Reducing Hospital-Acquired Venous Thromboembolisms (VTE): Interventions That Work (Text Version)

Slide presentation from the AHRQ 2009 conference.

On September 16, 2009, Denise Faulkner-Cameron made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (2.74 MB) (Plugin Software Help).


Slide 1

Reducing Hospital-Acquired Venous Thromboembolisms (VTE): Interventions That Work

Wednesday, September 16, 2009
8:00 am - 9:30 am
AHRQ Annual Conference
Bethesda North Marriott
Rockville, Maryland 

Slide 2

Preventing VTEs Web Conference Series

  • Partners:
    • Agency for Healthcare Research and Quality
    • IPRO
    • Illinois Foundation for Quality Health Care
    • Iowa Foundation for Medical Care
  • Subject matter expert:
    • Dr. Greg Maynard, Univ. of California San Diego
  • Tool:
    • AHRQ Preventing VTEs in the Hospital Toolkit
  • Duration:
    • 7 Web conferences from Sept. 2008 to May 2009 

Slide 3

Web Conference Series Overview

  • Approach
    • 7 interactive Web conferences with participating hospitals
      • Several featured expert review of draft protocol
    • Assignments between Web conferences
      • Identify physician champion,
      • Audit VTE prophylaxis rates
      • Changes in protocol
    • 1 additional "train-the-trainer" event for QIO staff
  • 44 hospitals participated (at least 3 events)
    • Iowa: 12 hospitals
    • Illinois: 14 hospitals
    • New York: 18 hospitals 

Slide 4

Early Results

  • Outreach to hospitals to gauge impact is ongoing
  • To date, out of 32 hospitals queried:
    • 19 revised existing protocols
    • 5 developed a new protocol (did not have an existing protocol)
  • Of the 24 new/revised protocols:
    • 15 have passed all stages of hospital review
    • 9 have been implemented (others expected to be implemented by end of year) 

Slide 5

Reducing Hospital-Acquired Venous Thromboembolisms (VTE): Interventions That Work

Greg Maynard MD, MSc
Clinical Professor of Medicine and Chief,
Division of Hospital Medicine
University of California, San Diego 

Slide 6

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, motor vehicle accidents, breast cancer 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 

Slide 7

Risk Factors for VTE

Stasis

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

Slide 8

Risk Factors for VTE

Most hospitalized patients have at least one risk factor for VTE

Slide 9

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.

Slide 10

The "Stick" is coming..

  • National Quality Forum 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
  • Centers for Medicare & Medicaid Services (CMS) - deep vein thrombosis (DVT) or pulmonary embolism (PE) with knee or hip replacement reimbursed as though complication had not occurred

Slide 11

2005 AHRQ Grant

  • 2005 - AHRQ grant to:
    • Design and implement VTE prevention protocol
    • Monitor impact on VTE prophylaxis and hospital-acquired (HA) VTE
    • Validate a VTE risk assessment model / protocol
  • Attempt to use portable methodology, build toolkit to allow others to accomplish the same thing

Slide 12

Percent of Randomly Sampled Inpatients with Adequate VTE Prophylaxis

A run chart showing rates of adequate VTE prophylaxis rates at UCSD, based on randomly selected inpatients. Baseline rate = about 50%, consensus building and education phase shows improvement to 70%, order set implementation gets the rate of adequate prophylaxis to 80 – 90%, and real time identification push the adequate prophylaxis rates up to 98%.

Slide 13

UCSD - Decrease in Patients with Preventable HA VTE

Run charts depicts a declining number of preventable VTE as the VTE prophylaxis rate improves, which affected all services. 10-13 preventable VTE per quarter were occurring at baseline in the first quarter of 2005, whereas this became 2 per quarter at times after implementation.

Slide 14

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

Slide 15

VTE Prevention Guides

Cover of AHRQ publication "Preventing Hospital-Acquired Venous Thromboembolism" on right side of slide, showing medical personnel on the cover, with the cover of the parallel publication on the left side of the screen labelled as being from the Society of Hospital Medicine. Web addresses where those publications can be downloaded are beneath the images of the publication covers.

http://www.ahrq.gov/qual/vtguide/
http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_VTE/VTE_Home.cfm

Slide 16

VTE QI Resource Room www.hospitalmedicine.org

Screen shot of web page: Society of Hospital Medicine title at the top, with a blue banner labelled Quality Improvement Resource Rooms across the middle of the page. A gold box on the right of the screen shot has "Venous Thromboembolism outlined with a red rectangle.

Slide 17

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) - 44 sites
  • IHI Expedition to Prevent VTE - 60 sites
  • SHM Team Improvement Award
  • NAPH Safety Net Award (Honorable Mention)
  • Venous Disease Coalition

Slide 18

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

Slide 19

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

Slide 20

Hierarchy of Reliability

Level Predicted Prophylaxis Rate
1No protocol* (“State of Nature”)40%
2Decision support exists but not linked to order writing, or prompts within orders but no decision support50%
3Protocol well-integrated (into orders at point-of-care)65%-85%
4Protocol enhanced (by other quality improvement / high reliability strategies)90%
5Oversights identified and addressed in real time95+%

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

Slide 21

Map to Reach Level 3
Implementing an Effective VTE Prevention Protocol

  • Examine existing admit, transfer, perioperative order sets with reference to VTE prophylaxis
  • Design a protocol-driven DVT prophylaxis order set (with integrated risk assessment model [RAM])
  • Vet / Pilot - Plan Do Study Act (PDSA)
  • Educate / consensus building
  • Place new standardized DVT order set 'module' into all pertinent admit, transfer, periop order sets
  • Monitor, tweak - PDSA

Slide 22

Too Little Guidance Prompt? Protocol

DVT Prophylaxis Orders

  • Anti thromboembolism Stockings
  • Sequential Compression Devices (SCD)
  • 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

Slide 23

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-pharmacologic prophylaxis too much
  • Failure to pilot, revise, monitor
  • Linkage between risk level and prophylaxis choices are separated in time or space

Slide 24

Is your order set in a competition?

A photo of a table top with 15-20 order sets spread all over it is depicted.

Slide 25

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

LowMediumHigh
Ambulatory 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

IPC needed if contraindication to AC exists

Slide 26

Hierarchy of Reliability

Level Predicted Prophylaxis Rate
1No protocol* (“State of Nature”)40%
2Decision support exists but not linked to order writing, or prompts within orders but no decision support50%
3Protocol well-integrated (into orders at point-of-care)65%-85%
4Protocol enhanced (by other quality improvement / high reliability strategies)90%
5Oversights identified and addressed in real time95+%

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

Slide 27

Map to Reach Level 5 

95+ % 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!

Slide 28

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"

Slide 29

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

Slide 30

Questions?

Slide 31

Reducing Hospital-Acquired Venous Thromboembolisms (VTE): Interventions That Work

Lisa Clark, RN, BSN
Clinical Reviewer
Performance Improvement Department
Catskill Regional Medical Center
Harris, New York

Slide 32

How did we know that we had a problem?

  • Existing in-house committee to review VTE issues chaired by MD champion
  • Recognized need for house-wide protocol to promote more uniform practice
  • Sought to reduce physician confusion and clarify prophylaxis needs

Slide 33

What do we aim to do about it?

  • What is our goal?
    • To achieve adequate universal prophylaxis by risk factors / orders to promote patient safety
  • What are we doing to get there?
    • Protocol revision, continue to build institutional support for universal prophylaxis, look to other options besides education

Slide 34

How has our VTE prevention protocol changed?

  • Changes in Protocol
    • Before:
      • Our facility set out to make it the most inclusive best point -based protocol ever to cover ALL ANGLES of VTE prophylaxis
      • End product was experience with a move to a different protocol
    • After:
      • Found it was too busy and difficult to use
      • Streamlining is the key !!!
      • Formatted more to look like usual order set

Slide 35

Old VTE prevention protocol

Slide 36

New VTE Prevention protocol

Slide 37

What other changes are we making?

  • Changes in Measurement
    • Before:
      • Monthly retroactive review of those coming up with a diagnosis of DVT/PE and sent letters to MDs who fell out.
    • After:
      • Do daily real time reviews for orders and have started to make calls as well.
  • Other Process Changes
    • Before:
      • No protocol at all
    • After:
      • Protocol revised and in place

Slide 38

Where are we in the process of implementation?

  • Stage of Implementation
    • Revise orthopedic protocol
    • Change format of ongoing protocol to a carbonated form with more emphasis on chart flow as currently a stand alone
  • Implementation Team
    • Multidisciplinary with Staff Development, MDs, PI, Nursing, Dietary and Pharmacy

Slide 39

Are we making progress?

Graph: % Either Mechanical or Pharmacological Prophylaxis Combined

Slide 40

What were our challenges and how did we overcome them?

  • Protocol revision
  • Increased buy-in
  • Orthopedic more on board with ordering
  • More physician awareness with order writing once protocol was out

Slide 41

Biggest revelations?

  • Introduction of the new orders spurred MDs to order prophylaxis even if they wrote their own orders
  • Need to promote the orders for risk factor choices but 1:1 intervention very helpful
  • Education of various groups despite best efforts is not enough

Slide 42

In retrospect, what would we do differently?

  • Initiate 1:1 intervention sooner
  • Discover a more effective way to incorporate the stand alone order set in your process
  • Identify your champion group early and engage them as much as possible (e.g., hospitalists)

Slide 43

Reducing Hospital-Acquired Venous Thromboembolisms: Interventions That Work

Marcia Kruse, RN, BA, CPHQ
Director Case Management
Fort Madison Community Hospital
Fort Madison, Iowa

Slide 44

FMCH's Journey

  • Journey began in 2005
  • Iowa Hospitals - 113 out of 116 (97%) were involved in a Survey of the National Quality Forum 30 Safe Practices-aimed at measuring Iowa hospital's engagement in implementing strategies endorsed by NQF
  • Sponsored by Iowa Healthcare Collaborative and Texas Medical Institute of Technology
  • Risk assessment and appropriate prophylaxis for VTE was one of the safe practices

Slide 45

How did we know that we had a problem?

  • Listened to the first webinar
  • Decided we were way ahead of the game
  • Later QIO petitioned hospitals for data- I sent ours!
  • QIO asked for protocol and asked if they could share with Dr. Maynard

Slide 46

What did we aim to do about it?

  • What was our goal?
    • To revise current protocol, simplify the process, physician driven
  • What did we do to get there?
    • Discussed with Chief of Adult Medicine
    • Slide presentation to our Adult Medicine Committee
    • Revised Risk Assessment/Protocol and implemented June 1st
    • Placed on all admissions-flagged
    • To be completed in 24 hours

Slide 47

Moving on.

  • Risk Assessment/Orders taken to Surgery Committee
  • Post op VTE prophylaxis is embedded in post op order sets
  • Voted to use the new forms - box checked when already ordered

Slide 48

How has our VTE prevention protocol changed?

Changes in Protocol

  • Before:
    • Nurses completed the assessment on line and auto printed for physicians to complete
    • Auto scored by point system
    • Complicated order set
  • After:
    • Simple risk groups - Low, Medium and High
    • Response to risk level and contraindications drive default choices

Slide 49

Lots of Choices-Old Version

Slide 50

New Version-Simplified

Slide 51

What other changes are we making?

  • Changes in Measurement
    • Monitored quarterly in past-random records
    • Reported to Adult Med Committee
    • Monitors showed good compliance
    • Basically monitored if the form was signed-not appropriateness
    • Did not do metrics for DVT, PE incidence
  • New monitors
    • Baseline determined-on appropriate orders
    • Weekly, now monthly-watch for appropriate orders

Slide 52

Monitors for Old Version

Image: The graph shows the quarterly rate of DVT Risk Assessments completed by the nurse from Q3 2006 to Q1 2009 and the quarterly rate for the DVT Orders signed by the doctor. The Risk Assessment completed by the nursing staff improved from 70% compliance initially to 100% compliance for the last 4 quarters. Over the 2 years the compliance for the orders signed by the doctor was variable, from 32% to the last quarter at 100%.

Slide 53

New Monitor

Image: The graph shows the weekly, then monthly monitor for compliance on appropriately assigning the risk and ordering appropriate prophyaxis. The baseline data from May 2009 was produced from a monitor to determine appropriateness of prophylaxis prior to implementing the new form. The Compliance was 80% and improved to mid 90's percentile.

Slide 54

Barriers

  • Occasionally form not available
  • Risk not assessed appropriately
  • Form not completed accurately

Slide 55

What is Next??

  • Post op DVT/PE already go to MSQRC
  • Hospital Acquired will go to MSQRC?
  • Address at peer review level those doctors not using form appropriately
  • Investigate ER Doctors/Clinical Pharmacist initiating orders
  • Monitor incidence of hospital acquired VTE/PE

Slide 56

Next Steps

  • Monitoring implementation
  • Continued support through QIOs on:
    • Protocol development
    • Measurement
    • Identifying physician champion
    • Securing buy-in from administration, surgeons/physicians, nurses, others

Slide 57

Q&A

  • Panelists
    • Denise Faulkner-Cameron, IPRO
    • Greg Maynard, UCSD
    • Lisa Clark, Catskill Regional Medical Center
    • Marcia Kruse, Fort Madison Community Hospital
Current as of December 2009
Internet Citation: Reducing Hospital-Acquired Venous Thromboembolisms (VTE): Interventions That Work (Text Version). December 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2009/faulkner-cameron/index.html