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Venous Thromboembolism (VTE)

Venous Thromboembolism (VTE). Southern New Hampshire Medical Center Lynda Pittenger, RN, CPHQ Kathy Helberg, BSN,RN, CPHQ. 188-bed community hospital located in Nashua, NH; part of SNHHS with multi-specialty group practice, Foundation Medical Partners. Level III Trauma Center

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Venous Thromboembolism (VTE)

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  1. Venous Thromboembolism (VTE) Southern New Hampshire Medical Center Lynda Pittenger, RN, CPHQ Kathy Helberg, BSN,RN, CPHQ

  2. 188-bed community hospital located in Nashua, NH; part of SNHHS with multi-specialty group practice, Foundation Medical Partners. Level III Trauma Center > 45,000 ED visits /year > 5,500 surgeries / year 24/7 Hospitalist program Minimally invasive surgery program with daVinci 11 Bed ICU • Angioplasty / STEMI • 2 MRI and 2 CT scanners • Magnet (re-designated 2011) • American College of Surgeons • Cancer, Breast Center • Stroke Program- AHA/GWTG- Gold + award

  3. Process Measures: VTE 1: % Inpatients with VTE prevention in place day of or day VTE 2: % ICU Inpatients with VTE prevention in place VTE 3: % VTE patients on coumadin who received overlap therapy VTE 4: % VTE patients on heparin and PTT monitored as per order set VTE 5: % VTE patients received d/c instructions re: coumadin Outcome Measure: VTE 6: % Patients who develop VTE during hospitalization Process Measures; SCIP VTE 1: % surgery patients with recommended VTE prophylaxis ordered SCIP VTE 2: % surgery patients who received appropriate VTE prophylaxis within 24 hours prior to surgery to 24 hours after surgery VTE Measures Tracked and Trended at SNHMC

  4. VTE Tools in Use at SNHMC Prevention: • VTE Risk and Prevention Supplemental Order Set for admissions • Surgical Order Sets with built in mechanical /pharmacological prevention • DVT prevention cue built into EMR to remind staff that if pt is not ambulating, they are at risk. Treatment (for Dx of VTE): • Transitional Care Coordinators round on patients with VTE • Patient Education Information: • DVT/ PE etiology, care, treatment and prevention • Coumadin Patient Education and Discharge Instruction • Nutrition Guidelines

  5. Equipment Barriers Inconsistent use of pneumatic compression stockings Differing opinions by physicians on when to use recommendations - pneumatic + TEDs Not enough equipment Nurses concern with trip factor- may prevent patients from getting OOB. Patient dissatisfaction - comfort Solutions: Medical: Clarified order sets to remove TEDs Surgical: Kept TEDs option on order set and used in conjunction with SCD. Purchased more equipment Promoted a healthy respect for role of pneumatic compression stockings in VTE prevention Memos, unit rounding and staff education Enhanced pre-op teaching & expectations for patients

  6. Medication Barriers Variation in med use for chemoprophylaxis: Use of lovenox vs heparin for prevention $$$$ difference Daily vs. bid/tid dosing Physician concern with bleeding risk in peri op pts Some surgeon hold outs Hospitalists co-managing “twitch” NEW- anticoagulant for arthroscopy-Rivaroxaban Solutions: Endorsed use of SQ heparin for VTE prevention thru P&T Updated VTE evidence based order set Enhanced surgeon & hospitalist partnership Created a new order set in partnership with pharmacy

  7. Medication Barriers cont. Inconsistent use of post op surgical order sets – VTE anticoagulation prophylaxis during off-shifts / weekends. Lack of clarity with overlap CMS definition states minimum 5 days and INR > than 2 Physicians reluctant to continue overlap > 48-72H if INR > than 2 Embedded VTE prompts in transfer orders from PACU to nursing units Proposed Solution Provide Physician education Build cue into CPOE Engage Transitional Care Coordinators

  8. SNHMC Performance Measures VTE 1&2: Sample Population VTE 3-6 All Cases 8

  9. SNHMC SCIP Performance Measures *Source: www.NHQualityCare.org - a partnership between the Foundation for Healthy Communities and the Northeast Health Care Quality Foundation Q310-Q211 (Composite does not include Card2 or Inf10)(National Average obtained from Hospital Quality Alliance Report) ** Source: Northeast Health Care Quality Foundation - Qtr 4, 2011 (NHCQF Composite score includes the following: 1,2,3,4,6,9,10 VTE1&2, Card2)

  10. What Can Others Learn From Our Journey? 10 • Engage a physician champion and form a multidisciplinary team • Research best practice • Create evidence based tools - order sets and checklists • Test the tool- round, encourage feedback and make changes • PDCA • Roll out to a larger group • Implement and include 1:1 feedback • ROUND- to scan the environment for opportunities

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