122-静脉血栓形成（英文）

nullThe Surgical Care Improvement Project: VTE MeasuresThe Surgical Care Improvement Project: VTE MeasuresMasspro June 21, 2007This material was prepared by Masspro, the Medicare Quality Improvement Organization for Massachusetts, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily represent CMS policy. 8sow-ma-hosp-07-76 SCIP-VTEMeasures-juneObjectivesObjectivesReview the science / medicine Share improvement strategies and tools Discuss the performance measures and key data elements Review frequently asked questions Respond to new and unanswered questionsVTE ReferencesVTE ReferencesAnderson Frederick, PhD University of Massachusetts Bratzler Dale, DO, MPH HI QIOSC Medical Director Dalton Vanessa MD American College of Obstetricians and Gynecologists DePalma Ralph, MD National Director of Surgery, Acute Care Strategic Healthcare Group, Dept of Veterans Affairs Flum David, MD University of Washington Geerts William, MD Canada: chairs the ACCP Consensus committee on VTE prevention Heit John, MD Mayo Clinic, Rochester Hyman Neil, MD American Society of Colon and Rectal Surgeons Kresowik Timothy, MD Society for Vascular Surgery Lieberman Jay R, MD American Academy of Orthopedic Surgeons Padberg Frank, MD Chief, Vascular Surgery, Dept of Veterans Affairs Raskob Gary, PhD University of Oklahoma, Dean of College for Public Health Sidawy Anton, MD Chief, Vascular Surgery, Dept of Veterans Affairs VTE ReferencesVTE ReferencesPrevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, Ray JG. Chest. 2004 Sep;126(3 Suppl):338S-400S. From the Seventh American College of Chest Physicians Conference, this article provides guidelines for the prevention of venous thromboembolism in hospitalized patients and represents an update of the guideline published in 2001. VTE 101VTE 101A venous thromboembolism (VTE) is a formation, development, or existence of a blood clot or thrombus within the venous system. Virchow’s Triad: Vascular wall abnormality Venous stasis Activation of coagulation Symptoms include: None Calf / Thigh pain Leg swelling Dyspnea, chest pain, hemoptysisRisk Factors for VTERisk Factors for VTESurgery Trauma (major or lower extremity) Immobility, paresis Malignancy Cancer therapy Previous DVT Increasing age Pregnancy and the postpartum period Estrogen-containing oral contraceptives or hormone replacement therapySelective estrogen receptor modulators Acute medical illness Heart or respiratory failure Inflammatory bowel disease Nephrotic syndrome Myeloproliferative disorders Parxysmal nocturnal hemoglobinuria Obesity Smoking Varicose veins Central venous catheterization Inherited or acquired thrombophiliaVTE and the Hospitalized PatientVTE and the Hospitalized PatientVenous thromboembolism (VTE) includes deep vein thrombosis (DVT) and pulmonary embolism (PE) VTE is one of the most common complications of the hospitalized patient Thromboemboloic complications Excess length of stay Excess mortality Excess hospital charges PE is the most common preventable cause of hospital deathAbsolute Risk of DVTAbsolute Risk of DVTPatient Group Medical patients General surgery Major gynecologic surgery Major urologic surgery Neurosurgery Stroke Hip or knee arthroplasty, hip fracture surgery Major trauma Spinal cord injury Critical care patientsDVT Prevalence, % 10 – 20 15 – 40 15 – 40 15 – 40 15 – 40 20 – 50 40 – 60 40 – 80 60 – 80 10 – 80 Clinical Evidence for VTE ProphylaxisClinical Evidence for VTE ProphylaxisHundreds of randomized trials Over 20 published evidence-based guidelines showing clear evidence of benefits and safety Reductions in: Incidence of DVT Incidence of PE All-cause mortality CostsVTE Prophylaxis: Grade 1 RecommendationsVTE Prophylaxis: Grade 1 RecommendationsVTE Prophylaxis: Grade 1 RecommendationsVTE Prophylaxis: Grade 1 RecommendationsVTE Prophylaxis: Grade 1 RecommendationsVTE Prophylaxis: Grade 1 RecommendationsVTE Prophylaxis: Grade 1 RecommendationsVTE Prophylaxis: Grade 1 RecommendationsRational for ThromboprophylaxisRational for ThromboprophylaxisHigh prevalence of VTE Adverse consequences of unprevented VTE Efficacy and Effectiveness of thromboprophylaxis Without prophylaxis, deep vein thrombosis occurs in 25% and pulmonary embolism occurs in 7% of all major surgical procedures. Despite the well-established efficacy and safety of preventive measures, studies show that prophylaxis is often underused or inappropriately used. Improvement Strategies and ToolsImprovement Strategies and ToolsIncorporate into routine patient care Develop a written policy on VTE prophylaxis Recognize the role of nursing staff Pre-printed orders – sensible prophylaxis Computer reminders with CPOE (Computerized Physician Order Entry) Audit and feedback VTE MeasuresVTE MeasuresVTE 1 - Surgery patients with recommended venous thromboembolism prophylaxis ordered VTE 2 - Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery VTE 3 - Intra- or postoperative pulmonary embolism (PE) diagnosed during index hospitalization and within 30 days of surgery VTE 4 - Intra- or postoperative deep vein thrombosis (DVT) diagnosed during index hospitalization and within 30 days of surgery.Version 2.2b ExclusionsVersion 2.2b ExclusionsPatients who are less than 18 years of age Procedures performed entirely by laparoscope Procedures where total surgery time is < 30 minutes Length of stay < 24 hours postop Burn patients Patients on Warfarin prior to admission Patients with contraindication to both mechanical and pharmacological prophylaxis Principal procedure occurred prior to the date of admissionKey Data Elements: VTE ProphylaxisKey Data Elements: VTE ProphylaxisDocumentation of venous thromboembolism (VTE) prophylaxis ordered anytime during this admission. 1 Low dose unfractionated heparin (LDUH) 2 Low molecular weight heparin (LMWH) 3 Intermittent pneumatic compression devices (IPC) 4 Graduated compression stockings (GCS) 5 Factor Xa Inhibitor 6 Warfarin A None of the above / not documented / UTDKey Data Elements: VTE ProphylaxisKey Data Elements: VTE ProphylaxisIPCs include: AE pumps DVT boots EPC cuffs / stockings Flotron / Flotron DVT system Impulse pump Plexipluse Sequential compression device Sequential TEDS Venodyne boots GCS include: Anti-embolism stockings Anti-thrombosis stockings Elastic support hose Graduated compression elastic stockings Jobst stockings Surgical hose Ted hose (TEDS) Thrombo-guard White hose Thrombosis stockingsKey Data Elements: VTE TimelyKey Data Elements: VTE TimelyDocumentation of venous thromboembolism (VTE) prophylaxis received within 24 hours prior to Surgical Incision Time to 24 hours after Surgery End Time. If VTE prophylaxis was ordered and administered within the defined time frame, select “Yes” If VTE prophylaxis was ordered and not administered, select “No” If VTE prophylaxis was ordered and not administered within the defined time frame, select “No”Key Data Elements: ContraindicationKey Data Elements: ContraindicationDocumentation by a physician / advanced nurse practitioner / physician assistant of contraindications to both pharmacological and mechanical venous thromboembolism (VTE) prophylaxis. In order to select “Yes”, patients must have documentation of contraindications to both mechanical and pharmacological prophylaxis Documented Bleeding Risk is not a contraindication to all types of VTE prophylaxisKey Data Elements: Bleeding RiskKey Data Elements: Bleeding RiskDocumentation by a physician / advanced nurse practitioner / physician assistant of a risk for bleeding that contraindicates an order for pharmacological VTE prophylaxis. If the physician / APN / PA documents that the patient is at risk for bleeding or that pharmacological prophylaxis is not being ordered “due to bleeding”, select “Yes” If there is documentation of a bleeding risk, the patient may still be eligible for mechanical prophylaxisNewport Hospital Initiative 2004Newport Hospital Initiative 2004Absolute Contraindication Active hemorrhage Epidural/indwelling spinal catheter – placement or removal Heparin or warfarin use in patients with heparin-induced thrombocytopenia (HIT) Severe trauma to head, spinal cord, or extremities with hemorrhage within the last 4 weeks Warfarin use in the first trimester of pregnancy Relative contraindication Active intracranial lesions / neoplasms / monitoring devices Coagulopathy (PT > 18 sec) Craniotomy within 2 weeks GI / GU hemorrhage within the last 6 months Hx of cerebral hemorrhage Proliferative retinopathy Thrombocytopenia Uncontrolled HTN (SPB>200, DBP>120, or both) Vascular access / biopsy site inaccessible to hemostatic controlKey Data Elements: Neuraxial AnesthesiaKey Data Elements: Neuraxial AnesthesiaDocumentation that the patient received neuraxial anesthesia for the surgical procedure. Neuraxial anesthesia is medication administered into the epidural space (“epidural”) or spinal canal (“spinal”) to block sensations of pain An epidural catheter whether for anesthesia or pain management is consistent with neuraxial anesthesia and this data element should be answered “Yes”Key Data Elements: Preadmission WarfarinKey Data Elements: Preadmission WarfarinDocumentation that the patient was on Warfarin prior to admission. If there is documentation that warfarin was a “home” or “current” medication, select “Yes” If warfarin was listed as a “home” or “current” medication, but placed on hold prior to surgery, select “Yes” If there is no documentation that the patient was on warfarin prior to admission, select “No” Key Data Elements: LaparoscopeKey Data Elements: LaparoscopeDocumentation that the surgical procedure was performed entirely with a laparoscope. If there is documentation the surgical procedure was performed entirely by laparoscope, select “Yes” If there is documentation the surgical procedure was not performed entirely by laparoscope, select “No” If unable to determine, select “UTD” If the only incision that is made is to introduce the laparoscope or thorascope, the operation is laparoscopic onlySCIP: VTE MeasuresSCIP: VTE MeasuresFrequently Asked QuestionsSCIP: VTE MeasuresSCIP: VTE MeasuresNew and Unanswered Questions