AHRQ / QIO

Venous Thromboembolism (VTE) Prevention in the Hospital

Greg Maynard MD, MScClinical Professor of Medicine and Chief,

Division of Hospital MedicineUniversity of California, San Diego

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

StasisAge > 40ImmobilityCHFStrokeParalysisSpinal Cord injuryHyperviscosityPolycythemiaSevere COPDAnesthesiaObesityVaricose Veins

Hypercoagulability CancerHigh estrogen statesInflammatory BowelNephrotic SyndromeSepsisSmokingPregnancyThrombophilia

Endothelial Endothelial DamageDamageSurgerySurgeryPrior VTEPrior VTECentral linesCentral linesTraumaTrauma

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

Risk Factors for VTE

StasisAge > 40ImmobilityCHFStrokeParalysisSpinal Cord injuryHyperviscosityPolycythemiaSevere COPDAnesthesiaObesityVaricose Veins

Hypercoagulability CancerHigh estrogen statesInflammatory BowelNephrotic SyndromeSepsisSmokingPregnancyThrombophilia

Endothelial Endothelial DamageDamageSurgerySurgeryPrior VTEPrior VTECentral linesCentral linesTraumaTrauma

Anderson FA Jr. & Wheeler HB. Anderson FA Jr. & Wheeler HB. Clin Chest MedClin Chest Med 1995;16:235. 1995;16:235. Bick RL & Kaplan H. Bick RL & Kaplan H. Med Clin North AmMed Clin North Am 1998;82:409. 1998;82:409.

Most hospitalized patients have

at least one ris

k factor for V

TE

ENDORSE Results

• Out of ~70,000 patients in 358 hospitals, appropriate prophylaxis was administered in:– 58.5% of surgical patients– 39.5% of medical patients

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.

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

8

Percent of Randomly Sampled Inpatients with Adequate VTE Prophylaxis

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline

Consensus building

Order Set Implementation & Adjustment

Real time ID & intervention

Percent of Randomly Sampled Inpatients with Adequate VTE Prophylaxis

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline

Consensus building

Order Set Implementation & Adjustment

Real time ID & intervention

N = 2,944 mean 82 audits / monthIn press, JHM 2009

UCSD – Decrease in patients with preventable ha vteUCSD - Decrease in Patients with Preventable HA

VTE

0

2

4

6

8

10

12

14

Q 1 '0

5

Q2 '05

Q3 '05

Q4 '05

Q1'06

Q2 '06

Q3 '06

Q4 '06

Q1 '07

Quarter

# o

f P

ati

en

ts

Medicine

Surgery

Ortho

Other

Total

9

Level 5 Oversights identified and addressed in real timeOversights identified and addressed in real time 95+%

UCSD VTE 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

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

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

VTE QI Resource Room www.hospitalmedicine.org

VTE QI Resource Room

Collaborative Efforts and Kudos

• 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

• 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

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 patientsTrade-off between guidance and ease of use /

efficiency 15

VTE Protocol

Hierarchy of Reliability

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 enhancedProtocol enhanced

(by other QI / high reliability strategies)(by other QI / high reliability strategies)

Oversights identified and addressed in Oversights identified and addressed in real timereal time

Level

4

1

2

3

5

Predicted

Prophylaxis rate

40%

50%

65-85%

90%

95+%

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

Map to Reach Level 3Implementing 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 GuidancePrompt ≠ 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

• 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

20

Is your order set in a competition?

Low Medium HighAmbulatory with no other risk factors. Same day or minor surgery

CHF

COPD / Pneumonia

Most Medical Patients

Most Gen Surg Patients

Everybody Else

Elective LE arthroplasty

Hip/pelvic fx

Acute SCI w/ paresis

Multiple major trauma

Abd / pelvic CA surgery

Early ambulation

UFH 5000 units q 8 h (5000 units q 12 h if > 75 or weight <50 kg)

LMWH Enox 40 mg q day

Other LMWH

CONSIDER add IPC

Enox 30 mg q 12 h or

Enox 40 q day or

Other LMWH or

Fondaparinux 2.5 mg q day or

Warfarin INR 2-3

AND MUST HAVE

IPC 21

IPC needed if contraindication to AC exists

Example from UCSD Keep it Simple – A “3 bucket” model

Hierarchy of Reliability

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 enhancedProtocol enhanced

(by other QI / high reliability strategies)(by other QI / high reliability strategies)

Oversights identified and addressed in Oversights identified and addressed in real timereal time

Level

4

1

2

3

5

Predicted

Prophylaxis rate

40%

50%

65-85%

90%

95+%

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

Map to Reach Level 595+ % prophylaxis

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

GREEN ZONE - on anticoagulationYELLOW ZONE - on mechanical

prophylaxis only RED ZONE – on no prophylaxis

Act to move patients out of the RED!

Situational Awareness and Measure-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

• 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