, handout, etc.) but also to evaluate how well the patient can satisfactorily describe the concept or perform the task.

2. Early mobilization.

"It used to be that hospitals didn’t mobilize patients until three days after surgery," Currie says. "We thought we were doing them a favor, letting them recuperate in bed, but in retrospect, that was probably the worst thing we could have done as far as preventing DVT/PE."

Today, patients are informed in the pre-op teaching session that they will be sitting up in a chair the first day after surgery and walking with a walker or crutches in physical therapy by the second. (See activity section of care map excerpt, p. 126.)

3. Mechanical prophylaxis.

Although care maps don’t usually specify the brand names of products, Currie says the team opted to list Kendall’s compression devices. "We felt like they worked better than others and would give us the results we wanted, so we wanted those exact products on the care map," she explains.

Patients are informed that they may be wearing anti-embolism stockings after surgery, or have foot pumps or wraps on their legs to help prevent blood clots, she adds.

4. Pharmaceutical interventions.

In conjunction with mechanical prophylaxis, medications are such as Coumadin and low-dose heparin also are used to prevent DVT/PE.

The coumadin patient information sheet the team designed addresses dosage, lifestyle changes, and warning signs.

5. Standardize physicians’ orders.

In conjunction with creating care maps containing these best practices, the team also developed a pre-printed physicians’ order sheet for total hips and knees.

"All the essentials on the care map are included. We found that when you have to hand-write a order, it’s easy to overlook a step such as anticoagulation, mobilization, or foot pumps," she explains. (See copy of order sheet, inserted in this issue.)

[Editor’s note: For more information, contact Tami Currie, Charleston Area Medical Center, 5 S. Trauma, 501 Morris St., Charleston, WV 25312. Or contact Jeffrey J. Lersch, Kendall Healthcare Products Co., 15 Hampshire Mansfield, MA 02048, (800) 346-7197.]