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Michael B. Streiff, MD Associate Professor of Medicine Division of Hematology Medical Director,

Optimizing Venous Thromboembolism Prophylaxis using Physician Order Entry: Johns Hopkins Hospital Experience. Michael B. Streiff, MD Associate Professor of Medicine Division of Hematology Medical Director, Johns Hopkins Anticoagulation Management Service.

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Michael B. Streiff, MD Associate Professor of Medicine Division of Hematology Medical Director,

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  1. Optimizing Venous Thromboembolism Prophylaxis using Physician Order Entry: Johns Hopkins Hospital Experience Michael B. Streiff, MD Associate Professor of Medicine Division of Hematology Medical Director, Johns Hopkins Anticoagulation Management Service

  2. Venous thromboembolism (VTE) Prevention- Why should we care? • Venous thromboembolism is common • 900,000 DVT/PE annually • VTE is deadly • 10% of hospital deaths due to PE • Only 1/3 suspected ante-mortem • VTE causes long-term morbidity • Recurrent VTE occurs in 40% by 10 years • Post-thrombotic syndrome affects 30% by 5 years • VTE is preventable • Effective prophylaxis reduces DVT incidence by 60%

  3. VTE Prevention- We are failing our patients! • Worchester VTE study- 1897 patients with VTE from 12 hospitals • Seventy-four percent were outpatients • Sixty percent recently hospitalized • Only 43% received DVT prophylaxis (Spencer FA et al. Arch Intern Med 2007) Prophylaxis (%) Anderson Arch Intern Med 1991 Rahim et al. Thromb Res 2003. Tapson et al. Blood 2004, Rashid J Royal Soc Med 2005; Spencer et al. Arch Intern Med 2007; Tapson et al. Chest 2007; Cohen AT Lancet 2008

  4. Joint Commission Standards for VTE Management • Prevention • Documentation of Venous Thromboembolism Risk Assessment/Prophylaxis within 24 Hours of Hospital Admission • Documentation of Venous Thromboembolism Risk Assessment/Prophylaxis within 24 Hours of Transfer to ICU • Treatment • Documentation of Inferior Vena Cava Filter Indication • Venous Thromboembolism Patients with Overlap of Parenteral and Warfarin Anticoagulation Therapy • Venous Thromboembolism Patients Receiving Unfractionated Heparin with Platelet Count Monitoring • Venous Thromboembolism Patients Receiving Unfractionated Heparin Management by Nomogram/Protocol • Venous Thromboembolism Discharge Instructions • Outcome • Incidence of Potentially Preventable Hospital-Acquired Venous Thromboembolism

  5. Hopkins Surgical Services:DVT Prophylaxis Baseline Adherence 2005 ACCP Guideline Adherence (%) Data courtesy of Deb Hobson RN Center for Innovations in Quality Patient Care

  6. Physical Medicine & Rehabilitation VTE Prophylaxis Performance N=914 ACCP Adherence (%) Data courtesy of S Mayer MD PM&R & Deb Hobson RN Center for Innovations in Quality Patient Care

  7. General Surgery Overall Compliance with Recommended VTE Prevention ACCP Compliance (%) 42/161 178/262 2/2 9/19 72/103 95/138 N= 297 cases reviewed 11/2006 (35 cases contraindicated for pharmacologic prophylaxis) Data courtesy of Deb Hobson RN Center for Innovations in Quality Patient Care

  8. Johns Hopkins VTE Prevention Collaborative – Version 1.0 Results • Evidence-based Paper VTE Prophylaxis Tool • Success • Improved VTE Prophylaxis compliance from 25% to 50-100% • Decreased VTE incidence on some floors • Shortcomings • Complex • Forms not always available • Labor intensive data collection • Out of usual work flow stream on CPOE units Result = Sub-optimal VTE prevention Solution = Electronic Risk Stratification/Order Entry

  9. Impact of the POE VTE Order set on Compliance on the Orthopedic Spine Service Admissions (%) N= 15 40 35 42 37 21 42 40 37

  10. Impact of the POE VTE Order set on Compliance on the Medicine Service N=20 N=1059 N=1039 N=1097

  11. Annual Incidence of VTE at JHH VTE (% of discharges)

  12. Conclusions • We have developed a POE VTE prophylaxis order set that facilitates rapid VTE risk stratification and evidence-based VTE prophylaxis ordering • Benefits of the order set include… • Increased VTE risk stratification • Increased risk-appropriate VTE prophylaxis • Enhanced VTE performance monitoring/reporting • Targeted provider education of VTE risk factors and prophylaxis modalities • More effective strategy to improve VTE prevention than electronic alerts

  13. Future Plans • Study the impact of the order set on VTE and bleeding event rates • Study the impact of the order set on provider VTE management knowledge base

  14. Acknowledgments • Paula Biscup-Horn PharmD, BCPS • Deb Hobson, BSN • Elliot Haut, MD • Peggy Kraus, PharmD, CAPS • Chad Smith, FACHE • Katy Olive • JHMCIS • Peter Greene MD • Steve Mandell, Peggy Ardolino, Pat Zeller, Annette Durrette-Smith, Irma Sutanto, Bonnie McCoy & JHMCIS Team • The VTE Collaborative Teams • The Center for Innovation in Quality Patient Care • Renee Demski, MSW, MBA and the Johns Hopkins Health System Quality Improvement Office

  15. Questions ?

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