1. RESEARCH POSTER PRESENTATION DESIGN © 2012
www.PosterPresentations.com
Venous Thromboembolism (VTE) is the leading cause of preventable hospital
deaths. It can be prevented by either mechanical or pharmacological
prophylaxis. VTE describes two closely related conditions: deep vein
thrombosis (DVT) and pulmonary embolism (PE). Sequential Compression
Devices (SCD) is a mechanical prophylaxis and is among the least invasive
prophylaxis to prevent VTE. At the hospital that the project is conducted there
is a low compliance on SCD despite health care provider orders. The Clinical
Nurse Leader (CNL) student is working with nursing leadership to improve
compliance of SCD. This particular issue involves a multidisciplinary team of
professionals such as Sterile Processing, Central Processing and Distribution,
Infection Control and Medical- Surgical Nursing Department. The importance
of this project is decreased mortality due to hospital acquired issues, to have
better outcomes and lower readmissions. The author’s approach with this
hospital wide issue is providing patients with educational materials in order to
be more informed on their health and increase patient satisfaction.
Problem Education Material
Data Assessment
Conclusion
The assessment was an invaluable tool for nursing leadership to utilize as a
bases for hospital-wide improvement on SCD compliance and VTE
prevention. The finding from the assessment illustrated by the root cause
analysis that improvement in SCD compliance necessitated involvement of
different departments. The finding illustrate the requirement of a system wide
policy change within all medical-surgical units, which goes beyond the time
constraint and parameter of involvement of the CNL student. Therefore, the
student improvement project involved patient education materials, decided by
nursing leadership. The intended goal is for the patient to be further informed in
their healthcare experience, to improve on quality of care and better
outcomes. Further improvements are necessary to increase compliance of SCD
orders and decrease hospital acquired VTE.
Financial Perspective
• SCD Machines are available for no extra charge
• SCD pair of sleeves is $727, a one time charge
• Readmission for PE can cost as much as $14,722
• Readmission for DVT can cost as much as $11,862
Past Fiscal Year (July 1, 2014 - June 30, 2015)
• 67 patients had a diagnosis code of VTE after admission
• Approximately costing the hospital $986,374 - $794,754 for the past fiscal
year
• 3/67 (4.5%) had no documentation that VTE prophylaxis was administered
prior to the day of the diagnostic test order for VTE
Alexander Wong, MSN
Improving Patient Outcomes: Development of Patient Education
Material to Increase Use of Sequential Compression Devices
Background
• The main public hospital in a major metropolitan area serving 1.5 million
residents. Predominately cares for the poor, elderly people, uninsured
working families and immigrants.
• Patient population receives public funded health insures or is uninsured
• Only hospital in the major metropolitan area that provides twenty-four hour
psychiatric emergency services and Trauma Center: Level 1care
• This is a teaching hospital with over 600 beds for medical/ surgical and
psychiatric patients
• Assessments were conducted on Cardiac Step Down and Traumatic Brain
Injury Unit
• VTE is the leading cause of preventable hospitals deaths; more than
pneumonia and infection.
• Approximately 350,000 – 900,000 persons develop incident VTE annually in
the United States; about 100,000 die mostly of sudden death, caused of which
often goes unrecognized (Tietze and Gurley, 2014)
Root Cause Analysis
Timeline
References: Available upon request