Utility of a Nurse-Led Pathway for Patients with Acute Venous Thromboembolism Discharged on Rivaroxaban: A Prospective Cohort Study

Ming Sheng Lim; Tishya Indran; Anita Cummins; Ashwini Bennett; Erica Wood; Susan Brown; Zoe McQuilten; Huyen Tran; Master Clin Epi; Noel C. Chan; Sanjeev Chunilal

doi:10.1055/s-0038-1676320

Seminars in Thrombosis and Hemostasis, Table of Contents

Semin Thromb Hemost 2019; 45(02): 187-195
DOI: 10.1055/s-0038-1676320

Review Article

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Utility of a Nurse-Led Pathway for Patients with Acute Venous Thromboembolism Discharged on Rivaroxaban: A Prospective Cohort Study

Authors

Ming Sheng Lim

¹Department of Hematology, Monash Medical Centre, Monash Health, Clayton, Victoria, Australia
Tishya Indran

¹Department of Hematology, Monash Medical Centre, Monash Health, Clayton, Victoria, Australia
Anita Cummins

¹Department of Hematology, Monash Medical Centre, Monash Health, Clayton, Victoria, Australia
Ashwini Bennett

¹Department of Hematology, Monash Medical Centre, Monash Health, Clayton, Victoria, Australia
Erica Wood

¹Department of Hematology, Monash Medical Centre, Monash Health, Clayton, Victoria, Australia

³Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
Susan Brown

¹Department of Hematology, Monash Medical Centre, Monash Health, Clayton, Victoria, Australia
Zoe McQuilten

¹Department of Hematology, Monash Medical Centre, Monash Health, Clayton, Victoria, Australia

³Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
Huyen Tran
Master Clin Epi

⁴The Australian Centre for Blood Diseases, Monash University, Alfred Medical Research and Educational Precinct, Melbourne, Australia

⁵Department of Clinical Hematology, The Alfred Hospital, Melbourne, Australia
Noel C. Chan

⁶Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada

⁷Department of Medicine, McMaster University, Hamilton, Ontario, Canada
Sanjeev Chunilal

¹Department of Hematology, Monash Medical Centre, Monash Health, Clayton, Victoria, Australia

²Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Victoria, Australia

Abstract

The highest risk of adverse events for patients with acute venous thromboembolism (VTE) is during the early anticoagulation period. However, no established model exists for early clinical monitoring of patients treated with non–vitamin K antagonist oral anticoagulants (NOACs). The authors' aim was to evaluate the utility of a nurse-led pathway to minimize adverse events in acute VTE patients starting on rivaroxaban. The rivaroxaban VTE treatment pathway is a prospective cohort study of consecutive patients with objectively confirmed VTE between July 2015 and May 2017. Primary outcome was the proportion of patients identified at major risk of adverse events (bleeding or recurrent VTE). Secondary outcomes were rates of interventions, major or clinically relevant nonmajor bleeding (CRNMB), recurrent VTE, and all-cause mortality at 90 days. Among 304 participants, 5% (n = 15) were identified to be at major and 9% (n = 28) at possible risk for adverse events. Appropriate interventions to prevent harm were required in 40 patients. Rates of major bleeding, CRNMB, recurrence, and all-cause mortality were 0.3% (95% confidence interval [CI]: 0.1–1.8), 7.2% (95% CI: 4.8–10.7), 1.0 (95% CI: 0.3–2.9), and 1.6% (95% CI: 0.7–3.8), respectively. In conclusion, following discharge of acute VTE patients, a nurse-led pathway identified one in seven (14%) patients at major or possible risk of adverse events. Preemptive interventions to reduce harm translated into the low rates of bleeding and recurrence. The authors' experience highlights the feasibility and importance of a structured clinical surveillance pathway for acute VTE patients initiating NOAC therapy.

Keywords

adverse drug event - clinical pathways - nurse-led pathway - rivaroxaban - venous thromboembolism

Full Text

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