PREVENTING VENOUS

THROMBOEMBOLISM IN AN INPATIENT

SETTINGChad Hodge

Mark RimbergasAmy Rubin

PROBLEM-INTRODUCTION Identify High Risk Area Make It Easy to do Right Thing at Right

Time Standardized, Structured, and Reliable

Approach

Venous Thromboembolism (VTE) Prevention

DEFINITION Two conditions

Life-threatening

Very Preventable

PREVALENCE 200,000 people per year develop

venous thrombi with 50,000 going on to develop a pulmonary embolism (PE)

1 in 10 of the 2 million patients per year that develop PE will die

Incidence is 80 cases/100,000 patients

CLINICAL RELEVANCE: RISK FACTOR

STRATIFICATION & TREATMENT Stratification levels

High, Moderate and Low

TreatmentEarly and frequent ambulationPharmacologicMechanical

CONTRAINDICATIONS Pharmacologic

Absolute Active hemorrhage, severe trauma to head or spinal

cord with hemorrhage in last 4 weeks Relative

Intracranial hemorrhage within last year, craniotomy or intraocular surgery within 2 weeks, gastrointestinal, genitourinary hemorrhage within last month, thrombocytopenia or coagulopathy, end stage liver disease, active intracranial lesions/neoplasm, hypertensive urgency/emergency and post-operative bleeding concerns

Mechanical Known DVT, previous immobility, severe arterial

insufficiency

ADMINISTRATIVE RELEVANCE Cost Regulatory

National Quality Forum (NQF)Centers for Medicare and Medicaid Services

(CMS) Clinical Measures Never Events EHR Incentive Program

Meaningful Use Clinical Quality Measures

EXISTING TOOLS Showed Impact/Improvement however…

Not comprehensive enoughNot proactiveNot fully incorporated into workflow

CLINICAL GOALS Automation of risk stratification Streamlined and automated process for:

Recommendation of prophylaxis based on stratification

Mechanical prophylaxis order for placement and/or

Pharmacologic prophylaxis order Associated safety processes

Incorporated into workflow

CLINICAL GOALS

To Prevent Venous Thromboembolism and

associated complications!

ADMINISTRATIVE GOALS Cost Reduction Meet regulatory and quality assurance

requirementsNational Quality Forum (NQF)Centers for Medicare and Medicaid Services

(CMS) Clinical Measures Never Events EHR Incentive Program

Meaningful Use Clinical Quality Measures

MODEL – CDS RULERule Category VTE Intervention protocolRule Title Stratify the patient’s level of VTE risk and prompt clinicians to intervene.

Risk Group Definition Age >= 70 (demographic data);Obese ((the weight in kilograms divided by the square ofthe height in meters) >= 30) OR ICD9 code of 278.0;Bed Rest or Immobility (found through NLP of nursing documentation);Female Hormone Replacement Therapy or oral contraceptives (found on active medication list);Major Surgery (any surgery lasting over 1 hour);Active Cancer (ICD9 149.0 to 172.99, 174.0 to 209.9);Prior VTE (ICD9 415.1, 415.19, 453.8, 453.9, and 671.31 to 671.50);Hypercoagulability (presence of factor V Leiden, lupus anticoagulant, andanticardiolipin antibodies);

Trigger Condition Admission of Hospitalized patient;During normal activities of patients stay (time and data driven);During discharge;

Displayed Message This patient has been identified as having a risk for venous thromboembolism (VTE). Based on his recent medical/surgical history, his risk level is (LOW|MED|HIGH). His contra-indications for potential interventions are: (list indications). Based on both his risk status and his contra-indications, the following interventions are appropriate for this patient: (list any pharmacological and any mechanical interventions that are still appropriate)

Coded Responses A. Order early and frequent ambulationB. Order suggested pharmacological intervention;C. Order suggested mechanical intervention;D. Acknowledge alert, but take no action; (Reason Required )

MODEL - TRIGGER

MODEL – CONTRAINDICATIONS Active hemorrhage (Boolean) Severe trauma to head or spinal cord with hemorrhage in the

last 4 weeks (Boolean) Intracranial hemorrhage within last year (Boolean) Craniotomy within 2 weeks (Boolean) Intraocular surgery within 2 weeks (Boolean) End stage liver disease (Boolean) Thrombocytopenia (<50k) of prothrombin time > 18 seconds)

(Boolean) Hypertensive emergency (Boolean) Allergic to warfarin (Boolean, and severity) Allergic to un-fractionated heparin (UFH) (Boolean, severity) Allergic to low molecular weight heparin (LMWH) (Boolean,

severity) Has skin lesions on left leg (Boolean) Has skin lesions on right leg (Boolean)

MODEL - RESPONSE Alert trigger time (date/time) Alert ignored / cancelled (Boolean) Risk group pre-selected on alert by CDSS (enumeration:

Low, Med, High) Pharmacological intervention selected (enumeration:

UFH, LMWH, warfarin) Pharmacological intervention dosage (unsigned integer) Early and frequent Ambulation Pharmacological intervention rate in hours (unsigned

integer) Mechanical intervention selected (enumeration:

(sequential compression device, leg hose) Mechanical intervention area: (enumeration: left leg,

right leg, both)

MODEL – KNOWLEDGE REPOSITORY CDS rule to be coded using standard

terminology and stored in KR.Semantic shiftBetter criteria for ruleNew / different coding schemes.

LayeringDepartment specific contraindications

(OB/GYN) Analytics / Reports

SYSTEM - COMPONENTS

End User Interface EMR Analysis and Data Mining Module Knowledge Base Interface Knowledge Base Module Active Integrated NLP-CDS inference engine

SYSTEM – ARCHITECTURE

SYSTEM – INPUT /ALERT OUTPUT

SYSTEM - STANDARDS HL7: Will be used for the exchange, integration, sharing,

and retrieval of electronic health data. XML: Will be used document storage and data integration. CDA: For specifying encoding, structure, and semantics of

clinical documents for exchange. LOINC: For identifying medical laboratory observations. SNOMED: To help index, store, retrieve, and aggregate

the data. CCOW: To enable the disparate applications in our

organization to synchronize in real-time. HIPPA: To ensure patient confidentiality when patients are

transferred to other healthcare providers and hospitals. ICD-9: To classify diseases, injuries, and cause of death.

SYSTEM - INTERFACES

Interface Engine Interfacing with internal systems Interfacing with external systems

EVALUATION Implementation Settings and Test Environment Utilizing Plan, Do, Study and Act

(PDSA) Challenges

THE END Questions?