Decreasing Refusals of Anticoagulants on a Medical-Surgical Unit to Help Prevent Thrombotic Events

Background: Oncology patients are at a higher risk of developing venous thromboembolism when compared to that of any other patient population. Thrombotic events are the 2nd leading cause of death in cancer patients after death from the cancer itself. One missed dose of anticoagulation places the patient at 5 times greater risk of developing a VTE. The purpose of this initiative was to decrease the refusal rate of all ordered anticoagulants to help improve patient outcomes of our patients on a medical surgical floor, including our oncology patients, by reducing their risk of VTEs, thus reducing their risk of morbidity/mortality.

Methods: Evidence was found that once-nightly Lovenox works just as well if not more efficiently than three times daily heparin. The unit default for anticoagulant was changed from heparin to Lovenox in quarter 3 of FY 2018. Next, an algorithm was created in quarter 2 of FY 2019 that the RN would follow if the patient refused a dose of anticoagulant. If the patient refused, the RN would be required to notify the charge RN or clinician. If the patient remained adamant on refusal after the charge RN or clinician went in to further educate, then pharmacy would be consulted to also speak with the patient. This ensured that all possible resources were used to fully educate the patient regarding risks of refusal.

Documentation was also monitored to ensure unit RNs were documenting properly when anticoagulants were ordered to be held due to parameters or MD order. If improper documentation was noted, then the RN would receive 1:1 coaching regarding proper documentation to reflect orders. Topical anesthetic spray was ordered and used on patients whose refusal was due to pain from injection.

Results: When the anticoagulant default was changed from heparin to Lovenox in April of quarter 3 FY 2018, the unit saw a decrease in monthly refusals (March 2018=130 refusals, April=42 refusals). FY 2018 finished with 871 total refusals with a goal of 1188. Once the algorithm and documentation audits were put into action, the average refusals per month went from 72.5 (FY 2018) to 39.6 (FY 2019). FY 2019 ended with a refusal total of 534 with a goal of 1,020. There has been a 38.6912% decrease in VTE refusals from FY 2018 to current. This is a decrease in almost 340 VTE refusals in FY 2019.

Conclusions: Changing the default anticoagulant, adding a chain of command, chart audits, and 1:1 education has improved our refusal rate for anticoagulants drastically. Our refusals continue to decrease and are currently at all-time monthly low of 22. Due to the success of this project, this initiative continues to hold strong, and daily chart audits are completed at 0700 Monday through Friday, and the algorithm remains in place and is used daily. A possible recommendation for future continuation of this project would be to see if oral anticoagulants, which have shown to reduce risk of venous and arterial thromboembolism in large randomized clinical trials, would benefit our oncologic and medical-surgical patient population.