Venous Thromboembolism Safety Tool Kit (Text Version)

Slide Presentation from the AHRQ 2008 Annual Conference

On September 10, 2008, Brenda K. Zierler, Ph.D., RN, RVT, made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (3.8 MB; ).

Slide 1

Venous Thromboembolism (VTE) Safety Tool Kit

Brenda K. Zierler, Ph.D., RN, RVT
University of Washington

Medication Safety: Tools for Diverse Settings
September 10, 2008
8:00 a.m.-9:30 a.m.

Slide 2

VTE Safety Toolkit

• Partnership in Patient Safety Grant.
• AHRQ (Agency for Healthcare Research and Quality).
• 2-year grant to improve care for patients at risk for or diagnosed with VTE:
  • PI: Brenda Zierler, Ph.D.
  • Co-PI: Gene Peterson, M.D.

Slide 3

VTE Safety Toolkit—What is It?

• Evidence-based algorithms, guidelines, recommendations, and order sets for preventing, diagnosing, treating and educating patients and providers about VTE.
• Educational intervention and compliance training.
• Medications-heparin, warfarin.

Slide 4

Interdisciplinary Clinical Team

Slide 5

Why Study VTE? Epidemiology of VTE

• VTE encompasses deep vein thrombosis (DVT) and pulmonary embolism (PE).
• Most common preventable cause of hospital death.
• 900,000 Americans suffer VTE each year:
  • 400,000 DVT.
  • 500,000 PE.

Slide 6

Epidemiology of VTE

In 300,000 patients, PE proves fatal:

• 3rd most common cause of hospital-related deaths in the United States.
• Post-thrombotic syndrome will be seen in 800,000 pts.:
  • 7% of these individuals will have a severe form of the problem and will become disabled.
• Survivors are at risk for recurrence of PE:
  • Pulmonary hypertension develops in approximately 30,000 patients who survive their PE.

Slide 7

Epidemiology of VTE (continued)

• 1 of 20 hospitalized medical patients will suffer a fatal PE if they have not received appropriate thrombosis prophylaxis.
• 50% of the 2 million cases of DVT yearly are "silent."

Slide 8

Risk Factors for VTE

• Determine who should receive prophylaxis.
• Every patient at University of Washington Medical Center (UWMC) should be assessed for risk of developing VTE.
• Understand contraindications to pharmacologic prophylaxis (heparin, warfarin).
• Offer mechanical prophylaxis when pharmacologic prophylaxis is not safe.

Slide 9

VTE Safety Toolkit- Components

• VTE Prophylaxis (focus of today's talk).
• Risk Assessment Tool.
• DVT Diagnostic Algorithm.
• PE Diagnostic Algorithm.
• Health Information Technology (IT) Assessment.
• Heparin nomograms (dosing).
• VTE Treatment Pathway.
• DVT Treatment Order Set.
• Vascular Lab Requisition.
• Neural-axial anesthesia guidelines.
• Patient Education (prevention & treatment).

Slide 10

VTE as a Clinical and System Problem

• System Barriers:
  • Providers are not employees of 450-bed academic medical center.
  • No standards of practice.
  • Multiple disciplines treating small numbers of patients (without experience or expertise).
  • Prophylaxis is underutilized.

Slide 11

Past Experience

• Implementation of DVT pathways.
• Reasons for failure:
  • Trying to change individual physician behavior.
  • No culture of safety.
  • Lack of systems supports.
  • No integrated information system.
  • Ownership/turf issues.

Slide 12

VTE Prophylaxis

• Every patient should be assessed for risk of developing VTE.
• Determine who should receive prophylaxis.
• Understand dosing and contraindications to pharmacologic prophylaxis (heparin, warfarin).
• Offer mechanical prophylaxis when pharmacologic prophylaxis is not safe.
• Document assessment and prophylaxis plan.

Slide 13

Steps in Implementation

• Dedicated Web Site.
• Training Modules—pilot in winter 2007.
• Test interactive cases as educational intervention.
• Gather feedback about training (effectiveness, clarity, timeliness, relevance).

Slide 14

VTE Web site

This slide shows a screen shot of the home page of the University of Washington Venous Thromboembolism (VTE) Web site at http://vte.son.washington.edu. The text reads:

This Web site contains multiple evidence-based tools called the VTE Safety Toolkit, for the prevention, diagnosis, and treatment of venous thromboembolism (VTE).

The development and implementation of the toolkit was funded by the Agency for Healthcare Research and Quality (AHRQ) for the purpose of increasing the implementation of safe practice interventions for patients at risk for or who are diagnosed with VTE, through use of an evidenced-based and system-supported interactive VTE Safety Toolkit.

Dedication

This project is dedicated to the late Dr. D. Eugene Strandness, Jr., MD, who was a Professor of Surgery at the University of Washington School of Medicine. Dr. Strandness had consecutive NIH funding for 15 years studying the natural history of venous thromboembolism. He was an outstanding clinical researcher, mentor, friend and colleague.

Note: This project was supported by grant number 1 U18 HS015898 from the Agency for Healthcare Research and Quality.

Slide 15

Toolkit

This slide is another screen shot from the University of Washington VTE Web site at http://vte.son.washington.edu, this one showing the pull-down menu that opens as a result of clicking on "Toolkit" on the home page above. It lists the following links to other pages in the site:

• Prevention Guidelines.
• Screening & Assessment of VTE.
• Diagnostic Algorithms.
• VTE Treatment Pathways.
• Anticoagulation Management.

Slide 16

Prevention Guidelines

This slide is another screen shot from the University of Washington VTE Web site at http://vte.son.washington.edu. It shows the Web page that opens as a result of clicking on "Prevention Guidelines" on the page above. The text reads:

DVT and PE Prevention Guidelines for Adults

This toolkit component was created by providers at the University of Washington Medical Center and Harborview Medical Center and is the prophylaxis guidelines for the prevention of VTE. The levels of evidence for recommendations are included in the guideline.

The screen includes a link allowing the viewer to download the guidelines, along with the Terms of Use for using the guidelines.

Slide 17

Screening & Assessment

This slide is another screen shot from the University of Washington VTE Web site at http://vte.son.washington.edu. It shows the Web page that opens as a result of clicking on "Screening & Assessment" on a previous Web page [go to Slide 15]. The screen includes the following two links to downloadable documents:

• UW VTE risk assessment and prophylaxis order set.
• UWMC vascular diagnostic service (Vascular Lab Requisition).

Slide 18

Diagnostic Algorithms

This slide is another screen shot from the University of Washington VTE Web site at http://vte.son.washington.edu. It shows the Web page that opens as a result of clicking on "Diagnostic Algorithms" on a previous Web page [go to Slide 15]. The screen includes the following two links to downloadable documents:

• Diagnostic Workup for Patients Presenting with Signs and Symptoms of DVT.
• Diagnostic Workup for Patients Presenting with Signs and Symptoms of PE.

Slide 19

VTE Treatment Pathways

This slide is another screen shot from the University of Washington Venous Thromboembolism Web site at http://vte.son.washington.edu. It shows the Web page that opens as a result of clicking on "VTE Treatment Pathways" on a previous Web page [go to Slide 15]. The screen includes the following link to a downloadable document:

• Treatment of acute VTE.

Slide 20

Anticoagulation Management

This slide is another screen shot from the University of Washington VTE Web site at http://vte.son.washington.edu. It shows the Web page that opens as a result of clicking on "Anticoagulation Management" on a previous Web page [go to Slide 15]. The screen includes the following links to downloadable documents:

• Optimal Therapeutic Range and Duration of Anticoagulation.
• Flexible Initiation Methods for Warfarin.
• Dosing Adjustment Nomogram for Warfarin.
• Recommendations for the Frequency of Monitoring Warfarin.
• Clinical Management of Suspected Health IT.

Slide 21

Patient Education

This slide is another screen shot from the University of Washington VTE Web site at http://vte.son.washington.edu. It shows the pulldown menu that opens as a result of clicking on "Patient Education" on the VTE home page [go to Slide 14]. The screen includes the following links to downloadable documents:

• Signs and Symptoms and Prevention Measures.
• Outpatient Treatment Protocol.
• Patient Testimonials.

Slide 22

Links

This slide is another screen shot from the University of Washington VTE Web site at http://vte.son.washington.edu It shows the Web page that opens as a result of clicking on "Links" on the VTE home page [go to Slide 14]. The screen lists the following links:

• AHRQ Patient Safety Network
  http://psnet.ahrq.gov/.
• University of Washington Anticoagulation Clinic
  http://uwmcacc.org/.
• University of Washington Laboratory Medicine Guidelines for Hypercoagulable Workup (go to page 14 for Venous thromboembolism)
  http://depts.washington.edu/labweb/PatientCare/Clinical/Guides/hemostasis.pdf.
• Coalition to Prevent Deep Vein Thrombosis
  http://www.preventdvt.org/
• National Consensus Standards for the Prevention and Care of Venous Thromboembolism (including Deep Vein Thrombosis and Pulmonary Embolism)
  http://www.qualityforum.org/projects/ongoing/vte/default.asp.

Slide 23

References

This slide is another screen shot from the University of Washington VTE Web site at http://vte.son.washington.edu. It shows the top of the Web page that opens as a result of clicking on "References" on the VTE home page [go to Slide 14]. It lists the following references:

1. DVT and PE PRevention Guidelines for Adults

Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126:338S-400S

2. Anticoagulation Guidelines for Neuraxial Procedures

Horlocker TT, Wedel DJ, Benzon H, et al. Regional anesthesia in the anticoagulated patient: Defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med 2003; 28:172-97

3. UW VTE Risk Assessment and Prophylaxis Order Set

Caprini JA. Thrombosis risk assessment as a guide to quality patient care. Dis Mon 2005; 51:70-78

Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126:338S-400S

White RH. The epidemiology of venous thromboembolism. Circulation 2003; 107:I4-8

4. UWMC Vascular Diagnostic Service (Vascular Lab Requisition)

Anderson DR, Kovacs MJ, Kovacs G, et al. Combined use of clinical assessment and d-dimer to improve the management of patients presenting to the emergency department with suspected deep vein thrombosis (the EDITED Study). J Thromb Haemost 2003; 1:645-51

Wells PS, Anderson DR, Bormanis J, et al. Application of a diagnostic clinical model for the management of hospitalized patients with suspected deep-vein thrombosis. Thromb Haemost 1999; 81:493-97

Wells PS, Anderson DR, Rodger M, et al. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med 2003; 349:1227-1235

5. Diagnostic Workup for Patients Presenting with Signs and Symptoms of DVT

Anderson DR, Kovacs MJ, Kovacs G, et al. Combined use of clinical assessment and d-dimer to improve the management of patients presenting to the emergency department with suspected deep vein thrombosis (the EDITED Study). J Thromb Haemost 2003; 1:645-51

Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126:338S-400S

Kearon C, Ginsberg JS, Douketis J, et al. Management of suspected deep venous thrombosis in outpatients by using clinical assessment and D-dimer testing. Ann Intern Med 2001; 135:108-11

Slide 24

Developers

This slide is another screen shot from the University of Washington VTE Web site at http://vte.son.washington.edu. It shows the top part of the Web page that opens as a result of clicking on "Developers" on the VTE home page [go to Slide 14]. It contains the following text:

The work for this Web site is the culmination of ongoing venous research at the UWMC. The team members for the current AHRQ study include:

University of Washington Clinical and Research Faculty

Brenda K. Zierler, PhD, RN, RVT, Principle Investigator
Associate Dean, Technology Innovations in Education and Research
brendaz@u.washington.edu

Gene Peterson, MD, PhD, MHA, Co-Principle Investigator
Assistant Professor
Associate Medical Director for Quality
gpeterso@u.washington.edu

Ann K. Wittkowsky, PharmD, CACP, FASHP, FCCP
Associate Professor
akwitt@u.washington.edu

Robb Glenny, MD
Professor of Medicine and of Physiology and Biophysics
glenny@u.washington.edu

Paul Hendrie, MD, PhD
Hematology Division, Acting Instructor
phendrie@u.washington.edu

Pamela Mitchell, PhD, CNRN, FAAN
Professor Elizabeth S. Soule Professor, Associate Dean for Research, School of Nursing
pmitch@u.washington.edu

Frederick Wolf, PhD
Professor & Chair, Medical Education & Biomedical Informatics
wolf@u.washington.edu

Lynne Robins, PhD
Associate Professor, Medical Education and Biomedical Informatics
lynner@u.washington.edu

Karen A. McDonough M.D.
Division of General Internal Medicine
kmcdonou@u.washington.edu

Mark Meissner, MD

Slide 25

Randomized Controlled Trial

• Test knowledge acquisition about VTE prevention using interactive case studies.
• Control Group (passive didactic).
• Experimental Group (interactive case studies with feedback).
• Mandatory training (similar to the Health Insurance Portability and Accountability Act [HIPAA]).
• Tracking outcomes by provider (currently tracking pre-intervention data).

Slide 26

Provider Training Module

The slide includes a screen shot from the University of Washington's Web-based Provider Training Module at its VTE Web site, http://vte.son.washington.edu. The slide shows interactive entry of Username and Password log-in.

Slide 27

Pre Test

The slide includes a screen shot from the University of Washington's Web-based Provider Training Module. It displays the Pre Test page. The slide allows for interactive entry of Option 1 or Option 2. There is a commentary that states, "Both groups will be pre-tested on current VTE prophylaxis knowledge."

Slide 28

Patients Who Do Not Need Prophylaxis

The slide includes a screen shot from the University of Washington's Web-based Provider Training Module. It includes the following text:

Patients Who Do Not Need Prophylaxis

Almost every hospitalized patient should receive VTE prophylaxis.

Those who do NOT need VTE prophylaxis include patients who are fully anticoagulated with:
Warfarin (INR >2.0)
Heparin (aPTT >60)
Low molecular weight heparin (full dose)
Direct thrombin inhibitors (bivalirudin, lepirudin, argatroban)
Factor xA inhibitors (fondaparinux)

As long as patients remain fully anticoagulated with these medications during hospital admission, additional VTE prophylaxis is not required.

Although rare in the hospital setting, low risk patients who are fully ambulatory may not need VTE prophylaxis.

Below the text commentary has been added stating: "Passive Didactic Training on core principles."

Slide 29

Post Test

The slide includes a screen shot from the University of Washington's Web-based Provider Training Module. It includes buttons for Option 1 or Option 2. Below the screen is the commentary stating: "Control Group will take Post test after passive training."

Slide 30

Case 1

The slide includes a screen shot from the University of Washington's Web-based Provider Training Module. The screen shot contains the following text:

Case 1

59 year old male who presents to the Emergency Department with new atrial fibrillation. The patient is admitted to the hospital and started on an intravenous heparin drip (170 U/kg bolus, 15 U/kg/hr initial infusion). What is the most appropriate VTE prevention strategy?

___ No need for prophylaxis
___  Pharmacologic prophylaxis indicated
___ Mechanical prophylaxis indicated

Below the text is the commentary stating: "Interactive case studies with feedback."

Slide 31

Case 1 (continued)

The slide includes a screen shot from the University of Washington's Web-based Provider Training Module. The screen shot contains the same text as the previous slide but with "Mechanical prophylaxis indicated" checked; beside it is a red "X" indicating the answer is wrong, and below is the explanation:

This is not the correct answer. The patient will be fully anticoagulated with heparin as a bridge to transition to therapeutic oral anticoagulation for stroke protection. The therapy is adequate prophylaxis for VTE.

Slide 32

Case 1 (continued)

The slide includes a screen shot from the University of Washington's Web-based Provider Training Module. The screen shot contains the same text as the two previous slides but with "No need for prophylaxis" checked; beside it is a green check mark indicating the answer is correct, and below is the explanation:

This is the correct answer. The patient will be fully anticoagulated with heparin as a bridge to therapeutic oral anticoagulation for stroke prevention. The therapy is adequate for VTE.

Slide 33

Completion

The slide includes a screen shot from the University of Washington's Web-based Provider Training Module. The screen shot represents what the user would see upon completion of the interactive module.

Below the text is commentary stating: "100% pass rate expected; certification will be granted and linked to Quality Improvement (compliance)."

Slide 34

Implementation of VTE Toolkit

• Systems approach.
• Buy-in from Administration.
• Focus on patient safety.
• Mandatory training to meet core competencies on VTE prophylaxis.
• Joint Commission and the National Quality Forum.

Slide 35

Conclusion

• Improve patient safety by adopting practice standards based on evidence from the literature.
• Improve utilization of diagnostic services.
• Improve safety of medications (heparin nomograms/guidelines).
• http://vte.son.washington.edu.

Slide 36

Thank You

Below the text photos of the University of Washington Medical Center and campus are shown.