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Guide Available for Deep Vein Thrombosis

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

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Guide Available for Deep Vein Thrombosis

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  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)

  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

  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

  4. Hierarchy of Reliability Predicted Prophylaxis rate Level No protocol* (“State of Nature”) Decision support exists but not linked to order writing, or prompts within orders but no decision support Protocol well-integrated (into orders at point-of-care) Protocol enhanced (by other QI / high reliability strategies) Oversights identified and addressed in real time 1 40% 50% 2 3 65-85% 4 90% 5 95+% * Protocol = standardized decision support, nested within an order set, i.e. what/when

  5. 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 VTE Protocol 5

  6. Low Medium High Example from UCSD Keep it Simple – A “3 bucket” model 6 IPC needed if contraindication to AC exists

  7. Map to Reach Level 3Implementing 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

  8. Real time ID & intervention Order Set Implementation & Adjustment Consensus building Baseline N = 2,944 mean 82 audits / month In press, JHM 2009 In press, Maynard, Morris et al, J Hosp Med Real time ID & intervention Order Set Implementation & Adjustment Consensus building Baseline 8

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  10. Hierarchy of Reliability Predicted Prophylaxis rate Level No protocol* (“State of Nature”) Decision support exists but not linked to order writing, or prompts within orders but no decision support Protocol well-integrated (into orders at point-of-care) Protocol enhanced (by other QI / high reliability strategies) Oversights identified and addressed in real time 1 40% 50% 2 3 65-85% 4 90% 5 95+% * Protocol = standardized decision support, nested within an order set, i.e. what/when

  11. 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 tomove patients out of the RED!

  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”

  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

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