Venous Thromboembolism Treatment Non-Compliance

The EBP project investigates the problem of venous thromboembolism (VTE) treatment non-compliance since it is common in nursing practice and poses the risk of complications for patients admitted to the Medical/Surgical unit and post-operative patients. Hospital-acquired VTE causes about 25,000 preventable deaths annually and substantially increases hospital expenses (Nana et al., 2020, p.1). Medicaid Services do not cover the additional costs for the treatment of VTE complications triggered by patient non-compliance (Wiznia et al., 2019). 30% of patients reported poor understanding of the procedures and devices used for VTE prevention, so non-compliance might be caused by the lack of knowledge on VTE prophylactic treatment (Wiznia et al., 2019, p. 30). The following answerable PICO question emphasizes the need for VTE patient education to achieve high rates of prophylaxis compliance and positive outcomes. In adult patients admitted to the Medical/Surgical unit, what are the impact of VTE prevention education and instruction on VTE prophylaxis compliance and decreased mortality compared to VTE medication prescription without proper patient education/instruction? The following paper will discuss the transformations associated with patient VTE education, describe appropriate evaluation strategies, and specify outcome measures.

The changes in the nursing practice should respond to the need for patient education on the importance of pharmacologic anticoagulation treatment and instructions that explain how to use mechanical compression devices. The systematic review by Etxeandia-Ikobaltzeta et al. (2020) demonstrated that pregnant patients had high rates of compliance with Low Molecular Weight Heparin (LMWH) prophylaxis. Additionally, 46%-55% of cancer patients had a positive attitude to prophylactic injections and external compression devices (Etxeandia-Ikobaltzeta et al. 2020). The research concluded that the impact of VTE on patients’ lives varies from small to significant and depends on their values. The results reflect different preferences and compliance with VTE prophylaxis methods among diverse patient populations and need to be accounted for during the development of patient education materials on VTE prophylaxis and treatment. Thus, the materials in the forms of brochures, videos, and mobile apps should be appropriate for diverse patient populations admitted to the Medical/Surgical unit and respond to their particular preferences and values.

Patient compliance rates considerably increase after discussing the risks and the benefits of thromboprophylaxis. Blackwell et al. (2017) indicate that 31 patients accepted an offer of LMWH treatment after the discussion of VTE risks, while 30 preferred Aspirin as their primary thrombophylactic agent. 6 patients did not take VTE prophylactic medication because they were not informed and 15 patients reported missed doses (Blackwell et al., 2017). According to the research, the main reason for missed doses was that the patients forgot to take medicine, while none of them reported missed doses of LMWH due to side effects or pain. Therefore, evidence-based clinical practice should address the problem by introducing a mobile app or text message distribution system reminding the patients to take medication and indicating its brand name and correct dosage. Patient awareness of timely or scheduled administration of prescribed medications is an integral part of education dedicated to VTE prophylaxis.

Overall, the changes in the nursing practice should include the development of targeted patient education materials on VTE prophylaxis containing information on the risks and benefits of treatment. VTE resources such as specialized mobile apps or text messages might be used as a part of the educational support and to issue regular reminders for patients to take medication. Clinical guidelines provided by the American Society of Hematology (ASH) recommend using pharmacological prophylaxis or mechanical prophylaxis (intermittent compression devices) for all surgical patients (Anderson et al., 2019). Thus, patient education materials should focus on these preventative measures and contain detailed and clear instructions for the use of compression devices as well as directions and dosages for prescribed medications.

The changes in practice should be evaluated with the help of a nurse manager and a project team to ensure that the innovations are effective and function properly. The measurements used for the initial analysis of the care system might be checked repeatedly to control the adoption of the transformation and its impact on the practice (Brown, 2018). The strategy allows the project team to compare the performance results prior, during, and after the implementation of the changes. Additionally, the transformations should be constantly monitored to evaluate their long-term effectiveness and detect the need for revision if the desired results are not occurring. Moreover, patient care conferences may be organized to discuss the innovation, evaluate the results, and offer improvements.

Specific VTE outcome measures may include lab testing aimed at evaluating the effectiveness of informed administration of VTE prophylactic oral medication. VTE control questionnaires might be given to all Medical/Surgical and post-operative patients to assess their preferences and opinions about education on VTE prevention measures such as prescription medications or compression devices. The surveys of patients and nurses allow to register readmissions, complications, and positive outcomes associated with VTE patient education and compare it with baseline data obtained during the initial stages of the project. The evaluation of the results can help to optimize the measures according to patients’ symptoms, needs, and preferences, which might improve their quality of life and reduce hospital expenses.

Appendix 1

Appraisal Guide

Findings of a Qualitative Study

APA Formatted Citation: (4 pts.)

Answer Here: Wiznia, D. H., Swami, N., Nguyen, J., Musonza, E., Lynch, C., Gibson, D., & Pelker, R. (2019). Patient compliance with deep vein thrombosis prophylaxis after total hip and total knee arthroplasty. Hematology Reports, 11, 30–33. Web.

Synopsis (12 pts.):

  • What experience, situation, or subculture does the researcher want to understand?

Answer Here: The researchers want to examine post-operative patients’ compliance with thromboprophylaxis.

  • Does the researcher want to produce a description of an experience, or a social process, or an event, or is the goal to generate a theory?

Answer Here: The authors want to produce a description of the experience of patient compliance with VTE prophylactic oral medications and injectables.

  • How was data collected?

Answer Here: The data was collected using an observational, longitudinal method and surveys to collect the data from 103 post-operative patients.

  • How did the researcher control his or her biases and preconceptions?

Answer Here: The researchers did not indicate the use of measures to control their bias or preconceptions. The bias of the clinical staff involved in the research was not controlled.

  • Are specific pieces of data (e.g., direct quotes) and more generalized statements (themes, theories) included in the report?

Answer Here: The report does not contain any specific pieces of data or generalized statements.

  • What are the main findings of the study? (10 Pts.)

Answer Here: The study demonstrated that post-operative patients’ compliance with home DVT prophylaxis is high, but 17% of patients were non-compliant with VTE medication because of poor understanding of its side effects.

Credibility (18 pts.) Yes No Not Clear
Is the study published in a source that required peer review? +
Were the methods used appropriate to the study purpose? +
Was the sampling of observations or interviews appropriate and varied enough to serve the purpose of the study? +
*Were data collection methods effective in obtaining in-depth data? +
Did the data collection methods avoid the possibility of oversight, underrepresentation, or overrepresentation from certain types of sources? +
Were data collection and analysis intermingled in dynamic way? +
*Is the data presented in ways that provide a vivid portrayal of what was experience or happened and its context? +
*Does the data provided justify generalized statements, themes, or theory? +
All Some No
ARE THE FINDGINGS CREDIBLE? +
Clinical Significance (6 pts.) Yes No Not Clear
*Are the findings rich and informative? +
*Is the perspective provided potentially useful in providing insight, support, or guidance for assessing patient status or progress? +

*= Important criteria

Answer Here: The study produced in-depth data on the problem of post-operative patients’ compliance with VTE prophylaxis and discovered the reasons for non-compliance.

Appendix 2

Appraisal Guide

Findings of a Qualitative Study

APA Formatted Citation: (4 pts.)

Answer Here: Nana, M., Shute, C., Williams, R., Kokwaro, F., Riddick, K., & Lane, H. (2020). Multidisciplinary, patient-centered approach to improving compliance with venous thromboembolism (VTE) prophylaxis in a district general hospital. BMJ Open Quality, 9, 1–7. Web.

Synopsis (12 pts.):

  • What experience, situation, or subculture does the researcher want to understand?

Answer Here: The researchers want to examine the problem of risk assessment for hospital-acquired VTE.

  • Does the researcher want to produce a description of an experience, or a social process, or an event, or is the goal to generate a theory?

Answer Here: The authors want to produce a description of the experience of a three-tiered approach to VTE assessment.

  • How was data collected?

Answer Here: The data was collected from 39 patients via a standardized data collection tool for documentation of VTE risk assessment and prophylactic dose adjustment depending on a patient’s weight and renal function.

  • How did the researcher control his or her biases and preconceptions?

Answer Here: The researchers selected random days for data collection and assigned specific roles to minimize bias during collection and interpretation.

  • Are specific pieces of data (e.g., direct quotes) and more generalized statements (themes, theories) included in the report?

Answer Here: The report contains specific pieces of data, such as direct quotes and indications of relevant guidelines and researchers.

  • What are the main findings of the study? (10 Pts.)

Answer Here: The study demonstrated that the use of educational materials and a prescription prompt led to the improvement of quality standards and the increase in patient compliance with VTE prophylaxis.

Credibility (18 pts.) Yes No Not Clear
Is the study published in a source that required peer review? +
Were the methods used appropriate to the study purpose? +
Was the sampling of observations or interviews appropriate and varied enough to serve the purpose of the study? +
*Were data collection methods effective in obtaining in-depth data? +
Did the data collection methods avoid the possibility of oversight, underrepresentation, or overrepresentation from certain types of sources? +
Were data collection and analysis intermingled in dynamic way? +
*Is the data presented in ways that provide a vivid portrayal of what was experience or happened and its context? +
*Does the data provided justify generalized statements, themes, or theory? +
All Some No
ARE THE FINDGINGS CREDIBLE? +
Clinical Significance (6 pts.) Yes No Not Clear
*Are the findings rich and informative? +
*Is the perspective provided potentially useful in providing insight, support, or guidance for assessing patient status or progress? +

*= Important criteria

Answer Here: The study provides valuable knowledge on VTE prophylaxis and the significance of patient education and prescription prompts for VTE prevention.

Appendix 3

Appraisal Guide

Findings of a Qualitative Study

APA Formatted Citation: (4 pts.)

Answer Here: Blackwell, J. R., Raval, P., Quigley, J., Patel, A., & McBride, D. (2017). Patient compliance with venous thromboembolism prophylaxis (VTE). Journal of Clinical Orthopedics and Trauma, 369, 1–5. Web.

Synopsis (12 pts.):

  • What experience, situation, or subculture does the researcher want to understand?

Answer Here: The researchers want to investigate trauma patients’ compliance with low molecular weight heparin (LMWH) treatment after the discussion of their risks of VTE (Blackwell et al., 2017). Additionally, the authors aim to determine whether Aspirin is accepted by the patients as an alternative prophylactic treatment.

  • Does the researcher want to produce a description of an experience, or a social process, or an event, or is the goal to generate a theory?

Answer Here: The authors want to produce a description of the experience of patient compliance with thromboprophylaxis in the major trauma center.

  • How was data collected?

Answer Here: Adult trauma patients were given a questionnaire consisting of 17 questions after their immobilization treatment was complete. Clinical staff assisted the patients with the instruction on the completion of the questionnaires, but the answers were recorded in private. 5 out of 75 completed questionnaires were excluded due to inadequate results or inappropriate participants.

  • How did the researcher control his or her biases and preconceptions?

Answer Here: The researchers did not indicate the use of measures to control their bias or preconceptions. The bias of the clinical staff was controlled by allowing the patients to answer the questions in private.

  • Are specific pieces of data (e.g., direct quotes) and more generalized statements (themes, theories) included in the report?

Answer Here: The report does not contain any specific pieces of data or generalized statements.

  • What are the main findings of the study? (10 Pts.)

Answer Here: 31 patients accepted LMWH treatment after the discussion of VTE risks, while 30 preferred Aspirin as their primary thrombophylactic agent. 9 patients did not receive prophylaxis because they did not require VTE treatment or did not have the discussion of the risks with their healthcare provider. The main reason for missed doses was that the patients forgot to take medicine. None of the patients reported missed doses of LMWH due to side effects or pain.

Credibility (18 pts.) Yes No Not Clear
Is the study published in a source that required peer review? +
Were the methods used appropriate to the study purpose? +
Was the sampling of observations or interviews appropriate and varied enough to serve the purpose of the study? +
*Were data collection methods effective in obtaining in-depth data? +
Did the data collection methods avoid the possibility of oversight, underrepresentation, or overrepresentation from certain types of sources? +
Were data collection and analysis intermingled in dynamic way? +
*Is the data presented in ways that provide a vivid portrayal of what was experience or happened and its context? +
*Does the data provided justify generalized statements, themes, or theory? +
All Some No
ARE THE FINDGINGS CREDIBLE? +
Clinical Significance (6 pts.) Yes No Not Clear
*Are the findings rich and informative? +
*Is the perspective provided potentially useful in providing insight, support, or guidance for assessing patient status or progress? +

*= Important criteria

Answer Here: The study did not produce in-depth data on the problem of patient compliance with VTE prophylaxis, but it provided valuable insight into the issue of thromboprophylaxis in trauma patients. Moreover, the article evaluated the reasons for missed doses of LMWH and concluded that pain or side effects of VTE medicine were not the causes of patients’ skipping the treatment.

Appendix 4

Appraisal Guide

Findings of a Quantitative Study

APA Formatted Citation: (4 pts.)

Answer Here: Etxeandia-Ikobaltzeta, I., Zhang, Y., Brundisini, F., Florez, I. D., Wiercioch, W., Nieuwlaat, R., Begum, H., Cuello, C. A., Roldan, Y., Chen, R., Ding, C., Morgan, R. L., Riva, J. J., Zhang, Y., Charide, R., Agarwal, A., Balduzzi, S., Morgano, G. P., Yepes-Nuñez, J. J., … H. J. Schun̈emann. (2020). Patient values and preferences regarding VTE disease: A systematic review to inform American Society of Hematology guidelines. Blood Advances, 4(5), 953–968.

Synopsis (16 pts.):

  • What was the purpose of the study (research questions, purposes, and hypotheses)?

Answer Here: The purpose of the systematic review was to assess the patients’ VTE-related values and preferences in order to develop the guidelines for the management of VTE.

  • How was the sample obtained?

Answer Here: The sample was obtained through the evaluation of 14 quantitative studies describing VTE health states in a diverse patient population. Moreover, 34 qualitative and 15 qualitative sources were used to define the patients’ value on the reduction of VTE risks. The researchers developed a protocol (PROSPERO) for the inclusive systematic review of the sources.

  • What inclusion or exclusion criteria were used?

Answer Here: The studies were included based on their utility or health state values, indication of patient preferences, and appropriate qualitative data.

  • Who from the sample actually participated or contributed data (demographic or clinical profile and dropout rate)?

Answer Here: All participants from the quantitative and qualitative studies contributed data for the research.

  • What methods were used to collect data (e.g., sequence, timing, types of data, and measures)?

Answer Here: During the first step of the research, the titles and abstracts of the sources were independently examined by 22 screeners possessing different levels of expertise in patient values and preferences. The data obtained during the screening process was used for the development of a machine-learning Collaboratron screening model defining the probability of relevance. During the second stage, the references were evaluated by the model. Finally, the selected sources were independently assessed with the help of the third reviewer resolving disagreements.

  • Was an intervention tested?

Answer: Yes or No No

  • How was the sample size determined?

Answer Here: Since the intervention was not tested, the sample size for this measure was not determined.

  • Were patients randomly assigned to treatment groups?

Answer Here: No

  • What are the main findings of the study? (10 pts.)

Answer Here: The findings from the quantitative sources demonstrate high variability among the utility values with low to moderate certainty of evidence resulting from the diversity of patient populations. The studies conclude that VTE may have either a small or significant impact on patients’ lives (Etxeandia-Ikobaltzeta et al., 2020). The findings of the qualitative studies reflect patients’ preferences for oral administration of medication instead of subcutaneous injections. Overall, the findings conclude that patients have positive perceptions of VTE treatment if they are included in the decision-making process.

Credibility (14 pts.) Yes No Not Clear
Is the study published in a source that required peer review? +
*Did the data obtained and the analysis conducted answer the research question? +
Were the measuring instruments reliable and valid? +
*Were important extraneous variables and bias controlled? +
*If an intervention was tested, answer the following five questions:
Were participants randomly assigned to groups and were the two groups similar at the start (before the intervention)? +
Were the interventions well defined and consistently delivered? +
Were the groups treated equally other than the difference in interventions? +
If no difference was found, was the sample size large enough to detect a difference if one existed? +
If a difference was found, are you confident it was due to the intervention? +
Are the findings consistent with findings from other studies? +
All Some No
ARE THE FINDINGS CREDIBLE? +

Clinical Significance (6 pts.):

  • Note any difference in means, r2s, or measures of clinical effects (ABI, NNT, RR, OR)

Answer Here: The measures of clinical effects were not indicated in the study.

Yes No Not Clear
*Is the target population clearly described? +
*Is the frequency, association, or treatment effect impressive enough for you to be confident that the finding would make a clinical difference if used as the basis for care? +
All Some No
ARE THE FINDINGS CLINICALLY
SIGNIFICANT?
+

*= Important criteria

Answer Here: As the strongest source of evidence, the systematic review provided the comprehensive evaluation of patient values and preferences for VTE prophylaxis and treatment in evidence-based clinical practice.

References

Anderson, D. R., Morgano, G. P., Bennett, C., Dentali, F., Francis, C. W., Garcia, D. A., Kahn, S. R., Rahman, M., Rajasekhar, A., Rogers, F. B., Smythe, M. A., Tikkinen, K. A. O., Yates, A. J., Baldeh, T., Balduzzi, S., Brozek, J. L., Etxeandia-Ikobaltzeta, I., Johal, H., Neumann, I., … W. Wiercioch. (2019). American Society of Hematology 2019 guidelines for management of venous thromboembolism: Prevention of venous thromboembolism in surgical hospitalized patients. Blood Advances, 3(23), 3898–3944. Web.

Blackwell, J. R., Raval, P., Quigley, J., Patel, A., & McBride, D. (2017). Patient compliance with venous thromboembolism prophylaxis (VTE). Journal of Clinical Orthopedics and Trauma, 369, 1–5. Web.

Brown, S. J. (2018). Evidence-based nursing: The research-practice connection (4th ed.). Jones & Bartlett Learning.

Etxeandia-Ikobaltzeta, I., Zhang, Y., Brundisini, F., Florez, I. D., Wiercioch, W., Nieuwlaat, R., Begum, H., Cuello, C. A., Roldan, Y., Chen, R., Ding, C., Morgan, R. L., Riva, J. J., Zhang, Y., Charide, R., Agarwal, A., Balduzzi, S., Morgano, G. P., Yepes-Nuñez, J. J., … H. J. Schun̈emann. (2020). Patient values and preferences regarding VTE disease: A systematic review to inform American Society of Hematology guidelines. Blood Advances, 4(5), 953–968. Web.

Nana, M., Shute, C., Williams, R., Kokwaro, F., Riddick, K., & Lane, H. (2020). Multidisciplinary, patient-centered approach to improving compliance with venous thromboembolism (VTE) prophylaxis in a district general hospital. BMJ Open Quality, 9, 1–7. Web.

Wiznia, D. H., Swami, N., Nguyen, J., Musonza, E., Lynch, C., Gibson, D., & Pelker, R. (2019). Patient compliance with deep vein thrombosis prophylaxis after total hip and total knee arthroplasty. Hematology Reports, 11, 30–33. Web.