Guide Available for Guide Available for Deep Vein ThrombosisDeep Vein Thrombosis

Developed from Partnerships in Developed from Partnerships in Implementing Patient Safety Implementing Patient Safety program toolkitprogram toolkit

Based on quality improvement Based on quality improvement initiatives undertaken at the initiatives undertaken at the University of California, San Diego University of California, San Diego Medical Center and Emory Medical Center and Emory University HospitalsUniversity Hospitals

Assists quality improvement Assists quality improvement practitioners in preventing one of practitioners in preventing one of the most important problems facing the most important problems facing hospitalized patients - DVT / PE hospitalized patients - DVT / PE (VTE)(VTE)

Why build a toolkit for VTE Prevention?Why build a toolkit for VTE Prevention? VTE is a common source of inpatient M&MVTE is a common source of inpatient M&M

– Jumbo jet crash / day- Jumbo jet crash / day- >> Breast CA, HIV, MVA combined Breast CA, HIV, MVA combined– May be # 1 preventable source of hospital deathMay be # 1 preventable source of hospital death

Effective and safe methods of prevention existEffective and safe methods of prevention exist– Large “implementation gap” - best practice ≠ current practiceLarge “implementation gap” - best practice ≠ current practice

These methods are grossly underutilizedThese methods are grossly underutilized– Awareness, difficulty implementing, no validated risk assessmentAwareness, difficulty implementing, no validated risk assessment

P4P, public reporting, and core measuresP4P, public reporting, and core measures

Geerts WH, et al. Chest. 2008;133:381S-453S.Cohen, Tapson, Bergmann, et al. ENDORSE study: Lancet 2008; 371: 387–94.

Surgeon General’s Call to Action to Prevent DVT and PE 2008 DHHS

To Achieve ImprovementTo Achieve Improvement

Real institutional support / prioritizationReal institutional support / prioritization Will to standardizeWill to standardize Physician leadershipPhysician leadership Measurement of process / outcomesMeasurement of process / outcomes Protocol, integrated into order setsProtocol, integrated into order sets EducationEducation Continued refinement / tweaking- PDSAContinued refinement / tweaking- PDSA

SHM and AHRQ Guides on VTE Prevention

Hierarchy of ReliabilityHierarchy of Reliability

No protocol* (“State of Nature”)No protocol* (“State of Nature”)

Decision support exists but not linked to Decision support exists but not linked to order writing, or prompts within orders order writing, or prompts within orders but no decision supportbut no decision support

Protocol well-integrated Protocol well-integrated (into orders at point-of-care) (into orders at point-of-care)

Protocol enhancedProtocol enhanced (by other QI / high reliability strategies)(by other QI / high reliability strategies)

Oversights identified and addressed in Oversights identified and addressed in real timereal time

Level

4

1

2

3

5

Predicted

Prophylaxis rate

40%

50%

65-85%

90%

95+%

* Protocol = standardized decision support, nested within an order set, i.e. what/when

The Essential First InterventionThe Essential First Intervention

1) a standardized VTE risk assessment, linked to…1) a standardized VTE risk assessment, linked to…2) a menu of appropriate prophylaxis options, plus…2) a menu of appropriate prophylaxis options, plus…3) a list of contraindications to pharmacologic VTE 3) a list of contraindications to pharmacologic VTE

prophylaxisprophylaxis

Challenges:Challenges: Make it easy to use (“automatic”)Make it easy to use (“automatic”)

Make sure it captures almost all patientsMake sure it captures almost all patientsTrade-off between guidance and ease of use / efficiencyTrade-off between guidance and ease of use / efficiency

5

VTE Protocol

Low Medium HighLow Medium HighAmbulatory Ambulatory with no other with no other risk factors. risk factors. Same day or Same day or minor surgeryminor surgery

CHFCHFCOPD / PneumoniaCOPD / PneumoniaMost Medical PatientsMost Medical PatientsMost Gen Surg Most Gen Surg PatientsPatientsEverybody ElseEverybody Else

Elective LE arthroplastyElective LE arthroplastyHip/pelvic fxHip/pelvic fxAcute SCI w/ paresisAcute SCI w/ paresisMultiple major traumaMultiple major traumaAbd / pelvic CA surgeryAbd / pelvic CA surgery

Early Early ambulationambulation

UFH 5000 units q 8 h UFH 5000 units q 8 h (5000 units q 12 h if > 75 (5000 units q 12 h if > 75 or weight <50 kg)or weight <50 kg)

LMWH LMWH Enox 40 mg q dayEnox 40 mg q day Other LMWHOther LMWH CONSIDER add IPCCONSIDER add IPC

Enox 30 mg q 12 h or Enox 30 mg q 12 h or Enox 40 q day or Enox 40 q day or Other LMWH or Other LMWH or

Fondaparinux 2.5 mg q day Fondaparinux 2.5 mg q day or orWarfarin INR 2-3Warfarin INR 2-3AND MUST HAVEAND MUST HAVEIPCIPC 6

IPC needed if contraindication to AC exists

Example from UCSD Keep it Simple – A “3 bucket” model

Map to Reach Level 3Map to Reach Level 3Implementing an Effective VTE Prevention Implementing an Effective VTE Prevention

ProtocolProtocol

Examine existing admit, transfer, periop order Examine existing admit, transfer, periop order sets with reference to VTE prophylaxis.sets with reference to VTE prophylaxis.

Design a protocol-driven DVT prophylaxis order Design a protocol-driven DVT prophylaxis order set (w/ integrated risk assessment)set (w/ integrated risk assessment)

Vette / Pilot – PDSAVette / Pilot – PDSA Educate / consensus buildingEducate / consensus building Place new standardized DVT order set ‘module’ Place new standardized DVT order set ‘module’

into all pertinent admit, transfer, periop order into all pertinent admit, transfer, periop order sets. sets.

Monitor, tweak - PDSAMonitor, tweak - PDSA

8

Percent of Randomly Sampled Inpatients with Adequate VTE Prophylaxis

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline

Consensus building

Order Set Implementation & Adjustment

Real time ID & intervention

Percent of Randomly Sampled Inpatients with Adequate VTE Prophylaxis

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline

Consensus building

Order Set Implementation & Adjustment

Real time ID & intervention

N = 2,944 mean 82 audits / monthIn press, JHM 2009In press, Maynard, Morris et al, J Hosp Med

UCSD - Decrease in Patients with Preventable HA VTE

0

2

4

6

8

10

12

14

Quarter

# of

Pat

ient

s MedicineSurgeryOrthoOtherTotal

9

Hierarchy of ReliabilityHierarchy of Reliability

No protocol* (“State of Nature”)No protocol* (“State of Nature”)

Decision support exists but not linked to Decision support exists but not linked to order writing, or prompts within orders order writing, or prompts within orders but no decision supportbut no decision support

Protocol well-integrated Protocol well-integrated (into orders at point-of-care) (into orders at point-of-care)

Protocol enhancedProtocol enhanced (by other QI / high reliability strategies)(by other QI / high reliability strategies)

Oversights identified and addressed in Oversights identified and addressed in real timereal time

Level

4

1

2

3

5

Predicted

Prophylaxis rate

40%

50%

65-85%

90%

95+%

* Protocol = standardized decision support, nested within an order set, i.e. what/when

Map to Reach Level 5Map to Reach Level 595+ % prophylaxis95+ % prophylaxis

Use MAR or Automated Reports to Classify all patients Use MAR or Automated Reports to Classify all patients on the Unit as being in one of three zones:on the Unit as being in one of three zones:

GREEN ZONE - on anticoagulationGREEN ZONE - on anticoagulationYELLOW ZONE - on mechanical prophylaxis only YELLOW ZONE - on mechanical prophylaxis only RED ZONE – on no prophylaxisRED ZONE – on no prophylaxis

Act toAct to move patients out of the RED!move patients out of the RED!

Situational Awareness and Situational Awareness and Measure-vention: Getting to Level 5Measure-vention: Getting to Level 5

Identify patients on no anticoagulationIdentify patients on no anticoagulation Empower nurses to place SCDs in patients Empower nurses to place SCDs in patients

on no prophylaxis as standing order (if no on no prophylaxis as standing order (if no contraindications)contraindications)

Contact MD if no anticoagulant in place Contact MD if no anticoagulant in place and no obvious contraindicationand no obvious contraindication– Templated note, text page, etcTemplated note, text page, etc

Need Administration to back up these Need Administration to back up these interventions and make it clear that docs interventions and make it clear that docs can not “shoot the messenger”can not “shoot the messenger”

Collaborative Efforts and Collaborative Efforts and KudosKudos

SHM VTE Prevention Collaborative I - 25 sitesSHM VTE Prevention Collaborative I - 25 sites SHM / VA Pilot Group - 6 sitesSHM / VA Pilot Group - 6 sites SHM / Cerner Pilot Group – 6 sitesSHM / Cerner Pilot Group – 6 sites AHRQ / QIO (NY, IL, IA) - 60 sitesAHRQ / QIO (NY, IL, IA) - 60 sites IHI Expedition to Prevent VTE – 60 sitesIHI Expedition to Prevent VTE – 60 sites

SHM Team Improvement AwardSHM Team Improvement Award NAPH Safety Net Award NAPH Safety Net Award Venous Disease CoalitionVenous Disease Coalition