VTE Nursing Research
Venous Thromboembolism
Introduction
Venus thromboembolism (VTE) is a condition that includes both pulmonary embolism (PE) and deep vein thrombosis (DVT). DVT commonly occurs when blood clots in deep veins normally in the pelvic veins or in the legs. However, VTE is common any vein in the human body. Patients who develop VTE have a 35% to 65% chance of dying from it. It is important to research on Venus thromboembolism (VTE) because as the third most common cardiovascular disease, it is a leading cause of mortality and mobility worldwide. VTE results from slowing of the blood flow (stasis), damage of endothelial lining, and hypercoagulability (Amin, 2008, p. 234). Several risk factors are associated with VTE such as; increase in age, orthopedic surgery, genetics, and immobility. The risk factors of VTE have made the condition prevalent among the old people. However, the number of young people being diagnosed with VTE is on the rise. For the geriatric patients, timely diagnosis is the key to effective management of VTE and promotes positive patient outcomes. The biggest issue with this outcome is that it is not clear whether testing of thrombophilia will help solve the scientific management of issues concerning patients (Joint, 2010). In this study, VTE testing is evaluated as an effective management strategy for VTE among the young people.
Venous Thromboembolism (VTE) is a health condition characterized by blood clot forming within the veins thereby interfering with blood flow. VTE is the third most common cardiovascular condition and is fatal for up to 35% of patients who develop the condition (Deitelzweig, Johnson & Schulman, 2011). This high mortality rate is as a result of poor understanding of VTE compared to arterial thrombosis which is well understood in terms of risk factors, diagnosis and management interventions. Although many risk factors have been identified to cause VTE, thrombophilia is one of the underlying causes that characterize many cases of VTE. Thrombophilia is an abnormality in the ability of blood to clot. The problem which this study seeks to address is whether testing for thrombophilia can help resolve the nursing management problems facing VTE especially among the younger patients. The problems faced in the clinical management of VTE include, conducting accurate and timely diagnosis, devising effective and safe pharmacologic interventions, and reducing the health burden posed by the condition.
Literature Review
There are many risk factors associated with VTE including age, genetics, thrombophilia, and orthopedic surgery. Some of the clinical factors that cause VTE are increased clotting of blood (hypercoagulability), slow blood flow, damage of the endothelial lining of blood vessels. A blood clot in the veins impairs blood flow leading to fluid accumulation and swelling in the affected body part. This might cause inflammation and pain which are some of the symptoms of VTE. Thrombophilia is the other risking factor. It is a condition of repeated blood clotting which has no specific cause, but is attributed to genes of the family to develop the disorder. This inherited abnormality is called the V Leiden or activated protein C resistance (Maynard, & Stein, 2008). Due to variations in human beings, some families have developed the weakness of Thrombophilia, and it is passed on from one generation to another. It can also be acquired as antiphosholipid antibody (lupus inhibitor).The blood clotting resulting from the abnormalities is a contributing factor to VTE.
Other factors that cause VTE are increasing age. At old age, people are inactive, and immobility is high. Exercises such as jogging can prevent the development of the disorder. Lack of exercises and performing of mild and moderate, strenuous activities are a risk factor for the development of the disorder. This is due to improper flow of the blood up the veins in the body. Movement of blood up the veins from the lower limbs requires some force since the veins lack valves which prevent back flow of blood (McKean, 2012). Slowed flow of blood and lack of enough respiration, results to the formation of clumps that block the veins and lead to the condition. Major signs and symptoms of VTE include, pain and swelling of the lower limb veins. Pain results from inflammation by tension of tissues in the clogged veins. The swelling consequently caused reddening of the limb. Prolonged cases of the conditions lead to damage of the valves of the arteries that, in turn cause, improper flow of blood to the tissues, and this predisposes to other cardiovascular problems. When this problem develops in the lungs, it leads to difficulty in breathing and chest pains (Maynard, & Stein, 2008).
According to Deitelzweig et al. (2011), the advancement in technology has withdrawn the youths from participating in active activities that lead to physical fitness. For instance, the internet and the social networks like the Facebook, twitter, and whatsup.etc have preoccupied the young generations too much that they have not time for physical activities .The young generation can participate in engaging and healthy activities. These include activities such as such as sports, mountain climbing and athletics to keep fit and healthy while their bodies are still very active and energetic.
Engagement of youths in drug and substance taking has also a great contribution to the development of the condition. Smoking contributes to the development of VTE. Nutrition is also another important factor that exposes the youth to such incidences of VTE. Development of obese bodies by the youths due to overfeeding and doing very little or no physical exercises predisposes them to VTE (Amin, 2009). Proper nutrition and utilization of unprocessed food can reduce the risk. Most youths prefer fast food whose nutritional value does not support their bodies.
The diagnosis of VTE is a challenge because the condition presents different symptoms depending with the body part affected. One of the most commonly used methods is compression ultrasonography (CUS). Nurses who are responsible for the management of VTE should have competencies in the use of CUS in the diagnosis of VTE. In a study to determine the accuracy of nurse-performed CUS, Mucoli et al., (2014) found that nurses are capable of accurately using CUS to diagnosis VTE. This study is relevant since accurate diagnosis is the first challenge in the clinical management of VTE. One of the key applications of thrombophilia testing is detecting patients at a high risk of developing VTE. In this case thrombophilia testing contributes positively and helps solve some of the clinical challenges surrounding VTE. In a study to identify the tools used to predict the risk of VTE among hospitalized non surgical patients, Huang et al., (2013) identified 11 risk assessment models. Of this, thrombophilia testing was the most effective since it has generalizability and has been adequately validated unlike some of the other risk assessment models that were evaluated. This demonstrates the effectiveness of thrombophilia testing as a management strategy against VTE.
Why is thrombophilia testing is a dreadful and a common condition among young patients?
The number of young patients taking thrombophilia tests is on the rise especially due to the genetical link when one patient suffers from recurrent VTE. For instance, patients with thromboses or with current episodes of VTE are found to test for thrombophilia quite often. On the other hand, patients with recognized risks factors such as trauma, pregnancy, surgery, and puer-perium, are less likely to have a recurrence of VTE. However, based on the presence of thrombophilia, predictions of its occurrence are yet to be explored. In the surgery of VTE, presence of clinical risk factors such as; hypertension, obesity, dyslipidemia, smoking, and obesity should be integrated. It is suggest that the best approach for VTE is by evaluating all patients for primary prophylaxis to identify unidentified conditions because hospitalized patients could die from pulmonary embolism (PE) after developing asymptomatic deep vein thrombosis (Deitelzweig, 2011, p. 562).
Recent studies show that in the 15-35 and 15-48 age groups, mortality rate was high for patients with VTE. Notably, incidences of thrombosis mainly depend on age as it is a common affliction among the elderly. However, risk factors that are required to cause VTE invariably occur when a number of risk factors of acquiring thrombosis occur. Therefore, as one ages, the number of risk factors required to cause thrombosis decrease. As a multifactorial disease that results from the combination of various risk factors both acquired and inherited, recent studies show that younger people are more at risk compared to older people. It is estimated that close to 800,000 Americans develop DVT every year. Among these persons, 450,000 develop PE with 30% PEs being lethal. This study has focused on the recent developments of VTE (October, 2010, p. 222). Subsequently, it emerges that VTE is common among young people as compared to the elderly. Young patients suffering from VTE have a 35% to 65% chance of dying from it. It is important to research on Venus thromboembolism (VTE) because as the third most common cardiovascular disease, it is a leading cause of mortality and mobility worldwide. However, through intervention such as clinical tests, VTE can be controlled and patients can recover from it.
Clinical Management of VTE
Since VTE is associated with thrombophilia, many treatment options for the condition are based on using anti-coagulants to prevent the formation of blood clots in veins (Wells, Fordgie & Rodger, 2014). The efficacy of anti-coagulants depends on VTE resulting from thrombophilia. For instance, people who are at risk of recurrent VTE due to thrombophilia usually take anticoagulants for prolonged periods of time.
In one of the most comprehensive studies conducted on the effect of prolonged use of anti-coagulants, Schulman et al., (2013) tested the effects of long term use of dabigatran and warfarin compared to placebo. The researchers found that the drug regimen of either dabigatran or warfarin is effective in preventing recurrent of VTE compared to placebo. This high efficacy is based on the ability of these drugs to arrest thrombophilia. The challenge of using dabigatran and warfarin is that these drugs do not have a reversal of the anticoagulant effect and can lead to excessive bleeding. Therefore, the drugs must be taken on a daily basis for prolonged periods of time. At times the drug prescription stands indefinitely for high risk patients.
Another suitable drug that has reversal of the anticoagulant effect enabling it to be used once a week is indraparinux. This drug inhibits FXa activity making it a long acting anticoagulant. In a randomized double blind trial with 757 participants, Buller et al., (2011) demonstrated the safety and efficacy of a once a week injection of indraparinux in the management of VTE. Another FXa inhibitor that has the potential to be used in the treatment of VTE is rivaroxaban. Rivaroxaban is administered orally and provides a fixed dose for the management of VTE. Agnelli et al., (2010) conducted a study to determine the efficacy and safety of oral rivaroxaban for the symptomatic treatment of VTE. The study was designed as an open label non inferiority study in which rivaroxaban was compared to enoxaparin and a vitamin K antagonis t such as warfarin. In a parallel double blind, randomized study, the researchers compared rivaroxaban to placebo. The researchers found that over a period of 12 months, rivaroxaban is effective and safe in controlling the symptoms of VTE.
The cost of quality health care is a challenge to most patients and reduces access to health services. Using thrombophilia testing to reduce the cost of health care would reduce mortality and improve quality. In an open label, randomized non inferiority trial, Aujesky et al., (2011) demonstrated that with proper diagnosis such as that offered by thrombophilia testing, outpatient care compares well with inpatient care for the management of VTE. This finding is important since it demonstrates an actual application of thrombophilia testing in improving patient outcomes and quality of care.
The reviewed studies demonstrate that thrombophilia testing is effective in identifying patients at a high risk of developing VTE. Additionally the studies demonstrate the efficacy and safety of anticoagulants in treating and preventing recurrence of VTE. The mode of action of anticoagulants is based on the arrest of thrombophilia and making blood thinner to prevent spontaneous formation of blood clots in the veins. The reviewed studies are mainly designed as randomized controlled studies to enhance scientific rigor and produce high level evidence. The proposed approach for this study will be similar. In the proposed design, the participants who will be people with known VTE risk factors and who have already suffered from VTE in the recent past will be randomly allocated to either the intervention group or the control group. The intervention group will receive thrombophilia testing and anticoagulants when found to suffer from thrombophilia while the control group will receive regular care of treating the symptoms of VTE. This will enable the study to generate suitable data to evaluate the study hypothesis that thrombophilia testing can help in addressing the nursing challenges experienced in the management of VTE. This will help reduce the health burden posed by VTE which is a common cardiovascular condition that can cause mobility challenges or be fatal.
Statement of the Purpose
The purpose of this study is to evaluate whether thrombophilia testing is an effective strategy in the clinical management of VTE. VTE is increasingly being diagnosed in younger patients that make it a priority for nurses to target this group due to the risk. Thrombophilia is a condition that makes blood to clot abnormally and has been linked to many cases of VTE. Nurses have demonstrated capacity to accurately diagnose VTE using existing technologies such as CUS. Therefore, thrombophilia testing as an intervention in the management of VTE can be undertaken by nurses and improves patient outcomes since timely diagnosis gives room from curative interventions.
Research Question/Hypothesis
The research hypotheses that will be relied on in discussing the results include.
- H01: Nurses are aware of the risk factors to VTE.
- HA1: Nurses are not aware of the risk factors to venous VTE.
- H02: The prevalence of VTE is highest among the elderly.
- HA2: The prevalence of VTE is not highest among the elderly
- H03: There are measures in place to prevent and control the occurrence of VTE.
- HA3: There are no measures in place to prevent and control the occurrence of VTE.
Research Design
This research will correct data, analyze it and use the findings to either refute or confirm the research hypothesis. The data will be analyzed for the purpose of providing answers and appropriate recommendations in relation to venous thromboembolism (VTE). The research design that will be used in the project has elements such as the experimental design, sampling techniques, data collection and analysis, and ethical considerations in terms of fair treatment of the subjects.
Experimental Design of the Project
The most appropriate experimental design that suits the project is randomized control trial (RCT). To establish the right platform for collecting relevant data, the study sample will be randomly allocated into two groups that would be formations of VTE patients and a control group.. Additionally, the patients will be divided basing on age and genetic factors. Individuals will be grouped into different age groups to test the relationship between VTE and age. The literature on VTE state that prevalence increases as the age increases (Deitelzweig, Johnson, Lin, & Schulman, 2011). The adopted research design is also reliable because of the ease of comparing the data collected from the control group and from the study groups.
Recruitment of Subjects and the Sampling Technique
In this study, the subjects will be recruited at healthcare facilities or homecare facilities. They study sample will be made of VTE patients, nurses who take care of them, and some other people with no positive VTE diagnosis to be used as the control sample. The sampling technique will be purely non-probabilistic. This sampling technique is the best because it allows the researcher to choose the subjects without the limitation of probability factors (Marshall, 1996). The non-probabilistic sampling technique is usually cheaper and done for convenience sampling purposes. Therefore, it would be easier to classify members of the study sample into different groups in accordance with their age, stage of the VTE, gender, and genetic affiliations. This supports the fact that the non-random technique of choosing the subjects is important due to high specificity.
Experimental subjects that are selected through non-probabilistic sampling technique are likely to offer the desired results in relation to the topic of analysis. Through this technique, it would be easier to investigate the relationship between age and the onset of VTE. It is disadvantageous to use probabilistic sampling techniques because of their propensity to cause biasness (Shadish, Cook, & Campbell, 2001). For instance, probabilistic techniques can lead to creation of sample groups that are unwanted. In this case, they such techniques may not meet the age-group criteria. Therefore, the non-probabilistic techniques are the only techniques that can solve the randomness.
Data Collection
Three methods will be used to collect data from the study samples and the environment. The methods include questionnaire, interviews, and observation. The choice of the three methods relates to their cost friendliness, effectiveness, ease of application, and accuracy (Harrell & Bradley, 2009). For instance, observation collects primary data which is more reliable that secondary data from other sources. The questionnaire method is also accurate. An individual is likely to provide significant information through filling questionnaires. The method is not biased because the respondent has the right of refusing to answer the questions. However, most of them are usually cooperative especially when the questions do not need detailed answers.
The other technique of data collection that will be significant in this research is the use of interview. Interviewing the study subjects is one of the best methods of collecting primary data. Interviews also engage the subject into direct conversations, which are likely to expand the scope of the project. Consequently, more than enough data can be collected for analysis. For documentation purposes, the interview will be recorded using a digital audio recorder. Afterwards data analysis will be conducted on the reports to make the process of evaluation easier. Ultimately, answers from the patients and nurses regarding VTE will be recorded for analysis.
Ethical Considerations
Ethical considerations should always be part and parcel of any qualitative or quantitative research. The methods of data collection are the determinants of the ethical considerations that are appropriate for specific research projects. In this case, the study subjects will be protected in accordance with the rules of anonymity. For instance, their names will not appear anywhere on the documents during data collection. They will not record any private information on the documents to avoid infringement on their privacy. The other significant ethical consideration is to provide information about the intention of the research, its potential effects on the subjects, and the possible outcomes of the subjects’ involvement in the study. They will not be subjected to clinical actions that are likely to affect their wellbeing (DeRenzo & Moss, 2006). Ethical considerations and respecting the right of the subjects boost their cooperativeness in matters pertaining to the required information for analysis purposes. Additionally, the collected data shall be used for research purposes only. Therefore, the data is not transmissible to third persons. The subjects are assured of protection and anonymity as far as the documented information is concerned. In most cases, human samples must be guaranteed safety before agreeing to take part in the study. In fact, they would be requested to fill consent sheet before data collection. Getting informed consent from the subjects is consistent with the ethical considerations required in research.
Scope and Limitations of the Study
The scope and limitations of this study arise from the inclusion and exclusion criteria for the study participants. The scope of the study is patients with VTE irrespective of the affected body part or the causative factor. The following are some of the limitations that may negatively affect the research.
- Considering that the methods of data collection will include questionnaire, interviews, and observation, it is important to acknowledge the fact that the data collected is prone to get biased ensuing the invalidated responses and subjective observations
- Though the sample chosen is a representative, the sample is too small to be used in making generalized conclusions
- Though the sample chosen is economically viable, time postulated for the study is not adequate enough to collect validated information.
- Considering that it may be hard to acquire some particular information, formulations of mere assumptions will affect the conclusions made from the research
- Short of materials used in the research is also another imitation
Conclusion
VTE is a leading cardiovascular disease with a high mortality and a high burden. The high mortality of VTE partly results from poor understanding of the condition unlike arterial thrombosis. This leads to late diagnosis and negative patient outcomes. The clinical outcomes of VTE can be improved by a nursing led campaign since research show that nurses have the competency to conduct accurate VTE diagnosis. The problem to be addressed in this study is whether thrombopphilia testing can be used as an effective management strategy for the control of VTE. Thrombophilia is a condition that causes blood to clot abnormally in the veins and is the most common risk factor for VTE. The aim of the study will be to evaluate whether thrombophilia testing can lead to timely diagnosis of VTE by identifying patients most at risk of developing VTE. This will lead to positive patient outcomes since timely diagnosis gives room for curative interventions. The research will be designed as a randomized controlled trial to enable generating high level evidence and the necessary data to refute or support the research questions. The major ethical challenges in this study will be maintaining the confidentiality, privacy and self determinism of the participants. The research findings will be limited by the inclusion and exclusion criterion used but the scope of the study is sufficient to have practical applications in nursing practice.
References
Agnelli, G., Berkowitz, S., Bounameaux, H., Büller, H., Cohen, A., Gallus, A., & Spadari, G.
(2010). Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med, 363(26), 2499-510.
Amin, A. N., & Deitelzweig, S. B. (2009). Optimizing the prevention of venous thromboembolism: recent quality initiatives and strategies to drive improvement. Joint Commission Journal on Quality and Patient Safety, 35(11), 558-564.
Aujesky, D., Roy, P. M., Verschuren, F., Righini, M., Osterwalder, J., Egloff, M., & Yealy, D.
M. (2011). Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. The Lancet, 378(9785), 41-48.
Büller, H. R., Destors, J. M., Gallus, A., Prins, M. H., Raskob, G., Charbonnier, B., &
Matoska, P. (2011). Efficacy and safety of once weekly subcutaneous idrabiotaparinux in the treatment of patients with symptomatic deep venous thrombosis. Journal of thrombosis and haemostasis: JTH, 9(1), 92-99.
Deitelzweig, S. B., Johnson, B. H., Lin, J., & Schulman, K. L. (2011). Prevalence of clinical
venous thromboembolism in the USA: current trends and future projections. American journal of hematology, 86(2), 217-220.
DeRenzo, E. G., & Moss, J. (2006). Writing clinical research protocols ethical considerations. Burlington, MA: Elsevier Academic.
Harrell, M. C., & Bradley, M. (2009). Data collection methods: semi-structured interviews and focus groups. Santa Monica, CA: RAND.
Huang, W., Anderson, F. A., Spencer, F. A., Gallus, A., & Goldberg, R. J. (2013). Assessment models for predicting venous thromboembolism among hospitalized non surgical patients: a systematic review. Journal of thrombosis and thrombolysis, 35(1), 67-80.
Joint Commission. (2010). Performance Measurement Initiatives. Venous Thromboembolism
(VTE) Core Measures Set-Last Updated 4/2009. October, A. 2, 2010]; Surgical Care Improvement Project VTE Core Measures Set.
Marshall, M. N. (1996). Sampling for Qualitative Research. Family Practice 13: 522–526. doi:10.1093/fampra/13.6.522
Mumoli, N., Vitale, J., Cocciolo, M., Cei, M., Brondi, B., Basile, V., & Dentali, F. (2014).
Accuracy of nurse‐performed compression ultrasonography in the diagnosis of proximal symptomatic deep vein thrombosis: a prospective cohort study. Journal of Thrombosis and Haemostasis.
Schulman, S., Kearon, C., Kakkar, A. K., Schellong, S., Eriksson, H., Baanstra, D., &
Goldhaber, S. Z. (2013). Extended use of dabigatran, warfarin, or placebo in venous thromboembolism. New England Journal of Medicine, 368(8), 709-718.
Shadish, W. R., Cook, T. D., & Campbell, D. T. (2001). Experimental and quasi-experimental designs for generalized causal inference. Boston: Houghton Mifflin.
Shirato, K., & International Symposium on Pulmonary Thromboembolism. (2005). Venous
Thromboembolism: Prevention and treatment. Tokyo: Springer.
Welch, E., & Bonner, L. (2010). Venous thromboembolism: A nurse's guide to prevention
and Management. Chichester, West Sussex, U.K: Wiley-Blackwell.
Wells, P. S., Forgie, M. A., & Rodger, M. A. (2014). Treatment of Venous Thromboembolism.
JAMA, 311(7), 717-728.
