Optimizing Venous Thromboembolism Prophylaxis using Physician Order Entry: Johns Hopkins Hospital...
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Optimizing Venous Thromboembolism Prophylaxis using Physician Order Entry: Johns Hopkins Hospital Experience Michael B. Streiff, MD Associate Professor of Medicine Division of Hematology Medical Director, Johns Hopkins Anticoagulation Management Service
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Transcript of Optimizing Venous Thromboembolism Prophylaxis using Physician Order Entry: Johns Hopkins Hospital...
Optimizing Venous Thromboembolism Prophylaxis using Physician Order Entry:
Johns Hopkins Hospital Experience
Michael B. Streiff, MDAssociate Professor of Medicine
Division of HematologyMedical Director,
Johns Hopkins Anticoagulation Management Service
Venous thromboembolism (VTE) Prevention- Why should we care?
• Venous thromboembolism is common– 900,000 DVT/PE annually
• VTE is deadly– 10% of hospital deaths due to
PE– Only 1/3 suspected ante-
mortem• VTE causes long-term
morbidity– Recurrent VTE occurs in 40%
by 10 years– Post-thrombotic syndrome
affects 30% by 5 years• VTE is preventable
– Effective prophylaxis reduces DVT incidence by 60%
VTE Prevention- We are failing our patients!
29 33 29 28
50 50
0102030405060708090
100
US 91 Canada01
US 02 UK 03 World07
World08
Anderson Arch Intern Med 1991 Rahim et al. Thromb Res 2003. Tapson et al. Blood 2004, Rashid J Royal Soc Med 2005; Spencer et al. Arch Intern Med 2007; Tapson et al. Chest 2007; Cohen AT Lancet 2008
• Worchester VTE study- 1897 patients with VTE from 12 hospitals
• Seventy-four percent were outpatients
• Sixty percent recently hospitalized
• Only 43% received DVT prophylaxis (Spencer FA et al. Arch Intern Med 2007)
Pro
phyl
axis
(%
)
Joint Commission Standards for VTE Management
• Prevention• Documentation of Venous Thromboembolism Risk Assessment/Prophylaxis within 24
Hours of Hospital Admission• Documentation of Venous Thromboembolism Risk Assessment/Prophylaxis within 24
Hours of Transfer to ICU• Treatment• Documentation of Inferior Vena Cava Filter Indication • Venous Thromboembolism Patients with Overlap of Parenteral and Warfarin
Anticoagulation Therapy • Venous Thromboembolism Patients Receiving Unfractionated Heparin with Platelet
Count Monitoring • Venous Thromboembolism Patients Receiving Unfractionated Heparin Management
by Nomogram/Protocol • Venous Thromboembolism Discharge Instructions• Outcome• Incidence of Potentially Preventable Hospital-Acquired Venous Thromboembolism
Hopkins Surgical Services:DVT Prophylaxis Baseline Adherence 2005
12
17
50
21
50
30
20
27
0
5
10
15
20
25
30
35
40
45
50
Cardiac GI Gyn/Onc Halsted Orthopedics PMR Transplant Vascular
AC
CP
Gu
idel
ine
Ad
her
ence
(%
)
Data courtesy of Deb Hobson RN Center for Innovations in Quality Patient Care
26
8893
98 97 97.487.2
99.2 99.2 99.2 100
0102030405060708090
100
PreJan-Feb
2005
Mar-Apr2005
Qrt 22005
Qrt 32005
Qrt 42005
Qrt 12006
Qrt 22006
Qrt 32006
Qrt 42006
Qrt 12007
Qrt 22007
Physical Medicine & Rehabilitation VTE Prophylaxis Performance
N=914
AC
CP
Ad
her
ence
(%
)
Data courtesy of S Mayer MD PM&R & Deb Hobson RN Center for Innovations in Quality Patient Care
General Surgery Overall Compliance with Recommended VTE Prevention
N= 297 cases reviewed 11/2006 (35 cases contraindicated for pharmacologic prophylaxis)
42/161 178/262 2/2 9/19 72/103 95/138
100.0
26.1
68.867.9 69.9
47.4
0
20
40
60
80
100
Aggregate2005
Aggregate11/2006
Low Mod High Very High
AC
CP
Co
mp
lian
ce (
%)
Data courtesy of Deb Hobson RN Center for Innovations in Quality Patient Care
Johns Hopkins VTE Prevention Collaborative – Version 1.0 Results• Evidence-based Paper VTE Prophylaxis Tool
– Success• Improved VTE Prophylaxis compliance from 25% to 50-100%• Decreased VTE incidence on some floors
– Shortcomings• Complex• Forms not always available• Labor intensive data collection• Out of usual work flow stream on CPOE units
Result = Sub-optimal VTE prevention
Solution = Electronic Risk Stratification/Order Entry
0
10
20
30
40
50
60
70
80
90
100
Paper Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08
Risk stratification 24 hrs Risk Stratification Prophylaxis 24 hrs Prophylaxis
Impact of the POE VTE Order set on Compliance on the Orthopedic Spine Service
N= 15 40 35 42 37 21 42 40 37
Ad
mis
sio
ns
(%)
0
10
20
30
40
50
60
70
80
90
100
Paper Jan-08 Feb-08 Mar-08
Risk stratification Risk Stratification 24 hrs Prophylaxis Prophylaxis 24 hrs.
Impact of the POE VTE Order set on Compliance on the Medicine Service
N=20 N=1059 N=1039 N=1097
Annual Incidence of VTE at JHH
0
1
2
3
4
5
6
2004 2005 2006 2007V
TE
(%
of d
isch
arg
es)
Conclusions
• We have developed a POE VTE prophylaxis order set that facilitates rapid VTE risk stratification and evidence-based VTE prophylaxis ordering
• Benefits of the order set include…– Increased VTE risk stratification – Increased risk-appropriate VTE prophylaxis– Enhanced VTE performance monitoring/reporting – Targeted provider education of VTE risk factors and
prophylaxis modalities – More effective strategy to improve VTE prevention
than electronic alerts
Future Plans
• Study the impact of the order set on VTE and bleeding event rates
• Study the impact of the order set on provider VTE management knowledge base
Acknowledgments• Paula Biscup-Horn PharmD, BCPS• Deb Hobson, BSN• Elliot Haut, MD• Peggy Kraus, PharmD, CAPS• Chad Smith, FACHE• Katy Olive• JHMCIS
– Peter Greene MD– Steve Mandell, Peggy Ardolino, Pat Zeller, Annette Durrette-
Smith, Irma Sutanto, Bonnie McCoy & JHMCIS Team
• The VTE Collaborative Teams• The Center for Innovation in Quality Patient Care• Renee Demski, MSW, MBA and the Johns Hopkins
Health System Quality Improvement Office
Questions ?
