Venous Thromboembolism (VTE) Prevention in the Hospital (Text Version)

Slide presentation from the AHRQ 2009 conference

On September 16, 2009, Greg Maynard made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (1.68 MB) (Plugin Software Help).

 


Slide 1

AHRQ / QIO Venous 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 

Slide 2

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 

Slide 3

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 

Anderson FA Jr. & Wheeler HB. Clin Chest Med 1995;16:235.

Slide 4

Risk Factors for VTE

Image of previous slide with the following words over it: Most hospitalized patients have at least one risk factor for VTE.

Slide 5

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 6

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. 

Slide 7

Percent of Randomly Sampled Inpatients with Adequate VTE Prophylaxis

Image of a line graph showing progress over time.

 

  • 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.

In press, JHIM 2009. 

Slide 8

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 9

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 10

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 11

VTE Prevention Guides

Image: Two images are shown. One is the cover of the Preventing Hospital-Acquired Venous Thromboembolism, A Guide for Effective Quality Improvement - Version 3.0. The other cover is Preventing Hospital-Acquired Venous Thrombeenbolism, A guide to Effective Quality Improvement. 

Slide 12

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 13

Slide 13. Collaborative Efforts and Kudos

Slide 13. Collaborative Efforts and Kudos

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 

Slide 14

To Achieve Improvement

SHM and AHRQ Guides on VTE Prevention

  • Real institutional support / prioritization
  • Will to standardize
  • Physician leadership
  • Measurement of process / outcomes
  • Protocol, integrated into order sets
  • Education
  • Continued refinement / tweaking- PDSA 

Slide 15

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 16

Hierarchy of Reliability

Level / Predicted Prophylaxis rate

  • 1. No protocol* ("State of Nature"): 40%
  • 2. Decision support exists but not linked to order writing, or prompts within orders but no decision support: 50%
  • 3. Protocol well-integrated (into orders at point-of-care): 65-85%
  • 4. Protocol enhanced (by other QI / high reliability strategies): 90%
  • 5. Oversights identified and addressed in real time: 95+%

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

Slide 17

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 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

Slide 18

Too Little Guidance Prompt is Not Equal to 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

Slide 19

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

Slide 20

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 21

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

LowMediumHigh

Ambulatory with no other risk factors.  Same day or minor surgery

Early ambulation

CHF

COPD / Pneumonia

Most Medical Patients

Most Gen Surg Patients

Everybody Else

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

Elective LE arthroplasty

Hip/pelvic fx

Acute SCI w/ paresis

Multiple major trauma

Abd / pelvic CA surgery

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 22

Hierarchy of Reliability

Level / Predicted Prophylaxis rate

  • 1. No protocol* ("State of Nature"): 40%
  • 2. Decision support exists but not linked to order writing, or prompts within orders but no decision support: 50%
  • 3. Protocol well-integrated (into orders at point-of-care): 65-85%
  • 4. Protocol enhanced (by other QI / high reliability strategies): 90%
  • 5. Oversights identified and addressed in real time: 95+%

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

Slide 23

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 24

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 25

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
Current as of December 2009
Internet Citation: Venous Thromboembolism (VTE) Prevention in the Hospital (Text Version). December 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2009/maynard2/index.html