AHRQ / QIO Venous Thromboembolism (VTE) Prevention in the Hospital

1. AHRQ / QIOVenous Thromboembolism (VTE) Prevention in the Hospital Greg Maynard MD, MSc Clinical Professor of Medicine and Chief, Division of Hospital Medicine University of California, San Diego

2. 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, MVAs, Breast CA 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) Surgeon General’s Call to Action to Prevent DVT and PE 2008 DHHS

3. 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 Risk Factors for VTE Endothelial Damage Surgery Prior VTE Central lines Trauma Anderson FA Jr. & Wheeler HB. Clin Chest Med 1995;16:235.

4. 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 Risk Factors for VTE Endothelial Damage Surgery Prior VTE Central lines Trauma Most hospitalized patients have at least one risk factor for VTE Anderson FA Jr. & Wheeler HB. Clin Chest Med 1995;16:235. Bick RL & Kaplan H. Med Clin North Am 1998;82:409.

5. ENDORSE Results Cohen, Tapson, Bergmann, et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet 2008; 371: 387–94. • Out of ~70,000 patients in 358 hospitals, appropriate prophylaxis was administered in: • 58.5% of surgical patients • 39.5% of medical patients

6. The “Stick” is coming…. NQF 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 CMS – DVT or PE with knee or hip replacement reimbursed as though complication had not occurred.

7. 2005 – AHRQ grant to: • Design and implement VTE prevention protocol • Monitor impact on VTE prophylaxis and HA VTE • Validate a VTE risk assessment model / protocol Attempt to use portable methodology, build toolkit to allow others to accomplish the same thing

8. Percent of randomly sampled inpatients with adequate vte prophylaxis Real time ID & intervention Order Set Implementation & Adjustment Consensus building Baseline N = 2,944 mean 82 audits / month In press, JHM 2009 Real time ID & intervention Order Set Implementation & Adjustment Consensus building Baseline 8

9. UCSD – Decrease in patients with preventable ha vte Level 5 Oversights identified and addressed in real time 95+% 9

10. 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

11. VTE Prevention Guides VTE Prevention Guides http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_VTE/VTE_Home.cfm http://ahrq.hhs.gov/qual/vtguide/

12. VTE QI Resource Room www.hospitalmedicine.org VTE QI Resource Room

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 (Honorable Mention) • Venous Disease Coalition

14. 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

15. The Essential First Intervention VTE Protocol 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 15

16. Predicted Prophylaxis rate Hierarchy of Reliability 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

17. 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 model [RAM]) • Vette / Pilot – PDSA • Educate / consensus building • Place new standardized DVT order set ‘module’ into all pertinent admit, transfer, periop order sets. • Monitor, tweak - PDSA

18. Too Little GuidancePrompt ≠ Protocol DVT PROPHYLAXIS ORDERS • Anti thromboembolism Stockings • Sequential Compression Devices • 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

19. 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-pharm prophy too much • Failure to pilot, revise, monitor • Linkage between risk level and prophy choices are separated in time or space

20. Is your order set in a competition? 20

21. Low Medium High Example from UCSD Keep it Simple – A “3 bucket” model 21 IPC needed if contraindication to AC exists

22. Predicted Prophylaxis rate Hierarchy of Reliability 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% 95+% 5 * Protocol = standardized decision support, nested within an order set, i.e. what/when

23. 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!

24. 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”

25. 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