By Lynn Razzano, RN, MSN, ONCC (Clinical Nurse Consultant)
[This article first appeared in Healthcare News (Issue 1, 2014)]
We must be compelled to act.
Three pregnant mothers – one dead and two who could have been.
Danielle Ciccozzi, a 35-year-old mother of three, “died on Nov. 12, after suffering from a stroke, blood clots, two heart attacks and open heart surgery, all stemming from a clotting disorder triggered by pregnancy in March.”
Stacey Crom was luckier than Danielle. As she recounts, “They found that I actually had a blood clot under my placenta. They actually thought that I would miscarry at that point.” Although Stacey did not miscarry, she delivered at 30 weeks. After an emergency c-section, her two pounds, five ounces was immediately taken to neonatal intensive care unit.
Thirty-one-year-old Laurie Fancher-Long was seven weeks pregnant when she collapsed at work. She found out that she had “multiple blood clots — passing her lungs, heart and brain”. She survived “multiple life-threatening blot clots during a pregnancy” and accrued “tens of thousands of dollars in medical debt”.
These three stories point overwhelmingly to omission and lack of knowledge of the escalated risk of venous thromboembolism (VTE) (more commonly known simply as blood clots) that pregnant women have because the condition of pregnancy causes hypercoagulability.
As a health care professional nurse of 37 years and advocate of maximum patient safety, what comes clinically to mind, after reviewing, are costly clinical errors in failure to recognize the increased risk for blood clots in the pregnant patient. I am speaking costly in the terms of VTE complications that arose due to failure to assess rapidly and recognize signs of DVT.
This well known high DVT risk established fact is still being overlooked by clinicians and it boils down to consistent OB VTE risk factor assessment being conducted every time on all pregnant women. The DVT risk factor assessment should be made very specific to the at risk specialty patient population. Not conducting this type of specific RFA is a travesty and injustice that is inexcusable in 2013.
Moreover, this risk occurs in both delivery and non-delivery situation. A recent study found that pregnant women who were admitted to the hospital for reasons other than delivery had a significantly increased risk of blood clots. The major findings of this British study, which evaluated more than 200,000 pregnant women, were startling.
Compared with non-pregnant women, the risk of venous thromboembolism (VTE) is:
- Four times higher for pregnant women whose hospital stay was less than 3 days (adjusted incidence rate ratio, 4.05; 95% CI, 2.23-7.38).
- Almost 6 times more for women admitted in their third trimester either during or after hospital admission (961 per 100,000 person-years; adjusted incidence rate ratio, 5.57; 95% CI, 3.32-9.34).
- Six times higher for pregnant women during the 28 days after hospital discharge (676 per 100,000 person-years; adjusted incidence rate ratio, 6.27; 95% CI, 3.74-10.5).
All three women share the same fate — failure to recognize or diagnosis a deep vein thrombosis (DVT) that developed — all of which may have been prevented.
Physician-Patient Alliance for Health & Safety (PPAHS), the Institute for Healthcare Improvement and the National Perinatal Association recently released safety recommendations targeting the prevention of venous thromboembolism (VTE) in maternal patients.
The OB VTE Safety Recommendations, developed by an expert panel under the facilitation of the PPAHS, could not have come at a more timely moment to finally prevent these types of patient stories from ever occurring.
Frank Federico, RPh (Executive Director at the Institute for Healthcare Improvement and Patient Safety Advisory Group at The Joint Commission) urges the adoption of these recommendations. According to Mr. Federico, “These recommendations focus on prevention measures that can easily be adopted and used by healthcare facilities to prevent VTE and help ensure that delivering mothers go home safely with their babies.”
The OB VTE Safety Recommendations provide four easy action steps to initiate on every pregnant patient that enters your health care facility to form an all out effort to eradicate VTE ever being developed in one of you patients.
The four concise step process embodied in the OB VTE Safety Recommendations are similar to “Pillars of Safety” and are as follows:
- Assess patients for VTE risk with an easy to use automated scoring system
- Provide the recommended prophylaxis regimen, depending on whether the mother is antepartum or postpartum.
- Reassess the patient every 24 hours or upon the occurrence of a significant event, like surgery.
- Ensure that the mother is provided appropriate VTE prevention education upon hospital discharge.
These four steps define an OB VTE continuous improvement process that can be easily adopted by a health care system. All the work has been originated, verified and accepted by a panel of OB experts based on peer reviewed publications. Adoption should be a necessary required action and then the implementation is the other action process the institution needs to be willing to invest in with no question of doubt or clinical value in moving to this OB practice change.
Our clinical practice should reflect best practice standards and promote what we can do better, this is what the OB VTE Safety Recommendations do for us as they embody all the action steps and VTE considerations we should act on constantly. Actions should not allow for no excuses due to lack of clinical knowledge or access to well established Practice Standards in the prevention of VTE. This a plea to use the OB VTE Safety Recommendations and maternal VTE prevention is a cause worth fighting for in terms of aggressive implementation and never having to read these very sad pregnant patient accounts of their experience with preventable DVT.