Guide Available for Deep Vein Thrombosis

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

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

4. Hierarchy of Reliability 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

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

6. Low Medium High

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

10. Hierarchy of Reliability 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 Ideally, we’d find a way to check on all best practice performance in real time, and correct it before patient went on to next stage. Ideally, we’d find a way to check on all best practice performance in real time, and correct it before patient went on to next stage.

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 to move 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