Nurses as a Driving Force to Change Clinical Practice

Karley Trautman, DNP, ANP-BC

Patients with cancer have an elevated risk of venous thromboembolism (VTE), and of recurrence of VTE. Karley Trautman, DNP, ANP-BC, of University of Colorado Hospital noticed that the numbers for VTE and recurrence of VTE in their Blood Cancer and Bone Marrow Transplant program seemed higher than even that rate. Along with her colleague, Chelsea Boggs, MS, AGANP-BC, Trautman set out to decrease the incidence rate and the recurrence rate of VTE, as well as control the rate of bleeding in their inpatients.

Using existing standards, the two nurse practitioners created a quality improvement program and were able to reduce their rates of VTE occurrence, VTE recurrence and their rate of bleeding.

Oncology Nursing News: Why did you decide to embark on this quality control project?

Trautman: Blood clots are a big problem in the oncology population in general. Patients with cancer are at a significantly higher rate for both occurrence of blood clots and then recurrence. In our clinical practice, I work with patients with blood cancer and we see a high incidence of venous thromboembolism (VTE). I wanted to see what we could do to decrease the incidence rate and then also to decrease the recurrence rate, which was high.

The study showed that cancer patients are at about an 8%-20% risk of getting a clot in general, which is 4 times higher than what the normal population has, but the recurrence rate is about 20% higher in patients with cancer. What we found, at our institution, was that our recurrence rate is about 40%. I kind of knew just from clinical practice, that that was something that seemed higher than what it should be.

And we are at a unique position, where our patients are at risk for bleeding at well, from both their disease and their treatment. Because of that, we need to balance both the risk of clot and the risk of bleeding. That's what drove the project for us, determining that this is something we need to consider and look to the research to guide our practice.

What steps did you take to improve those rates?

We first did a literature search, to see what was out there. We found that the National Comprehensive Cancer Network (NCCN) has clinical practice guidelines for VTE prophylaxis and treatment. We also looked at what the literature says about preventing bleeding in this patient population, which is a pretty small amount of data and research. For the purposes of this quality improvement project, we used some of those bleeding prevention guidelines and married them with the NCCN guidelines about VTE. Then, we did a lot of education for our staff and providers, about how we were going to do the program. We had a systematic approach that we could then measure the outcomes.

Did you encounter any problems while implementing the program?

We had to do a lot of education and re-education. It seemed like things would take hold right away, and then started to slip. We had to go back and talk about things again. Sometimes I had to go to a physician colleague and say, "You didn't really follow our guidelines with this patient, what's going on?"

One of the things that we didn't predict was what to do with patients when they develop both bleeding and clotting at the same time. How do we work that into the guidelines? Honestly, what we've figured out is that you have to do it case-by-case, you can't just have a one-size fits all for it.

What are some of the outcomes and improvements that you’ve seen?

We started in August of 2014, so it's been about 2 ½ years. What we've seen is that our actual VTE rate has dropped. It started at about 13%, which is right in line with the baseline from what we know about the population. And it's dropped to 10%, which is a good start. Our recurrence rates have dropped significantly, from about 20% to closer to 10%.

The interesting thing is that we saw our bleeding rates drop, too. We just wanted them not to go up, but they decreased. We don't know exactly why that is, we're looking at it from a statistical standpoint. But just thinking it through, we think that possibly since we're not having to put as many people on anti-coagulation, because they're not developing clots, and therefore they're not bleeding

Additionally, before this project, we were only treating about 20% of our inpatients prophylactically for VTE. What the literature supports is that everyone, unless they meet the strict contra-indications, should be treated prophylactically. And with our project we saw that jump from 20% to about 50%.

We still have room to work and grow, to tweak some things so people feel more comfortable and safe, but we've seen some great outcomes that translate to some big cost savings. Not just for the patients, but also the healthcare system in general.

What are your next steps for this program?

We're going to continue to think about outpatient prophylaxis. Right now, the literature doesn't necessarily support that, but I suspect that's partly because it hasn't been looked at too much. We also need to continue to expand on dealing with thrombocytopenia and prophylaxis, because we’re still seeing clots with patients that are thrombocytopenic.

What would you say to other nurses who would like to make changes within their practice?

This was all driven by myself and another nurse practitioner. We were able to gather the literature and do all the work so when we presented it to our physician colleagues, it was easy for them to say “yes, let's start trying this.”

Sometimes it can feel, as a nurse or an advanced practice nurse, that we don't have as much control over changing true clinical guidelines but that's not true. We can drive this, because we're seeing the patients and we're seeing exactly where the problems lie. We took this quality improvement project and we're actually able to make research projects come out of it that can really contribute to this place in medicine that's a little lacking good research.