Deep vein thrombosis and pulmonary embolism (VTE) is a serious and common complication for hospitalized medical and surgical patients. Evidence shows that incidence of VTE can be substantially reduced or prevented by identifying patients at risk and providing appropriate evidence-based thromboprophylaxis interventions.
Cancer patients are at a significantly greater risk of developing a blood clot than patients without cancer. VTE risk assessment and clinical protocols are well established in the inpatient setting however clinical guidelines for ambulatory oncology patients are only just emerging.
In 2013, Guidelines for VTE Treatment and Secondary Prophylaxis in Oncology Outpatients were published. In June 2013, the American Society of Clinical Oncology (ASCO) issued guidelines affirming the use of a slightly modified Khorana score – a tool that predicts thrombosis risk based on a collection of simple variables. Specifically, new ASCO guidelines recommend that patients with cancer be assessed for VTE risk at the time of chemotherapy initiation and periodically thereafter. Patients with a Khorana score of 3 or greater should be assessed for VTE Prophylaxis on an individual basis. These recommendations have been built into the electronic care plans for all newly ordered chemotherapy regimens at the Walker Family Cancer Centre. A collaborative, hard-wired, measurable process has been implemented to ensure all patients who are beginning a course of chemotherapy are assessed for risk of VTE and appropriate evidence-based prophylaxis is implemented when warranted.
Planning for this innovation began in April 2015 and involved: 1) mapping out the decision-making process and workflow, 2) building the assessment and documentation in the electronic record and, 3) building reports to measure the impact of the change. Since implementation in June 2015, results have shown a high level of compliance with the VTE Screening Protocol.
The key to sustaining this innovation is the way the workflow has been hard-wired to all new chemotherapy care plans. A trigger is in place (ordering a new chemotherapy care plan) that automatically generates an action (a QCL) which signals to the nurse to calculate the patient’s Khorana score. Once the score is calculated, the workflow is such that the action is either marked ‘complete’ or results are forwarded to the Oncologist to consider next steps. The Systemic Program members at are monitoring the data closely to ensure appropriate uptake and follow-up.
VTE Screening Guidelines in the Ambulatory Oncology setting are now available. This practice can be adapted by other organizations that use an electronic information system/health record by automatically building the workflow into electronic care plans.
Contact Person:
Title: Director, Integrated Cancer Treatment Services
Contact information: potvin@hhsc.ca
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