“Decreasing Refusal Rates of Anticoagulants in the Hypercoagulable Population
of Oncology Patients to Aid in Prevention of Thrombotic Events”
Erika Shearey RN MSN PCRN CMSRN
• Oncology patients are at a higher risk of developing venous
thromboembolism when compared to that of any other
• Thrombotic events are the 2nd leading cause of death in
cancer patients after death from the cancer itself.
• One missed dose of anticoagulation places the patient at 5
times greater risk of developing a VTE.
• Decrease the refusal rate of patients with ordered
anticoagulants to help improve patient outcomes of oncology
patients by reducing the risk of VTEs, thus reducing the risk of
• When the anticoagulant default was changed from heparin to
enoxaparin sodium in April of quarter 3 FY 2018, the unit saw
a decrease in monthly refusals (March 2018 = 130 refusals,
April= 42 refusals).
• The fiscal year finished with 871 total refusals with a goal of 1188.
• See Table 1
IMPLICATIONS FOR PRACTICE
This quality improvement project shows how guiding nurses
communication along with creating a path for education can
help keep patients safe by ensuring that they receive much
needed anticoagulants. When patients receive their scheduled
anticoagulants, it helps promote a reduction in risk of a VTE
• Changing the default anticoagulant, adding a chain of
command for refusals, along with chart audits and 1:1
education has improved our refusal rate for anticoagulants
drastically and has stayed consistent.
• Daily chart audits are completed at 0700 Monday through
Friday and the algorithm remains in place and is used by all
• The unit currently finished the Month of February 2020 with
29 refusals and the month of March 2020 with 36 refusals.
• Bauer, K., Leung, L., & Tirnauer, J. (2019). Risk and prevention of venous thromboembolism in adults with
cancer. Up To Date. Retrieved from https://www.uptodate.com/contents/risk-and-prevention-of-venous-thromboembolism-
• Bauer, K., Leung, L., Mandel, J., & Finlay, G. (2020). Anticoagulation therapy for venous
thromboembolism (lower extremity venous thrombosis and pulmonary embolism) in adult patients with
malignancy. UpToDate. Retrieved from https://www.uptodate.com/contents/anticoagulation-therapy-for-venous-
• Farge, D., Frere, C., Connors, J., Ay, C., Khorana, A., & Munoz, A. et al. (2019). 2019 International clinical
practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer. The Lancet
Oncology, 20. doi: 10.1016/S1470-2045(19)30336-5
• Song AB, Rosovsky RP, Connors JM, Al-Samkari H. Direct oral anticoagulants for treatment and
prevention of venous thromboembolism in cancer patients. Vasc Health Risk Manag. 2019;15:175-186
• The unit default anticoagulant was changed from heparin to
enoxaparin sodium in quarter 3 of fiscal year 2018.
• An algorithm was created in quarter 2 of fiscal year 2019 that
the RN would follow if the patient refused a dose of
• If the patient refused the RN must notify the Charge RN or
• If patient remains adamant on refusal after Charge RN or Clinician
went in to further educate
• Pharmacy would be consulted to also come speak with the
• Topical anesthetic spray was ordered and used on patients whose
refusal was due to pain from injection.
• Documentation was also monitored to ensure unit RNs were
documenting properly when anticoagulants were ordered to
be held due to parameters or MD order. If improper
documentation was noted, then RN would receive 1:1
coaching regarding proper documentation to reflect orders.
• Once an algorithm and documentation audits were put into
action the average refusals per month went from 72.5 (FY
2018) to 39.6 (FY 2019). This was much more sustainable.
• FY 2019 ended with a refusal total of 534 with a goal of 1,020.
• See Table 2
• Overall there has been a 38.69% decrease in VTE refusals from
FY 2018 to current. This is a decrease in 340 VTE refusals in FY
• See Table 3