Evidenced based patient safety project/Nursing Protocol and Procedures

Evidenced based patient safety project/Nursing Protocol and Procedures Nursing Protocol and Procedures Name: MCD Protocol Scope: Organization-wide Page 1 of 12 Patient care is revised to meet the individual patient needs. DISCLAIMER: This policy was developed solely for the use of Children’s Hospital of Chicago Medical Center and its affiliates (“Medical Center”). The information contained herein shall not be relied upon by individuals or entities outside Medical Center for accuracy, timeliness, or any other purpose. PURPOSE: To outline the nursing management for the prevention of deep vein thrombosis and venous thromboembolism in patients who are thirteen years (13) of age or older. DEFINITIONS: Thromboembolism: Blood clot in an artery or vein is known as thromboembolism. Deep Vein Thrombosis (DVT): Development of thrombosis in one of the deep veins of the extremities, frequently the iliac or femoral veins or major upper extremity veins. These clots can break off from the vein, travel through the heart, and lodge in the arteries of the lungs, causing a potentially fatal pulmonary embolism. Pulmonary Embolism (PE): A thrombus that breaks free from a vein, travels through the veins, reaches the lungs, and lodges in a major or minor pulmonary vessel. A pulmonary embolism is a potentially fatal condition that may cause death within minutes to hours. Mechanical Compression device (MCD): A mechanical device that is used for pneumatic compression, applied via a cuff that inflates and deflates uniformly. The cuff may be applied to the extremity. Thrombophlebitis: The formation of a venous clot accompanied by inflammation of the vein wall. This may be the result of trauma to the vessel wall, hypercoagulability of the blood, or infection. Intra or post-operative venous stasis, prolonged sitting, standing, or immobilization or a long period of IV catheterization (eg. PICC line) may also cause thrombophlebitis. Venous Thromboembolism (VTE): A condition including DVT and PE. Venous thrombosis: A condition that occurs when a clot forms within a vein without inflammation. Nursing Protocol and Procedures Name: MCD Protocol Scope: Organization-wide Page 2 of 12 Patient care is revised to meet the individual patient needs. DISCLAIMER: This policy was developed solely for the use of Children’s Hospital of Chicago Medical Center and its affiliates (“Medical Center”). The information contained herein shall not be relied upon by individuals or entities outside Medical Center for accuracy, timeliness, or any other purpose. Supportive Data The prevalence of blood clots in pediatric patients is on the rise. Nearly 80% of blood clots in this population occur in the hospitalized setting and about 1 in 200 hospitalized pediatric patients develop blood clots. Considering the long-term morbidity of blood clots, prevention is vital. It is recommended that every child thirteen (13) years of age or older be assessed for the need of MCD sleeves. If the patient is under the age of thirteen (13), application of MCD sleeves and devices are per Physician/APN discretion only. EQUIPMENT LIST: Mechanical Compression Sleeves Mechanical Compression Device SECTION TITLES: A. Pre-Procedural Patients B. Intra-Procedural Patients C. Post-Procedural Patients D. Non-Procedural Patients Nursing Protocol and Procedures Name: MCD Protocol Scope: Organization-wide Page 3 of 12 Patient care is revised to meet the individual patient needs. DISCLAIMER: This policy was developed solely for the use of Children’s Hospital of Chicago Medical Center and its affiliates (“Medical Center”). The information contained herein shall not be relied upon by individuals or entities outside Medical Center for accuracy, timeliness, or any other purpose. DVT Risk Factor Assessment Sheet Directions: For patients 13 years of age or older review the risk factors listed below. Total the number of Major and Minor Risk factors. YES = 1 point NO = 0 point Major Risk Factor of 1 point or more = Place MCD Sleeves on the patient Minor Risk Factor of 3 points or more = Place MCD Sleeves on the patient Possible Risk Factors Yes / No Major Risk Factors Personal history of blood clot Yes / No Personal history of known thrombophilia (clotting disorder) Yes / No History of blood clots in immediate family (mother, father, brother, sisters, aunts, uncles, grandparents) Yes / No Immobilization (bed ridden/wheel chair bound) for at least 72 hours prior to or following the admission/procedure Yes / No Major orthopedic fractures: hip and/or pelvis Yes / No Pregnancy or Post-Partum Period Yes / No Morbid obesity (BMI >40 kg/m2) Yes / No History of Anticoagulant Therapy Yes / No TOTAL NUMBER OF MAJOR RISK FACTORS ________points Minor Risk Factors General Anesthesia Yes / No Patient on Birth Control Pills / Hormone Therapy Yes / No Scheduled Surgery time > 1hour Yes / No Orthopedic fractures: Lower Extremity Yes / No Disease etiology predisposing to DVT: Crohn’s Disease/Ulcerative Colitis Nephrotic Syndrome SLE (Lupus) Sepsis Diabetes Yes / No Cancer Yes / No Obesity (BMI>30- to 40 kg/m2 Yes / No Scheduled surgery on the limb that has a central venous catheter Yes / No Patients receiving Genitourinary, Gynecological or Extremity Surgeries Yes / No TOTAL NUMBER OF MINOR RISK FACTORS ________points Nursing Protocol and Procedures Name: MCD Protocol Scope: Organization-wide Page 4 of 12 Patient care is revised to meet the individual patient needs. DISCLAIMER: This policy was developed solely for the use of Children’s Hospital of Chicago Medical Center and its affiliates (“Medical Center”). The information contained herein shall not be relied upon by individuals or entities outside Medical Center for accuracy, timeliness, or any other purpose. CONTENT: A. PRE-PROCEDURAL PATIENTS STEPS NURSING MANAGEMENT Assess the patient for risk factors for DVT/VTE The pre-procedure nurse (including all in-patient nurses) will assess all patients thirteen (13) years of age or older using the ‘DVT Risk Factor Assessment Sheet’. If the pre-procedure patient has any 1 or more Major Risk Factors or has 3 or more Minor Risk Factors the patient is at risk for DVT/VTE. Follow below steps. Note: MCD use for patients under the age of thirteen (13) will be to the discretion of the Physician/APN and will need an order prior to application. Locate and obtain equipment and supplies. Locate and obtain equipment and supplies: • MCD sleeves can be obtained from Central Supply and on the units’ equipment store rooms. • MCD machines can be obtained from unit equipment store rooms and VIP. They will also be stored in the Intra- Procedural (OR) areas and in the PACU/Recovery areas. Orders For In-Patient Nurses: If patient meets criteria from DVT Risk Factor Assessment Sheet obtain order from Physician/APN before placing MCD sleeves on patient. If no order has been obtained before the patient leaves the in-patient area place the MCD sleeves on the patient’s bed. For Procedural Department Nursing Staff: No orders needed from Physician/APN if patient meets minimum from DVT Risk Factor Assessment Sheet. Note: If the patient is under the age of thirteen (13), application of MCD sleeves is per Physician/APN orders only. Nursing Protocol and Procedures Name: MCD Protocol Scope: Organization-wide Page 5 of 12 Patient care is revised to meet the individual patient needs. DISCLAIMER: This policy was developed solely for the use of Children’s Hospital of Chicago Medical Center and its affiliates (“Medical Center”). The information contained herein shall not be relied upon by individuals or entities outside Medical Center for accuracy, timeliness, or any other purpose. Application Prior to applying the MCD sleeves remove ALL clothing including undergarments (except- for patient’s hospital gown) Measure the size of patient’s calf to determine appropriate MCD sleeve size and ensure that the MCD sleeves are applied properly per the manufacturer’s instructions. In order to apply the compression sleeves: • Place sleeves over the lower extremity(s) below the knee. • Overlap the edges of sleeves and secure with the Velcro. • If the sleeve is too wide, fold one edge of the sleeve lengthwise until an appropriate fit is obtained. Overlap the edges of the sleeves and secure with the Velcro. • The compression sleeve may be applied to just one extremity if needed. Note: In order to provide effective DVT prevention, the MCD sleeves must be applied PRIOR to the patient receiving anesthesia. Documentation Document the application of MCD sleeves in the patient’s Pre- Procedure Checklist: • Click ‘Yes’: If the patient meets criteria and sleeves were placed on patient • Click ‘No’: If the patient does not meet criteria or the proceduralist does not want sleeves placed on patient • Click ‘N/A’: If the patient is under 13 years of age B. INTRA-PROCEDURAL PATIENTS STEPS NURSING MANAGEMENT Arrival in the Intra- Procedural area If the patient arrives in the Intra-Procedural area with MCD sleeves applied: • Confirm that the MCD sleeves are applied on the patient properly. • Obtain the mechanical compression device (located and stored in the intra-procedure sub-sterile room(s)). • Connect the device to the MCD sleeves • Turn the mechanical compression device to ‘ON’. Nursing Protocol and Procedures Name: MCD Protocol Scope: Organization-wide Page 6 of 12 Patient care is revised to meet the individual patient needs. DISCLAIMER: This policy was developed solely for the use of Children’s Hospital of Chicago Medical Center and its affiliates (“Medical Center”). The information contained herein shall not be relied upon by individuals or entities outside Medical Center for accuracy, timeliness, or any other purpose. If the patient arrives in the Intra-Procedural area with MCD sleeves on cart: • Obtain confirmation from the proceduralist for the application of the MCD sleeves and device and follow above steps for application. Transfer of patient to procedural table After transferring the patient to the procedural table, confirm placement of MCD sleeves and device. • Ensure that the MCD sleeves and device is turned on (prior to induction of general anesthesia or prior to regional anesthesia has been administered) and is functioning properly (including that the tubing is not kinked or twisted)Avoid when possible extreme degrees of flexion and internal rotation of the hip and knee during the procedure as this may cause a tourniquet effect to occur. • Avoid the use of Trendelenburg positioning when possible because of the potential reduction in the blood flow rate to the legs. Documentation Document the following in the ‘Equipment Log Section’ in the patient’s intra-procedural record: • Presence of a MCD machine and sleeves. Document the following in the ‘Skin Assessment’ section in the patient’s intra-procedural record: • Skin assessment under the compression sleeves. Departure from the intraprocedural area Prior to leaving the intra-procedural area: • Remove the mechanical compression device from the mechanical sleeves (while keeping the sleeves on patient). Ensure that you keep the connection hose with the mechanical compression device. This connection hose is NOT disposable. • Wipe the mechanical compression device and connection hose with the hospital approved germicidal agent. • Return the mechanical compression device and connection hose to the appropriate intra-procedural room. (Note: All mechanical compression devices are labeled with room numbers for return.) Nursing Protocol and Procedures Name: MCD Protocol Scope: Organization-wide Page 7 of 12 Patient care is revised to meet the individual patient needs. DISCLAIMER: This policy was developed solely for the use of Children’s Hospital of Chicago Medical Center and its affiliates (“Medical Center”). The information contained herein shall not be relied upon by individuals or entities outside Medical Center for accuracy, timeliness, or any other purpose. C. POST-PROCEDURAL PATIENT STEPS NURSING MANAGEMENT Arrival in the Post- Procedural Area Ensure that the MCD sleeves are properly positioned and have not rolled down the leg during transfer, as this may cause a tourniquet effect to occur. Reapply the MCD Machine to the sleeves Assess patient Orders Obtain a new MCD machine and re-connect it to the MCD sleeve. Ensure: • Proper connections and no kinked or twisted tubing • That the MCD is only removed for short periods of time. • That the MCD does not hinder ambulation efforts. Assess patient at least every 8 hours for: • Skin integrity: Assess extremity(s) by removing the compression sleeves for ten (10) minutes every 8 hours. • Neurovascular CMS check (While the MCD is in use and not in use) Continuous use of MCDs is recommended and any interruption of therapy for a substantial length of time should be at the discretion of the Physician/APN. The MCD sleeves should be removed immediately and Physician/APN notified if the patient experiences tingling, numbness or pain. If the post-procedure patient is being admitted to an in-patient floor and does not have an order yet for MCD use, obtain Physician/APN order. Documentation Education Document the application of MCD sleeves in the patient’s record. Educate the patient and family on: • Purpose of therapy • Problems that should be reported to nursing staff (i.e. tingling, numbness, pain, sleeves have rolled down patient). • Importance of early ambulation (if applicable- as directed per Physician/APN) in preventing post-procedural development of DVT / VTE. • To not to stand or walk with the MCD sleeves on. Nursing Protocol and Procedures Name: MCD Protocol Scope: Organization-wide Page 8 of 12 Patient care is revised to meet the individual patient needs. DISCLAIMER: This policy was developed solely for the use of Children’s Hospital of Chicago Medical Center and its affiliates (“Medical Center”). The information contained herein shall not be relied upon by individuals or entities outside Medical Center for accuracy, timeliness, or any other purpose. Discontinuation MCDs can be discontinued if: • There is Physician/APN order • When the patient becomes fully ambulatory • If the patient experiences any adverse reactions such as tingling, numbness, or pain. The Physician/APN must then be notified. Sleeves are disposable and are utilized for single patient use. The machine and tubing will be placed in the unit soiled utility room for cleaning by unit staff and then stored in unit’s clean equipment store room. D. NON-PROCEDURAL PATIENTS STEPS NURSING MANAGEMENT Assess the patient for risk factors for DVT/VTE The in-patient nurses will assess all patients thirteen (13) years of age or older using the ‘DVT Risk Factor Assessment Sheet’. If the patient has any 1 or more Major Risk Factors or has 3 or more Minor Risk Factors the patient is at risk for DVT/VTE. Follow below steps. Note: MCD use for patients under the age of 13 will be to the discretion of the Physician/APN. Locate and obtain equipment and supplies. Locate and obtain equipment and supplies: • MCD sleeves can be obtained from Central Supply and on the units’ equipment store rooms. • MCD machines can be obtained from unit equipment store rooms and VIP. Orders If patient meets criteria from DVT Risk Factor Assessment Sheet obtain order for the application of MCD sleeves from Physician/APN. Note: If the patient is under the age of thirteen (13), application of MCD sleeves is per Physician/APN orders only. Application Prior to applying the MCD sleeves remove ALL clothing including undergarments (except- for patient’s hospital gown) Nursing Protocol and Procedures Name: MCD Protocol Scope: Organization-wide Page 9 of 12 Patient care is revised to meet the individual patient needs. DISCLAIMER: This policy was developed solely for the use of Children’s Hospital of Chicago Medical Center and its affiliates (“Medical Center”). The information contained herein shall not be relied upon by individuals or entities outside Medical Center for accuracy, timeliness, or any other purpose. Connect Compression Sleeves To Mechanical Device Measure the size of patient’s calf to determine appropriate MCD sleeve size and ensure that the MCD sleeves are applied properly per the manufacturer’s instructions. In order to apply the compression sleeves: • Place sleeves over the lower extremity(s) below the knee. • Overlap the edges of sleeves and secure with the Velcro. • If the sleeve is too wide, fold one edge of the sleeve lengthwise until an appropriate fit is obtained. Overlap the edges of the sleeves and secure with the Velcro. • The compression sleeve may be applied to just one extremity if needed. Obtain a MCD machine and connect it to the MCD sleeve. Insure: • Proper connections and no kinked or twisted tubing • That the MCD is only removed for short periods of time. • That the MCD does not hinder ambulation efforts. Assess patient Documentation Education Assess patient at least every 8 hours for: • Skin integrity: Assess extremity(s) by removing the compression sleeves for ten (10) minutes every 8 hours. • Neurovascular CMS check (While the MCD is in and not in use) Continuous use of MCDs is recommended and any interruption of therapy for a substantial length of time should be at the discretion of the Physician/APN. The MCD sleeves should be removed immediately and Physician/APN notified if the patient experiences tingling, numbness or pain. Document the application of MCD sleeves in the patient’s record. Educate the patient and family on: • Purpose of therapy • Problems that should be reported to nursing staff (i.e. Nursing Protocol and Procedures Name: MCD Protocol Scope: Organization-wide Page 10 of 12 Patient care is revised to meet the individual patient needs. DISCLAIMER: This policy was developed solely for the use of Children’s Hospital of Chicago Medical Center and its affiliates (“Medical Center”). The information contained herein shall not be relied upon by individuals or entities outside Medical Center for accuracy, timeliness, or any other purpose. tingling, numbness, pain, sleeves have rolled down patient). • Importance of early ambulation (if applicable- as directed per Physician/APN) in preventing development of DVT / VTE. • To not to stand or walk with the MCD sleeves on. Discontinuation MCDs can be discontinued if: • There is Physician/APN order • The patient becomes fully ambulatory • If the patient experiences any adverse reactions such as tingling, numbness, or pain. The Physician/APN must then be notified. Sleeves are disposable and are utilized for single patient use. The machine and tubing will be placed in the unit soiled utility room for cleaning by unit staff and then stored in unit’s clean equipment store room. DOCUMENTATION: Documentation Document the following in the patient’s electronic medical record: • For procedural patients: Presence and assessment of MCD sleeves in the ‘SIDe’ flowsheet, equipment log section of intra-procedural record , and Pre-Procedure checklist. • For non-procedural patients: Presence and assessment of MCD sleeves in the ‘SIDe’ flowsheet. • Assessment of skin integrity, neurovascular CMS status, and other pertinent patient findings, including interventions, at least every 8 hours. • Removal of compression sleeves for ten (10) minutes every eight (8) hours. • Patient and family education. Nursing Protocol and Procedures Name: MCD Protocol Scope: Organization-wide Page 11 of 12 Patient care is revised to meet the individual patient needs. DISCLAIMER: This policy was developed solely for the use of Children’s Hospital of Chicago Medical Center and its affiliates (“Medical Center”). The information contained herein shall not be relied upon by individuals or entities outside Medical Center for accuracy, timeliness, or any other purpose. REFERENCES: AORN (2010). Prevention of venous stasis: perioperative standards and recommended practices, AORN 2010, 631-647. Calhoon, M.J., et al. (2010, September). High prevalence of thrombophilic traits in children with family history of thromboembolism. The Journal of Pediatrics, 157(3), 485-9. Geerts, W.H. et al. (2004). Prevention of venous thromboembolism: the seventh ACCP conference on antithrombotic and ahrombolytic therapy. Chest, 126(3 Suppl), 338S- 400S. Goldenberg, N.A. & Bernard, T.J. (2010). Venous thromboembolism in children. Hematology/ Oncology Clinics of North America, 24,151-166. Jackson, P.C., & Morgan, J.M. (2008). Perioperative thromboprophylaxis in children: development of guidelines for management. Pediatric Anesthesia, 18(6), 478-487. Monagal, P. & et al. (2008, June). Antithrombotic therapy in neonates and children: American College of Chest Physicians Evidence-based Clinical Practice Guidelines. Chest, 133(6 Suppl), 887S-968S. Raffini L., et al. (2011). Thromboprophylaxis in pedicatric hospital: A patient safety and quality-improvement initiative. Pediatrics,127(5), e1326-1332. Raffini L, Huang Y-S, Witmer C, et al. (2009). Dramatic increase in venous thromboembolism in children's hospitals in the United States from 2001 to 2007. Pediatrics, 24(4),1001- 1008. Setty B., O'Brien S.H., & Kerlin, B.A. (2010, March). Pediatric venous thromboembolism: redefining epidemiology [Abstract]. The National Conference on Blood Disorders in Public Health, Atlanta, GA. Young G., et al. (2009, September 23). Impact of inherited thrombophilia on venous thromboembolism in children: a systematic review and meta-analysis of observational studies. Circulation, 118(13),1373-82. Nursing Protocol and Procedures Name: MCD Protocol Scope: Organization-wide Page 12 of 12 Patient care is revised to meet the individual patient needs. DISCLAIMER: This policy was developed solely for the use of Children’s Hospital of Chicago Medical Center and its affiliates (“Medical Center”). The information contained herein shall not be relied upon by individuals or entities outside Medical Center for accuracy, timeliness, or any other purpose. AUTHOR: Christine Pytel, MSN, RN, CPN, CNOR Leah S. Weidner, MBA, BSN, RN, CPN DISTRIBUTION: All patient care areas except Emergency Department, Inpatient Psych, Outpatient Department. REVIEWED BY: Marybeth Browne, MD Laura Molenda, MBA, BSN, RN Debra Harker, MBA, BSN, RN Mary Hammes, BSN, RN, CNOR Carol VanProoyen, MSN/MBA/HCM, RN, CPN Frank Pulice, RN Susan Kolakowski, RN APPROVAL: Housewide Nursing Protocol and Procedure Committee APPROVAL DATE: 10/2012 EFFECTIVE DATE: 10/2012 REVIEW DATE: 10/201