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Blood Clots: The Least-Appreciated Complication of Hospital Care?

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If you were undergoing a surgical procedure, would you ever think to refuse the antibiotics your physician had ordered to prevent an infection?

For most hospitalized patients, that would be unfathomable. And yet, when it comes to another common complication with a far greater death toll than surgical-site infections, both patients and health care professionals aren't nearly as vigilant. Each year, dangerous blood clots claim the lives of about 100,000 Americans. Many of those deaths occurred during or after a hospitalization, despite evidence showing that most of these events could have been prevented.

The most dangerous clots are those that travel to the lungs, a potentially fatal event known as pulmonary embolism that makes it difficult or impossible to breathe. Clots can also form in large veins in the leg — a condition called deep vein thrombosis — where they cause pain and swelling. These clots can become pulmonary embolisms when they break off and travel toward the lungs.

Hospitalized patients face a higher risk of these scary complications, which also go by the acronyms PE and DVT. During periods of hospitalization, conditions are ripe for clot formation. When we experience trauma, whether it's due to an auto accident or going under the surgical knife, there is a larger chance of a blood clot breaking off. (Indeed, former NBA star Jerome Kersey died this year from a pulmonary embolism following knee surgery.) Patients with cancer, heart disease and lung disease, and obese patients, pregnant women and those who have just delivered a baby also have elevated risks of harmful clots.

Still, blood clots are under the radar. Most of these cases are preventable when patients are screened for their risk of clot formation and are provided therapy to match that risk. Yet many patients do not receive appropriate therapy.

Before The Johns Hopkins Hospital focused on this several years ago, physicians prescribed risk-appropriate therapies approximately half of the time — mirroring the performance of many other hospitals. Then an improvement team made a host of changes, such as creating a "hard stop" in our computerized ordering system that made it mandatory for physicians to review blood clot prevention. Now, we prescribe appropriate therapies for more than 96 percent of patients, and blood clots have gone down.

It's tempting to chalk up the remaining clots to the patient's condition — their cancer, surgery or just plain bad luck — yet we kept looking for ways to further prevent these complications. And we soon learned that measuring how often a doctor prescribes a therapy doesn't always equal how often a patient receives that therapy.

Injection of enoxaparinStudies by our hospital’s researchers showed that nearly 12 percent of the physician-prescribed doses of blood clot prophylaxis never reach patients. About 60 percent of those missed doses were due to patient refusal. Some don’t want the injections of anti-clotting medication, which is typically delivered via a needle in the belly. Others don’t understand the reason they are supposed to wear the "squeezy boots" or other mechanical devices that keep blood moving in legs and feet.

Researchers also found that nurses' attitudes regarding blood clot prevention played a role in missed doses. They sometimes second-guessed physicians' orders and presented the preventive steps as optional when speaking to patients. Some nurses believed that if patients were walking, they didn't need to worry about clots — a stance not supported by the scientific evidence. Yet in one study conducted on hospital floors, researchers heard statements such as: "Hey, Mr. R, it's time for your heparin dose, but as long as I see you up, high-fiving me in the hallways, we can hold off for now."

Elliott Haut, a Johns Hopkins trauma surgeon on our blood clot prevention team, says that focusing on missed doses has the potential to be a "game changer," helping us realize dramatic reductions in this complication. Missing even a single dose of heparin, a common anti-clotting medication, increases your risk of developing a blood clot. Respecting patient preferences is important for clinicians, but both they and patients should be fully aware of these risks.

Perhaps one reason that blood clots do not get enough attention is that they often strike after a patient has gone home. In seconds, you can go from feeling normal to struggling for air, with a sharp pain in your chest as clots block the main arteries to your lungs. The clinicians who took care of you in the hospital probably don’t know if you are readmitted or — worse — pass away from preventable blood clots.

All of us — physicians, nurses, patients and their families — need to work together and do a better job of raising the profile of this danger. The needless suffering is real and largely expensive. Yet change occurs not only by directing the mind, but by motivating the heart and removing barriers to better care. As such, with funding from the Patient-Centered Outcomes Research Institute, we recently worked with blood clot survivors to develop an educational video and handout for patients about prevention. It has been said that statistics are humans with the tears wiped away. The stories in the videos put back those tears and hopefully will encourage everyone to take an active role in preventing these complications.

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This post first appeared on the U.S. News and World Report Patient Advice blog.


Peter Pronovost

One of the world’s leading authorities on patient safety, Peter Pronovost served a the director of the Armstrong Institute, as well as senior vice president for patient safety and quality, at Johns Hopkins Medicine from 2011 until January 2018.

5 thoughts on “Blood Clots: The Least-Appreciated Complication of Hospital Care?”

  1. Another amazing article from Dr. Pronovost.

    Suggested related reading:

    A) "Reality check for checklists"

    B) The Checklist Paradox – Lorelei Lingard – video:

    C) book "Safe Patients, Smart Hospitals"

    D) book "Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care"

  2. A cut whether big or small should never be taken lightly. A small disfigure such as a blood clot could somehow cause major disease if not treated well. Always took on consideration those little details. Practicing better work ethics and analysing the patient's state before release should always be number one priority.

  3. Pingback: Blood Clots: The Least-Appreciated Complication of Hospital Care? | Doctella

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