Guide Available for Deep Vein Thrombosis (Text Version)

Slide presentation from the AHRQ 2009 conference

On September 15, 2009, Greg Maynard made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (1.1 MB) (Plugin Software Help).


Slide 1

Guide Available for Deep Vein Thrombosis

  • Developed from Partnerships in Implementing Patient Safety program toolkit
  • Based on quality improvement initiatives undertaken at the University of California, San Diego Medical Center and Emory University Hospitals
  • Assists quality improvement practitioners in preventing one of the most important problems facing hospitalized patients - DVT / PE (VTE) 

Slide 2

Why build a toolkit for VTE Prevention?

  • VTE is a common source of inpatient M&M
    • Jumbo jet crash / day- > Breast CA, HIV, MVA combined
    • May be # 1 preventable source of hospital death
  • Effective and safe methods of prevention exist
    • Large "implementation gap" - best practice? current practice
  • These methods are grossly underutilized
    • Awareness, difficulty implementing, no validated risk assessment
  • P4P, public reporting, and core measures

Geerts WH, et al. Chest. 2008;133:381S-453S.
Cohen, Tapson, Bergmann, et al. ENDORSE study: Lancet 2008; 371: 387-94.
Surgeon General's Call to Action to Prevent DVT and PE 2008 DHHS 

Slide 3

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 4

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 QI / 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 5

The Essential First Intervention

VTE Protocol

1) A standardized VTE risk assessment, linked to.
2)  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 6

Example from UCSD
Keep it Simple - A "3 bucket" model

LowMediumHigh
Ambulatory with no other risk factors. Same day or minor surgeryCHF
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 7

Map to Reach Level 3
Implementing 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)
  • Vette / Pilot - PDSA
  • Educate / consensus building
  • Place new standardized DVT order set 'module' into all pertinent admit, transfer, periop order sets.
  • Monitor, tweak - PDSA

Slide 8

Percent of Randomly Sampled Inpatients with Adequate VTE Prophylaxis

In press, Maynard, Morris et al, J Hosp Med

Image of line graph from Q1 2005 to Q4 2007.  It shows baseline; consensus building; order set implementation and adjustment; and real time ID and intervention.

Slide 9

UCSD - Decrease in Patients with Preventable HA VTE

Image of line graph from Q1 2005 to Q1 2007.  There are separate graphs for different departments including: medicine, surgery, ortho, other and then total of all.

Slide 10

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 QI / 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 11

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 12

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 13

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
  • Venous Disease Coalition
Current as of December 2009
Internet Citation: Guide Available for Deep Vein Thrombosis (Text Version). December 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2009/maynard/index.html