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Preventing VTEs Web Conference Series. Partners:Agency for Healthcare Research and QualityIPROIllinois Foundation for Quality Health CareIowa Foundation for Medical CareSubject matter expert:Dr. Greg Maynard, Univ. of California San DiegoTool:AHRQ Preventing VTEs in the Hospital ToolkitDura
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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
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
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
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)
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
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)
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
8. 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
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
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
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
12. Percent of Randomly Sampled Inpatients with Adequate VTE Prophylaxis
13. UCSD – Decrease in Patients with Preventatble HA VTE
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
15. VTE Prevention Guides
16. VTE QI Resource Roomwww.hospitalmedicine.org
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
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
19. The Essential First Intervention
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
20. Hierarchy of Reliability
21. Map to Reach Level 3Implementing 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
22. Too Little GuidancePrompt ? 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
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
24. Is your order set in a competition?
25. Low Medium High
26. Hierarchy of Reliability
27. Map to Reach Level 595+ % 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!
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”
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
30. Questions?
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
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
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
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
35. Old VTE prevention protocol
36. New VTE Prevention protocol
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
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
39. Are we making progress?
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
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
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)
43. Reducing Hospital-Acquired Venous Thromboembolisms: Interventions That Work Marcia Kruse, RN, BA, CPHQ
Director Case Management
Fort Madison Community Hospital
Fort Madison, Iowa
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
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
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
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
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
49. Lots of Choices-Old Version
50. New Version-Simplified
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
52. Monitors for Old Version
53. New Monitor
54. Barriers Occasionally form not available
Risk not assessed appropriately
Form not completed accurately
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
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
57. Q&A Panelists
Denise Faulkner-Cameron, IPRO
Greg Maynard, UCSD
Lisa Clark, Catskill Regional Medical Center
Marcia Kruse, Fort Madison Community Hospital