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
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
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”
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