Preventing Hospital-Acquired Venous Thromboembolism

Slide Presentation from the AHRQ 2011 Annual Conference

On September 20, 2011, Vicky Agramonte made this presentation at the 2011 Annual Conference.

Slide 1

Slide 1: Preventing Hospital-Acquired Venous Thromboembolism

Preventing Hospital-Acquired Venous Thromboembolism

AHRQ Annual Meeting
September 20, 2011

Vicky Agramonte, RN, MSN
Project Manager
QIO Learning Network

Slide 2

 Slide 2: Preventing H-A VTE Toolkit

Preventing H-A VTE Toolkit

  • Focuses on the basics of quality improvement.
  • Physician driven QI effort.
  • Though development of VTE risk assessment and order sets, preventable H-A VTEs have dropped.
  • Developed based on the research of Dr. Gregory Maynard, in association with the Society of Hospital Medicine.

Slide 3

Slide 3: VTE Toolkit

VTE Toolkit

  • Comprehensive guide that focuses on the basics of quality improvement.
  • Step-by-step instructions on the development and implementation of an improved VTE prevention protocol.
  • Hierarchy of Reliability.
  • Provides sample VTE protocol:
    • 3-bucket risk assessment (low, moderate, and high risk).
    • Sample order set.
  • Measurement strategy for continuous improvement.

Protocol = Risk assessment and corresponding order set of pharmacological agents and/or mechanical prophylaxis.

Slide 4

Slide 4: Toolkit Applicability

Toolkit Applicability

  • VTE toolkit is usable in varying provider settings:
    • Large hospital settings.
    • Smaller community hospitals.
    • Critical Access Hospitals.
  • Usable toolkit for providers that are:
    • Have EHR.
    • Paper medical record.
    • Hybrid (both EHR and paper).

Slide 5

Slide 5: VTE Toolkit Contents

VTE Toolkit Contents

  • Taking the Essential First Steps.
  • Laying Out the Evidence and Identify Best Practices.
  • Analyzing Care Delivery.
  • Tracking Performance with Metrics.
  • Layering Interventions.
  • Continuing to Improve.

Slide 6

Slide 6: VTE Toolkit - Layer Interventions

VTE Toolkit Layer Interventions

  • The VTE protocol serves as the main intervention and focal point for the improvement project:
    • Keep the protocol simple.
    • Do not interrupt workflow.
    • Design reliability into the process.
    • Pilot interventions on a small scale before attempting wide scale implementation.
    • Monitor use of the protocol.

Protocol = Risk assessment and corresponding order set of pharmacological agents and/or mechanical prophylaxis.

Slide 7

Slide 7: Complex VTE Order Set

Complex VTE Order Set

Image: The Complex VTE Order Set is shown.

Slide 8

Slide 8: Simple VTE Order Set

Simple VTE Order Set

Image: The Simple VTE Order Set is shown.

Slide 9

Slide 9: Simple Order Set

Simple Order Set

Image: The Simple Order Set is shown.

Slide 10

Slide 10: Hierarchy of Reliability

Hierarchy of Reliability

LevelPredicted Prophylaxis
Rate %
1 No protocol (i.e. "state of nature")40
2 Decision support exists but not linked to order writing or prompts exist within orders but no decision support at hand50
3 Protocol well-integrated into orders at point of cre65-85
4 Protocol enhanced by other QI and high-reliability strategies80-90
5 Oversights identified and addressed in real time95+

Slide 11

Slide 11: Situational Awareness and "Measure-vention"- Getting to 95%

Situational Awareness and "Measure-vention"— Getting to 95%

  • Identify patients on no anticoagulation.
  • Empower nurses to place mechanical prophylaxis.
  • Contact MD if no anticoagulant in place and no obvious contraindication:
    • Template note, text page, etc.
  • Back up these interventions:
    • Physicians can not "shoot the messenger."

Maynard G, Stein J. Designing and Implementing Effective VTE Prevention Protocols: Lessons from Collaboratives. J Thromb Thrombolysis 2010 Feb:29(2):159-166.

Slide 12

Slide 12: Making the Right Thing to Do…

Making the Right Thing to Do...

  • ...The easy thing to do:
    • The desired action is the default action (i.e., not doing the desired action requires opting out).
    • The desired action is prompted by a reminder or a decision aide.
    • The desired action is standardized into a process.
    • The desired action is scheduled to occur at known intervals.
    • Responsibilities for desired action are redundant.
    • If designed well, the VTE protocol will be an intervention.

Slide 13

Slide 13: VTE Levels of Risk

VTE Levels of Risk

Levels of RiskDVT Risk Without ProphylaxisSuggested Options

Low risk

  • Mobile minor surgery patients.
  • Fully mobile medical patients.
<10 %
  • No specific thromboprophylaxis.
  • Early and “aggressive” ambulation.

Moderate risk

  • Most general, open gynecologic or urologic surgery.
  • CHF.
  • COPD, pneumonia.
  • Medically Ill.
10-40%
  • LMWH, UFH tid > bid, or fondaparinux.

High risk

  • Hip or knee arthroplasty, HFS.
  • Major trauma, SCI.
  • Abdominal/pelvic cancer surgery.
40-80%
  • LMWH, fondaparinux, VKA (INR 2-3).
  • Mechanical prophylaxis may be used if risk of bleeding is high; switch to anticoagulants when risk decreases.

Adapted from Geerts WH, et al. Chest 2008;133:381S-453S.

Slide 14

Slide 14: ACCP VTE Prophylaxis Guidelines 8th Edition

ACCP VTE Prophylaxis Guidelines 8th Edition

  1. Every hospital should develop formal strategy to prevent VTE.
  2. Do not use aspirin alone for prophylaxis.
  3. Use mechanical prophylaxis primarily for patients at high bleeding risk or as an adjunct to pharmacologic prophylaxis.
  4. Give thromboprophylaxis for:
    • Major trauma.
    • Spinal cord injury.
    • Acute medical illness.
    • Most ICU patients.
    • Moderate and high risk surgery.

Geerts WH, et al. Chest 2008;133:381S-453S.

Slide 15

Slide 15: "Patients Without Risk Factors for VTE are Called Outpatients." G. Maynard (2010)

"Patients Without Risk Factors for VTE are Called Outpatients." G. Maynard (2010)

Slide 16

Slide 16: VTE Prophylaxis: Effective, Safe, and Cost-Effective

VTE Prophylaxis: Effective, Safe, and Cost-Effective

  • Pharmacologic prophylaxis substantially reduces the risk for VTE:
    • Symptomatic and asymptomatic VTE reduced.
  • Bleeding complications are rare.
  • HIT is a serious complication of heparin therapy.
  • Cost-effectiveness of VTE prophylaxis well documented.

Slide 17

Slide 17: Barriers to Reducing VTE Risk

Barriers to Reducing VTE Risk

  • Belief that VTE incidence has declined.
  • VTE not perceived as important.
  • Lack of familiarity with guidelines.
  • Underestimation of thrombotic risk.
  • Overestimation of bleeding risk.
  • Translation of complicated guidance into simple orders.
  • Institutional / structural.

Slide 18

Slide 18: Barriers to Reducing VTE Risk

Barriers to Reducing VTE Risk

  • Implementation of protocol is flawed.
    • Order set not user friendly.
    • Process creates duplicate work for physicians.
    • Protocol does not fit individual patient.
    • Competing order sets.

Slide 19

Slide 19: VTE Impact Case Study Year 1 Provider

VTE Impact Case Study Year 1 Provider

Madison Memorial Hospital (MMH) in Rexburg, Idaho developed and implemented a standardized VTE protocol for all hospital admissions based on the recommendations presented in the toolkit. VTE incidence of hospital-associated VTE per 1000 patient days has decreased from a rate of 1.30 to 0.18, an 86% relative improvement, between baseline (4/09-2/10) and remeasurement periods (3/10-11/10). According to team leaders, there also has been significant qualitative impact to their hospital culture and quality performance as a result of the changes made to the VTE protocol: they have implemented the first standardized best practice protocol.

Slide 20

Slide 20: VTE Impact Case Study Year 2 Provider

VTE Impact Case Study Year 2 Provider

A New Mexico hospital entered the project without a VTE protocol in place. As a result of participating in the project, the facility developed a protocol consistent with the toolkit to include a three-level risk-stratified assessment linked to treatment options. The hospital aggressively pursued improvement of its VTE protocol by developing, approving, and implementing a new VTE protocol hospital-wide in less than one month after attending the initial learning session. As a result, compliance with physician use of the protocol is 100 percent, with prevalence of appropriate VTE prophylaxis increasing from 33 to 75 percent between March and July 2011. The facility is now implementing "measure-vention"—concurrent review and interventions of patients in real time—to continue to foster improvement in the prevalence of appropriate VTE prophylaxis.

Slide 21

Slide 21: VTE Impact Case Study Year 2 Provider

VTE Impact Case Study Year 2 Provider

When Memorial Health Care Systems in Seward, Nebraska began the collaborative, Hank Newburn, MD, Family Practice Physician explains, "When we joined the VTE Collaboration in February 2011 Memorial Health Care Systems did not have a risk assessment tool, or protocols for interventions in place. We completed the risk assessment tool which models Dr. Gregory Maynard's recommendations. Since the inception of the project, we have realized a 5% increase in VTE prophylaxis due to heightening the awareness. I anticipate a significant percentage increase after implementation due to the availability of a consistent risk assessment process, and protocols for interventions. This project has provided great direction for the development of our VTE tools, which will aid us in providing best practice for VTE prophylaxis consistently, promoting increased safety for our patients."

Slide 22

Slide 22: Key Points - Expert Recommendations

Key Points Expert Recommendations

  • VTE protocols embedded in order sets.
  • Simple risk stratification schema, based on VTE-risk groups (2-3 levels of risk should do it).
  • Institution-wide if possible (a few carve outs ok).
  • Local modification is OK:
    • Details in gray areas not that important.
  • Use "measure-vention" to accelerate improvement.

Maynard G, Stein J. Designing and Implementing Effective VTE Prevention Protocols: Lessons from Collaboratives. J Thromb Thrombolysis 2010 Feb:29(2):159-166.

Slide 23

Slide 23: Collaborative Efforts

Collaborative Efforts

  • AHRQ / QIO (NY, IL, IA)—40 sites.
  • AHRQ / QIO 2 and AHRQ / QIO 3—33 & 28 sites.
  • ASHP Advantage collaborative—6 sites.
  • CHW with CIIS—2 sites.
  • IHI Expedition for VTE Prevention—50 sites.
  • SHM VTE Prevention Collaborative I—25 sites.
  • SHM VTE Prevention Collaborative III—30 sites.
  • SHM / VA Pilot Group— 6 sites PLUS.
  • SHM / Cerner Pilot Group—6 sites.
  • Vancouver Hospital Medicine—25 sites.

Slide 24

Slide 24: QIO Learning Network Activity

QIO Learning Network Activity

Image: A map of the QIO Learning Network Activity is shown.

Slide 25

Resources

Slide 26

Slide 26: Reference

Reference

  • Maynard G, Stein, J. Preventing Hospital-Acquired Venous thromboembolism: A Guide for Effective Quality Improvement. Prepared by the Society of Hospital Medicine, AHRQ Publication No. 08-0075. Rockville, MD: Agency for Healthcare Research and Quality. August 2008. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/vtguide/index.html.
  • Society of Hospital Medicine: http://www.hospitalmedicine.org.
  • Maynard G, Stein J. Designing and Implementing Effective VTE Prevention Protocols: Lessons from Collaboratives. J Thromb Thrombolysis 2010 Feb:29(2):159-166.
  • Geerts et al. Prevention of Venous Thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest June 2008 133:381S453S; 10.1378/chest.08-0656.

Slide 27

Slide 27: Contact Information

Contact Information

AHRQ QIO Learning Network Project Team

Vicky Agramonte, RN, MSN
Project Manager
IPRO
AHRQ QIO Learning Network
518-426-3300 or 1-800-233-0360
Ext.115
vagramonte@ipro.org

Sheryl Ruhland
Contract Coordinator
IPRO
AHRQ QIO Learning Network
518-426-3300 or 1-800-233-0360
Ext.114
sruhland@ipro.org

Page last reviewed December 2011
Internet Citation: Preventing Hospital-Acquired Venous Thromboembolism: Slide Presentation from the AHRQ 2011 Annual Conference. December 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2011/agramonte/index.html