Preventing Hospital-Acquired Venous Thromboembolism

AHRQ Annual MeetingSeptember 20, 2011

Vicky Agramonte, RN, MSNProject Manager

QIO Learning Network

Preventing H-A VTE Toolkit

Focuses on the basics of quality improvement

Physician driven QI effort Though development of

VTE risk assessment and order sets, preventable H-A VTEs have dropped

Developed based on the research of Dr. Gregory Maynard, in association with the Society of Hospital Medicine

VTE Toolkit

Comprehensive guide that focuses on the basics of quality improvement

Step-by-step instructions on the development and implementation of an improved VTE prevention protocol

Hierarchy of Reliability Provides sample VTE protocol

– 3–bucket risk assessment (low, moderate, and high risk)– Sample order set

Measurement strategy for continuous improvement

Protocol = Risk assessment and corresponding order set of pharmacological agents and/or mechanical prophylaxis

Toolkit Applicability

VTE toolkit is usable in varying provider settings– Large hospital settings– Smaller community hospitals– Critical Access Hospitals

Usable toolkit for providers that are: – Have EHR – Paper medical record– Hybrid (both EHR and paper)

VTE Toolkit Contents

Taking the Essential First Steps Laying Out the Evidence and Identify Best

Practices Analyzing Care Delivery Tracking Performance with Metrics Layering Interventions Continuing to Improve

VTE Toolkit Layer Interventions

The VTE protocol serves as the main intervention and focal point for the improvement project– Keep the protocol simple– Do not interrupt workflow– Design reliability into the process– Pilot interventions on a small scale before attempting

wide scale implementation– Monitor use of the protocol

Protocol = Risk assessment and corresponding order set of pharmacological agents and/or mechanical

prophylaxis

Complex VTE Order Set

Simple VTE Order Set

Simple Order Set

Hierarchy of Reliability

Situational Awareness and “Measure-vention”- Getting to 95%

Identify patients on no anticoagulation Empower nurses to place mechanical

prophylaxis Contact MD if no anticoagulant in place and

no obvious contraindication– Template note, text page, etc

Back up these interventions– Physicians can not “shoot the messenger”

Maynard G, Stein J. Designing and Implementing Effective VTE Prevention Protocols: Lessons from Collaboratives. J Thromb Thrombolysis 2010 Feb:29(2):159-166.

Making the Right Thing to do…

…the easy thing to do: – The desired action is the default action (i.e., not doing

the desired action requires opting out)– The desired action is prompted by a reminder or a

decision aide.– The desired action is standardized into a process– The desired action is scheduled to occur at known

intervals– Responsibilities for desired action are redundant– If designed well, the VTE protocol will be an

intervention

Levels of Risk DVT Risk Without Prophylaxis Suggested Options

Low risk• Mobile minor surgery patients• Fully mobile medical patients

<10 %

• No specific thromboprophylaxis

• Early and “aggressive” ambulation

Moderate risk• Most general, open gynecologic

or urologic surgery• CHF• COPD, pneumonia• Medically Ill

10-40%• LMWH, UFH tid > bid, or

fondaparinux

High risk• Hip or knee arthroplasty, HFS• Major trauma, SCI• Abdominal/pelvic cancer surgery 40-80%

• LMWH, fondaparinux, VKA (INR 2-3)

• Mechanical prophylaxis may be used if risk of bleeding is high; switch to anticoagulants when risk decreases

VTE Levels of Risk

Adapted from Geerts WH, et al. Chest. 2008;133:381S-453S.

ACCP VTE Prophylaxis Guidelines 8th Edition

1. Every hospital should develop formal strategy to prevent VTE

2. Do not use aspirin alone for prophylaxis3. Use mechanical prophylaxis primarily for patients at high

bleeding risk or as an adjunct to pharmacologic prophylaxis

4. Give thromboprophylaxis for– Major trauma– Spinal cord injury– Acute medical illness– Most ICU patients– Moderate and high risk surgery

Geerts WH, et al. Chest. 2008;133:381S-453S.

“Patients without risk factors for VTE are called outpatients.” G. Maynard (2010)

VTE ProphylaxisEffective, Safe, and Cost-Effective

Pharmacologic prophylaxis substantially reduces the risk for VTE– Symptomatic and asymptomatic VTE reduced

Bleeding complications are rare HIT is a serious complication of heparin therapy Cost-effectiveness of VTE prophylaxis well

documented

Barriers to Reducing VTE Risk

Belief that VTE incidence has declined VTE not perceived as important Lack of familiarity with guidelines Underestimation of thrombotic risk Overestimation of bleeding risk Translation of complicated guidance into

simple orders Institutional / structural

Barriers to Reducing VTE Risk

Implementation of protocol is flawed Order set not user friendly Process creates duplicate work for

physicians Protocol does not fit individual patient Competing order sets

VTE Impact Case Study Year 1 Provider

Madison Memorial Hospital (MMH) in Rexburg, Idaho developed and implemented a standardized VTE protocol for all hospital admissions based on the recommendations presented in the toolkit. VTE incidence of hospital-associated VTE per 1000 patient days has decreased from a rate of 1.30 to 0.18, an 86% relative improvement, between baseline (4/09-2/10) and remeasurement periods (3/10-11/10). According to team leaders, there also has been significant qualitative impact to their hospital culture and quality performance as a result of the changes made to the VTE protocol: they have implemented the first standardized best practice protocol.

VTE Impact Case Study Year 2 Provider

A New Mexico hospital entered the project without a VTE protocol in place. As a result of participating in the project, the facility developed a protocol consistent with the toolkit to include a three-level risk-stratified assessment linked to treatment options. The hospital aggressively pursued improvement of its VTE protocol by developing, approving, and implementing a new VTE protocol hospital-wide in less than one month after attending the initial learning session. As a result, compliance with physician use of the protocol is 100 percent, with prevalence of appropriate VTE prophylaxis increasing from 33 to 75 percent between March and July 2011. The facility is now implementing “measure-vention”—concurrent review and interventions of patients in real time--to continue to foster improvement in the prevalence of appropriate VTE prophylaxis.

VTE Impact Case Study Year 2 Provider

When Memorial Health Care Systems in Seward, Nebraska began the collaborative, Hank Newburn, MD, Family Practice Physician explains, “When we joined the VTE Collaboration in February 2011 Memorial Health Care Systems did not have a risk assessment tool, or protocols for interventions in place. We completed the risk assessment tool which models Dr. Gregory Maynard’s recommendations. Since the inception of the project, we have realized a 5% increase in VTE prophylaxis due to heightening the awareness. I anticipate a significant percentage increase after implementation due to the availability of a consistent risk assessment process, and protocols for interventions. This project has provided great direction for the development of our VTE tools, which will aid us in providing best practice for VTE prophylaxis consistently, promoting increased safety for our patients.”

Key Points Expert Recommendations

VTE protocols embedded in order sets Simple risk stratification schema, based on

VTE-risk groups (2-3 levels of risk should do it) Institution-wide if possible (a few carve outs ok) Local modification is OK

– Details in gray areas not that important Use “measure-vention” to accelerate

improvement

Maynard G, Stein J. Designing and Implementing Effective VTE Prevention Protocols: Lessons from Collaboratives. J Thromb Thrombolysis 2010 Feb:29(2):159-166.

Collaborative Efforts

AHRQ / QIO (NY, IL, IA) - 40 sites AHRQ / QIO 2 and AHRQ / QIO 3 - 33 & 28 sites ASHP Advantage collaborative - 6 sites CHW with CIIS - 2 sites IHI Expedition for VTE Prevention - 50 sites SHM VTE Prevention Collaborative I - 25 sites SHM VTE Prevention Collaborative III - 30 sites SHM / VA Pilot Group - 6 sites PLUS SHM / Cerner Pilot Group - 6 sites Vancouver Hospital Medicine - 25 sites

QIO Learning Network Activity

Resources

Preventing HA VTE- a guide for effective quality improvement http://www.ahrq.gov/QUAL/vtguide/

Society of Hospital Medicine VTE Collaborative http://www.hospitalmedicine.org

Reference

Maynard G, Stein, J. Preventing Hospital-Acquired Venous thromboembolism: A Guide for Effective Quality Improvement. Prepared by the Society of Hospital Medicine, AHRQ Publication No. 08-0075. Rockville, MD: Agency for Healthcare Research and Quality. August 2008 http://www.ahrq.gov/qual/vtguide/.

Society of Hospital Medicine: http://www.hospitalmedicine.org

Maynard G, Stein J. Designing and Implementing Effective VTE Prevention Protocols: Lessons from Collaboratives. J Thromb Thrombolysis 2010 Feb:29(2):159-166.

Geerts et al. Prevention of Venous Thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest June 2008 133:381S453S; 10.1378/chest.08-0656

Contact InformationAHRQ QIO Learning Network Project Team

Vicky Agramonte, RN, MSN Project Manager

IPRO AHRQ QIO Learning

Network518-426-3300 or 1-800-233-

0360Ext.115

vagramonte@ipro.org

Sheryl RuhlandContract Coordinator

IPRO AHRQ QIO Learning

Network518-426-3300 or 1-800-233-

0360Ext.114

sruhland@ipro.org