Clot Chronicles – Problems with VTE in Nursing Homes

Dr. Sam Goldhaber discusses the risk of pulmonary embolism (PE) and deep vein thrombosis (DVT) in nursing home patients.

Hello, this is Dr. Sam Goldhaber, president of NATF, speaking to you today on Clot Chronicles about the problem of pulmonary embolism and deep vein thrombosis in nursing homes.

More than 1.5 million Americans live in nursing homes, and their risk for a pulmonary embolism or for a DVT is highest during the first week or month after admission to the nursing home. It turns out that patients admitted to nursing homes often have been in a hospital, where they’ve had a medical illness. They’re relatively immobilized, and they’re at high risk for pulmonary embolism and DVT after discharge from the hospital. In fact, in the nursing home they will probably not be receiving as much physical therapy and nursing ambulation around the corridors as they were receiving in the hospital. So, they might be even more at risk for DVT and pulmonary embolism in the nursing home than they were in the hospital.

Also, usually in a hospital patients’ at risk for DVT and pulmonary embolism are receiving low dose of an anticoagulant, such as low molecular weight heparin injections or unfractionated heparin injections.

Another factor about nursing homes is that the healthcare providers and staff working in nursing homes are concerned. They don’t want their patients to fall and so, due to this fear of falling, they may be reluctant to try to mobilize the patients and get the patients walking around as much as possible and as frequently as possible.

Many of the patients who are admitted to nursing homes also require a cane or a walker, some form of assisted ambulation. And so the nursing home, trying to keep safety at a premium might let these patients sit in a chair or stay in bed longer than they would otherwise if they were thinking, ‘How can we prevent DVT or pulmonary embolism?’

Another problem in the nursing homes is that the healthcare workers have a wide variety of educational backgrounds. Some of them may be transiently employed by the nursing home and might not be receiving as much continuing education on pulmonary embolism and DVT as one would like them to have under an ideal situation.

Those working in the nursing home, particularly the patient care assistants who are spending the most time with the nursing home residents, might potentially not know what a pulmonary embolism is, what a DVT is, and that these events are really increased in risk by a sedentary lifestyle. They might not know what the fundamental signs and symptoms are of pulmonary embolism and DVT. They might not realize that you have to be careful and concerned about the development of a DVT if the patient has, for example, cramping in a calf that gets worse over several days rather than getting better.

So, I think there are other problems in the nursing home. The patients are separated often from their family and friends. They don’t have the same type of advocacy that they might have in the hospital. And this is really a frontier where we have not done that much original medical research. So, it’s hard to document event rates, but research that is emerging indicates that the rate of DVT and pulmonary embolism in the nursing home residents might be as much as 30x higher than the rate in the general population.

So, this is an area where in the future, we need to pay more attention. We need to double down on our educational efforts for those who administer nursing homes and those who provide the medical and nursing care at nursing homes. And at NATF we need to make sure that our patient advocacy efforts do not forget those who are residents of nursing homes.

This is Dr. Sam Goldhaber, signing off for Clot Chronicles.