AHRQ QIO Venous Thromboembolism VTE Prevention in the Hospital

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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

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VTE A Major Source of Mortality and Morbidity

• 350,000 to 650,000 with VTE per year
• 100,000 to gt 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 Generals Call to Action to Prevent DVT
and PE 2008 DHHS
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Risk Factors for VTE

• Endothelial Damage
• Surgery
• Prior VTE
• Central lines
• Trauma

• Stasis
• Age gt 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

Anderson FA Jr. Wheeler HB. Clin Chest Med
199516235.
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Risk Factors for VTE

• Endothelial Damage
• Surgery
• Prior VTE
• Central lines
• Trauma

• Stasis
• Age gt 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

Most hospitalized patients have at least one risk
factor for VTE
Anderson FA Jr. Wheeler HB. Clin Chest Med
199516235. Bick RL Kaplan H. Med Clin North
Am 199882409.
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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 38794.
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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
  its 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.

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• 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

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Percent of randomly sampled inpatients with
adequate vte prophylaxis
N 2,944 mean 82 audits / month
In press, JHM 2009
Real time ID intervention
Order Set Implementation Adjustment
Consensus building
Baseline
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UCSD Decrease in patients with preventable ha
vte
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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

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VTE Prevention Guides
VTE Prevention Guides
http//www.hospitalmedicine.org/ResourceRoomRedesi
gn/RR_VTE/VTE_Home.cfm
http//ahrq.hhs.gov/qual/vtguide/
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VTE QI Resource Room
VTE QI Resource Room www.hospitalmedicine.org
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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

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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
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The Essential First Intervention
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

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Hierarchy of Reliability
Predicted Prophylaxis rate
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
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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

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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

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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

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Is your order set in a competition?
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Low Medium High
Example from UCSD Keep it Simple A 3 bucket
model
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IPC needed if contraindication to AC exists
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Hierarchy of Reliability
Predicted Prophylaxis rate
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
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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 anticoagulation
• YELLOW ZONE - on mechanical prophylaxis only
• RED ZONE on no prophylaxis
• Act to move patients out of the RED!

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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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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