1

MCIC VTE Prophylaxis All Team Call

Sean Berenholtz, MD MHS

and VTE Subcommittee

5.23.2006

2

MCIC VTE Subcommittee

JHH

Paula Biscup Lisa Rowen

Renee Demski Michael Streiff

David Hunt

Deborah Hobson

URMC

Edward Bell Robert Panzer

Diane Cockrell Ivelisse Vicente

Alan Curle Karen Zinnecker

Charles Francis

NYP

Audrey Compton

Joseph Cooke

David Diuguid

Sue Kim

YNHH

Nabil Atweh Andrea Benin

Veronica Chiang Ann Ertel

Charles Watson Kathy Hearn

Pamela Cullen Lori Ryder

Mary Ellen Ksoturko Keith Ruskin

Ena Williams

Walter Cholewczynski

3

Safety Measures

• How often do we harm patients?– Measures of harm (Surgical site infections (SSI))

• How often do we do what we should?– Surgical Care Improvement Project (SCIP) process measures,– Venous thromboembolism (VTE) prophylaxis,

• How often do we learn from defects?– Learn from one per month (National Quality Forum never events,

mislabeled specimens)

• How well do we improve culture?– Safety Attitude Questionnaire (SAQ), – Comprehensive Unit Safety Program (CUSP)

4

Most common preventable cause of hospital death

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

1,800,000

2,000,000

DVT PE PE deaths Cancer Cancerdeaths

Hirsh DR et al. JAMA 1995;274:335-7Bick RL Semin Thromb Hemost 1999;25:251-3

An

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5

Prevention of venous thromboembolism: the Seventh ACCP

Conference on Antithrombotic and Thrombolytic Therapy.

Chest. 2004 Sep;126(3 Suppl):338S-400S

6

Recommendations

• General surgery – surgical oncology, gynecology, urology,

vascular, transplant, thoracic surgery

• Orthopedics

• Trauma

• Neurosurgery

7

Overall Adherence for VTE Prophylaxis at JHHS: Baseline

32

88

23 23

30

25

75

39

20

0

20

40

60

80

100

% A

dher

ence

Aggregate Low Mod High Very High Knee Arth Spine Hip/KneeArthroplasty

Hip FX

n = 7/8n = 71/219* n = 3/13 n = 20/88 n = 13/44

* Aggregate DOES NOT INCLUDE GU cases that were contraindicated for pharmacologic interventions

n = 12/16 n = 12/31 n = 3/15n = 1/4

8

SCIP 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

• SCIP VTE 3: Intra- or postoperative PE diagnosed during index hospitalization and within 30 days of surgery (OUTCOME)

• SCIP VTE 4: Intra- or postoperative DVT diagnosed during index hospitalization and within 30 days of surgery (OUTCOME)

9

Assumptions

• Data collected in immediate periop period (preop holding area thru time of PACU/ICU admission

• Concurrent data collection preferred• Risk stratification defined by local consensus• Evidence of risk stratification includes a

completed risk stratification tool, a physician, NP, or PA note documenting that the patient is at risk for VTE

• Exclusions: < 18 yo, hospital LOS < 24 hours

10

Proposed MCIC VTE Measures

• General surgery (includes surg onc, urology, vascular and transplant surgery)

• Trauma

• Neurosurgery (intracranial, spinal cord injury, elective spine surgery)

• Bariatric surgery

11

Proposed MCIC VTE Measures

• Documentation of Risk Stratification– % patients with evidence of risk stratification in chart

• Prophylaxis for VTE– % patients who have an order written to start

prophylaxis during the time period within 24 hrs prior to incision through 24 hrs after surgery end time

– % patients who have an order written to start prophylaxis at the recommended dosing during the time period within 24 hrs prior to incision time through 24 hrs after surgery end time

12

Proposed MCIC VTE Measures

• Contraindications to VTE prophylaxis– % patients with any contraindication to

pharmacologic prophylaxis– % patients with contraindication to

pharmacologic prophylaxis due to a high risk of bleeding treated with mechanical prophylaxis (GCS or IPC or SCD)

• % patients included in review processGCS: graduated compression stockings; IPC: intermittent pneumatic compression devices; SCD: sequential compression devices

13

Data Collection Plan

• Data collection tool developed• Pilot testing: June 2006

– Concurrent data collection: convenience sample of 5-10 pts

– Retrospective Review: 10 randomly selected patient-charts

• Implementation: July 2006– Concurrent data collection: All patients seen by the

clinical area improvement team – Retrospective Review: 10 randomly selected

patient-charts per month per surgery type• Maintenance: >= 90% performance

– TBD

14

Reports

• Single period reports

• Performance over time

• Comparison to collaborative

• Data remains anonymous

15

Change is Local

• Educate staff– Partner with hematology, Guidelines, Fact sheet,

powerpoint slides

• Reduce complexity– Standardized tool, computerized decision support

• Create redundancy– Multidisciplinary teams, add to existing checklists,

briefings/debriefings

• Measure performance– Identify when this will occur during the periop period

16

Team Check-up Tool

• Reviewed data with team

• Number of team meetings

• Met with executive

• Reviewed data with executive

• Barriers to progress

17

Next Steps

• Finalize teams

• Gain consensus on evidence and risk stratification

• Pilot test data collection tool

• Conference call to review pilot phase– Burden, revise measures/tools, timeline

• Live the grid

• Conference calls for sharing