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AHRQ / QIO Venous Thromboembolism (VTE) Prevention in the Hospital. Greg Maynard MD, MSc Clinical Professor of Medicine and Chief, Division of Hospital Medicine University of California, San Diego. VTE: A Major Source of Mortality and Morbidity. 350,000 to 650,000 with VTE per year

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Ahrq qio venous thromboembolism vte prevention in the hospital

AHRQ / QIOVenous Thromboembolism (VTE) Prevention in the Hospital

Greg Maynard MD, MSc

Clinical Professor of Medicine and Chief,

Division of Hospital Medicine

University of California, San Diego


Vte a major source of mortality and morbidity
VTE: A Major Source of Mortality and Morbidity

  • 350,000 to 650,000 with VTE per year

  • 100,000 to > 200,000 deaths per year

  • Most are hospital related.

  • VTE is primary cause of fatality in half-

    • More than HIV, MVAs, Breast CA combined

    • Equals 1 jumbo jet crash / day

  • 10% of hospital deaths

    • May be the #1 preventable cause

  • Huge costs and morbidity (recurrence, post-thrombotic syndrome, chronic PAH)

Surgeon General’s Call to Action to Prevent DVT and PE 2008 DHHS


Risk factors for vte

Stasis

Age > 40

Immobility

CHF

Stroke

Paralysis

Spinal Cord injury

Hyperviscosity

Polycythemia

Severe COPD

Anesthesia

Obesity

Varicose Veins

Hypercoagulability

Cancer

High estrogen states

Inflammatory Bowel

Nephrotic Syndrome

Sepsis

Smoking

Pregnancy

Thrombophilia

Risk Factors for VTE

Endothelial Damage

Surgery

Prior VTE

Central lines

Trauma

Anderson FA Jr. & Wheeler HB. Clin Chest Med 1995;16:235.


Risk factors for vte1

Stasis

Age > 40

Immobility

CHF

Stroke

Paralysis

Spinal Cord injury

Hyperviscosity

Polycythemia

Severe COPD

Anesthesia

Obesity

Varicose Veins

Hypercoagulability

Cancer

High estrogen states

Inflammatory Bowel

Nephrotic Syndrome

Sepsis

Smoking

Pregnancy

Thrombophilia

Risk Factors for VTE

Endothelial Damage

Surgery

Prior VTE

Central lines

Trauma

Most hospitalized patients have at least one risk factor for VTE

Anderson FA Jr. & Wheeler HB. Clin Chest Med 1995;16:235.

Bick RL & Kaplan H. Med Clin North Am 1998;82:409.


Endorse results
ENDORSE Results

Cohen, Tapson, Bergmann, et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet 2008; 371: 387–94.

  • Out of ~70,000 patients in 358 hospitals, appropriate prophylaxis was administered in:

    • 58.5% of surgical patients

    • 39.5% of medical patients


The stick is coming
The “Stick” is coming….

NQF endorses measures already

Public reporting and TJC measures coming soon:

  • Prophylaxis in place within 24 hours of admit or risk assessment / contraindication justifying it’s absence

  • Same for critical care unit admit / transfers

  • Track preventable VTE

    CMS – DVT or PE with knee or hip replacement reimbursed as though complication had not occurred.


  • 2005 – AHRQ grant to:

    • Design and implement VTE prevention protocol

    • Monitor impact on VTE prophylaxis and HA VTE

    • Validate a VTE risk assessment model / protocol

      Attempt to use portable methodology, build toolkit to allow others to accomplish the same thing


Percent of randomly sampled inpatients with adequate vte prophylaxis
Percent of randomly sampled inpatients with adequate vte prophylaxis

Real time ID & intervention

Order Set Implementation & Adjustment

Consensus building

Baseline

N = 2,944 mean 82 audits / month

In press, JHM 2009

Real time ID & intervention

Order Set Implementation & Adjustment

Consensus building

Baseline

8


Ucsd decrease in patients with preventable ha vte
UCSD – Decrease in patients with preventable ha vte prophylaxis

Level 5

Oversights identified and addressed in real time

95+%

9


Ucsd vte protocol validated
UCSD prophylaxisVTE Protocol Validated

  • Easy to use, on direct observation – a few seconds

  • Inter-observer agreement –

    • 150 patients, 5 observers- Kappa 0.8 and 0.9

  • Predictive of VTE

  • Implementation = high levels of VTE prophylaxis

    • From 50% to sustained 98% adequate prophylaxis

    • Rates determined by over 2,900 random sample audits

  • Safe – no discernible increase in HIT or bleeding

  • Effective – 40% reduction in HA VTE

    • 86% reduction in risk of preventable VTE


Vte prevention guides
VTE Prevention Guides prophylaxis

VTE Prevention Guides

http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_VTE/VTE_Home.cfm

http://ahrq.hhs.gov/qual/vtguide/


Vte qi resource room

VTE QI Resource Room prophylaxiswww.hospitalmedicine.org

VTE QI Resource Room


Collaborative efforts and kudos
Collaborative Efforts and Kudos prophylaxis

  • SHM VTE Prevention Collaborative I - 25 sites

  • SHM / VA Pilot Group - 6 sites

  • SHM / Cerner Pilot Group – 6 sites

  • AHRQ / QIO (NY, IL, IA) - 60 sites

  • IHI Expedition to Prevent VTE – 60 sites

  • SHM Team Improvement Award

  • NAPH Safety Net Award (Honorable Mention)

  • Venous Disease Coalition


To achieve improvement
To Achieve Improvement prophylaxis

  • Real institutional support / prioritization

  • Will to standardize

  • Physician leadership

  • Measurement of process / outcomes

  • Protocol, integrated into order sets

  • Education

  • Continued refinement / tweaking- PDSA

SHM and AHRQ Guides on VTE Prevention


The essential first intervention
The Essential First Intervention prophylaxis

VTE Protocol

1) a standardized VTE risk assessment, linked to…

2) a menu of appropriate prophylaxis options, plus…

3) a list of contraindications to pharmacologic VTE prophylaxis

Challenges:

Make it easy to use (“automatic”)

Make sure it captures almost all patients

Trade-off between guidance and ease of use / efficiency

15


Hierarchy of reliability

Predicted prophylaxis

Prophylaxis rate

Hierarchy of Reliability

Level

No protocol* (“State of Nature”)

Decision support exists but not linked to order writing, or prompts within orders but no decision support

Protocol well-integrated

(into orders at point-of-care)

Protocol enhanced

(by other QI / high reliability strategies)

Oversights identified and addressed in real time

1

40%

50%

2

3

65-85%

4

90%

5

95+%

* Protocol = standardized decision support, nested within an order set, i.e. what/when


Map to reach level 3 implementing an effective vte prevention protocol
Map to Reach Level 3 prophylaxisImplementing an Effective VTE Prevention Protocol

  • Examine existing admit, transfer, periop order sets with reference to VTE prophylaxis.

  • Design a protocol-driven DVT prophylaxis order set (w/ integrated risk assessment model [RAM])

  • Vette / Pilot – PDSA

  • Educate / consensus building

  • Place new standardized DVT order set ‘module’ into all pertinent admit, transfer, periop order sets.

  • Monitor, tweak - PDSA


Too little guidance prompt protocol
Too Little Guidance prophylaxisPrompt ≠ Protocol

DVT PROPHYLAXIS ORDERS

  • Anti thromboembolism Stockings

  • Sequential Compression Devices

  • UFH 5000 units SubQ q 12 hours

  • UFH 5000 units SubQ q 8 hours

  • LMWH (Enoxaparin) 40 mg SubQ q day

  • LMWH (Enoxaparin) 30 mg SubQ q 12 hours

  • No Prophylaxis, Ambulate


Most common mistakes in vte prevention orders
Most Common Mistakes in VTE Prevention Orders prophylaxis

  • Point based risk assessment model

  • Improper Balance of guidance / ease of use

    • Too little guidance - prompt ≠ protocol

    • Too much guidance- collects dust, too long

  • Failure to revise old order sets

  • Too many categories of risk

  • Allowing non-pharm prophy too much

  • Failure to pilot, revise, monitor

  • Linkage between risk level and prophy choices are separated in time or space



Low medium high
Low Medium High prophylaxis

Example from UCSD

Keep it Simple – A “3 bucket” model

21

IPC needed if contraindication to AC exists


Hierarchy of reliability1

Predicted prophylaxis

Prophylaxis rate

Hierarchy of Reliability

Level

No protocol* (“State of Nature”)

Decision support exists but not linked to order writing, or prompts within orders but no decision support

Protocol well-integrated

(into orders at point-of-care)

Protocol enhanced

(by other QI / high reliability strategies)

Oversights identified and addressed in real time

1

40%

50%

2

3

65-85%

4

90%

95+%

5

* Protocol = standardized decision support, nested within an order set, i.e. what/when


Map to reach level 5 95 prophylaxis
Map to Reach Level 5 prophylaxis95+ % prophylaxis

  • Use MAR or Automated Reports to Classify all patients on the Unit as being in one of three zones:

    GREEN ZONE - on anticoagulation

    YELLOW ZONE - on mechanical prophylaxis only

    RED ZONE – on no prophylaxis

    Act tomove patients out of the RED!


Situational awareness and measure vention getting to level 5
Situational Awareness and prophylaxisMeasure-vention: Getting to Level 5

  • Identify patients on no anticoagulation

  • Empower nurses to place SCDs in patients on no prophylaxis as standing order (if no contraindications)

  • Contact MD if no anticoagulant in place and no obvious contraindication

    • Templated note, text page, etc

  • Need Administration to back up these interventions and make it clear that docs can not “shoot the messenger”


Summary of key strategies
Summary of Key Strategies prophylaxis

  • Basic Building Blocks

    • Institutional support, team, education, protocol, metrics, PDSA

  • Physician performs VTE risk assessment within easy to use order sets, which captures all admits / transfers

  • Active monitoring for non-adherents to protocol, intervene in real time


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