Tackling Patient Compliance with DVT Prophylaxis

Presented by Richard Parker

CEO, Midwest Medical

DVT Prevention | www.midwestmedical.info

Physician’s Bag

Patient Focused Physician Care

WALL – TO – WALL Patient Appreciation

Quality of life after DVT

Post Thrombotic Syndrome

Up to 1 million cases per year

Clinical Consequences of DVT

Post-Thrombotic Syndrome (PTS)

• Leg pain, tiredness, swelling, skin changes, ulcers

PTS is common (40%) lifelong complication

• Impairs quality of life, no proven effective treatments

Venous ulcers often recur

• Difficult and expensive to treat

Chronic Venous InsufficiencyChronic venous insufficiency can be painful and disabling.• Pain• Swelling• Cramps• Skin changes• Varicose veins• Leg ulcers

DVT Statistics

300,000 fatalities annuallymore than AIDs, breast cancer, prostate cancer and motor vehicle accidents COMBINED

2,000,000 Americans suffer with DVT

VTE is the 3rd most frequent readmission after total hip or knee joint replacement.

CMS and other payers are reducing payment for

readmissions due to post-

surgical DVT/PE

• CMS “Never Events”• Foreign Object Retained After Surgery• Air Embolism• Blood Incompatibility• Stage III and IV Pressure Ulcers• Falls and Trauma• Manifestations of Poor Glycemic Control• Catheter-Associated Urinary Tract Infection (UTI)• Vascular Catheter-Associated Infection• Surgical Site Infection, Mediastinitis, Following Coronary Artery Bypass Graft (CABG):• Surgical Site Infection Following Bariatric Surgery for Obesity• Surgical Site Infection Following Certain Orthopedic Procedures• Surgical Site Infection Following Cardiac Implantable Electronic Device (CIED)• Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Following Certain Orthopedic Procedures:• Total Knee Replacement• Hip Replacement

• Iatrogenic Pneumothorax with Venous Catheterization

Basic Terms

DVT (Deep Vein Thrombosis)PE (Pulmonary Embolism)VTE (Venous Thromboembolism)

DVT is a PROBLEM

STATS & NEWS & AWARENESS

2 MILLION ANNUALLY

Starts with a DVT

DVT Prevention DVT Detection (S&A) DVT Treatment (Thrombolytics)

David Bloom (1963-2003)Fatal PE

• David Bloom developed a DVT after extensive travel and cramped conditions in a Humvee ”Bloom-Mobile” while broadcasting news coverage of the Iraq War.

• David’s wife, Melanie, used this tragedy to begin raising awareness around the condition that took David’s life = DVT. • Today awareness of DVT is 10-fold due in

large part to David’s HIGH PROFILE death & Melanie’s crusade to explain “THE WHY”

Chris Bosh2015: Multiple DVTs ending his NBA career

Regis Philbin2010: DVT following hip replacement surgery

Serena Williams2017: PE following C-section2011: PE following foot surgeries & travel

Jimmy Stewart1997: Fatal PE after multiple DVTs

DVT CAN BE PREVENTED

Mechanical Prophylaxis Pharmacological Prophylaxis

Many Authorities = Surgeon General, AHRQ, CDC, AORN Guidelines, Accrediting Agencies, John’s

Hopkins, Emory University, Oregon ASC Workgroup 2014, ACCP Guidelines, Ortho & OBGYN Guidelines &

Physician DVT Key Opinion Leaders = Jack Hirsch, MD., Joseph Caprini MD., Elliot Haut MD. & Michael Streiff,

MD., Robert Barrack, MD., Denis Nam, MD.You can learn about DVT by the punch of a button today!!

EVOLUTION OF PREVENTION METHODS

FACILITYHOME

Pharmacological

FACILITYHOME

Mechanical

ACCP Guidelines for the Prevention of VTE 2012

In patients undergoing THA or TKA, we recommend use of one of the following for a minimum of 10 to 14 daysrather than no antithrombotic prophylaxis: low-molecular-weight heparin (LMWH), fondaparinux, apixaban, dabigatran, rivaroxaban, low- dose unfractionated heparin (LDUH), adjusted-dose VKA, aspirin (all Grade 1B), or an intermittent pneumatic compression device (IPCD) (Grade 1C).

We recommend the use of only portable, battery-powered IPCDs capable of recording and reporting proper wear time on a daily basis for inpatients and outpatients. Efforts should be made to achieve 18 h of daily compliance.

• Orthopedic Guideline for Prevention• NonOrthopedic Guiideline for Prevention• NonSurgical Guideline for Prevention

MUST BE A PROTOCOL IN FACILITY & AT HOME

• Total Joints – CMS – Readmissions – Penalties – Coming to ASC’s• 40-80% get a DVT without prophylaxis. There simply must be a protocol

• 1.5M Total Joints last year = expected to grow to 7.5M in 10 years.

Houma Outpatient Surgery Center, AAAHC ACCREDITED

3717 Houma Blvd, 3rd Floor P: 504 456 1515 Houma Outpatient Surgery.com

Metairie, La. 70006 F: 504 454 3810

VTE Guidelines

Each Risk Factor Represents 1 Point Age 41-60 years A Swollen legs (current) Var icose veins Overweight/Obese (BMI >25) History of Inflammatory Bowel Disease (Crohn’s/ UC) Minor surgery planned Surgery Sepsis (<1 month) COPD Congestive hear t failure (<1 month) Medical patient currently at bed rest Ser ious Lung disease including pneumonia (<1 month) Other r isk factors_________________________________________

Women Only Contraceptives or hormone replacement therapy Pregnancy or postpar tum (<1 month) History of unexplained stillborn infant,

recurrent spontaneous abortion (> 3), premature birth with toxemia or growth-restricted infant Subtotal:_________

Each Risk Factor Represents 2 Points Age 61-74 years Central venous access Arthroscopic surgery Surgery (>45 minutes) Malignancy (present or previous) Patient confined to bed (>72 hours) Immobilizing plaster cast (<1 month)

Subtotal:____________

Each Risk Factor Represents 3 Points Age >74 Family History of thrombosis* History of DVT/ PE Positive Prothrombin 20210A Positive Factor V Leiden Positive Lupus anticoagulant Elevated serum homocysteine Heparin-induced thrombocytopenia (HIT)

(Do not use heparin or any low molecular weight heparin) Elevated anticardiolipin antibodies Other congenital or acquired thrombophilia

If yes: Type_____________________________ * most frequently missed risk factor Subtotal:____________

Each Factor Represents 5 Points Stroke (<1 month) Multiple trauma (<1 month) Elective major lower extremity ar throplasty Hip, pelvis or leg fracture (<1 month) Acute spinal cord injury (paralysis) (<1 month)

Subtotal:_________

Total Risk Factor Score:___________________

Contraindications □ Active Bleeding □ Abnormal Clotting □ Known Coagulopathy □ Hypersensitivity to LMWH □ Uncontrolled HTN □ Other:____________________ ________________________________

I have reviewed the above risk factors and have ordered the appropriate prophylaxis Physician Signature: Date:

Total Points

Risk Levels

Select Appropriate Prophylaxis (All Patients will be instructed on early ambulation and SCDs will be

used for ALL General Anesthesia Cases) 0-1 Low □ Other: 2 Moderate □ TED Hose 3-4 High □ TED Hose

□ Other:____________________________________________________________________ □ Enoxaparin/Lovenox: (1st dose in Recovery + 2 days post-op) □ 40mg SQ daily (WT < 150kg □ 30mg SQ twice daily (WT > 150kg □ Send patient home with SCD for________________days

>5 Highest □ TED HOSE □ Other:____________________________________________________________________ □ Enoxaparin/Lovenox: (1st dose in Admit + 7 days post-op) □ 40mg SQ daily (WT < 150kg □ 30mg SQ twice daily (WT > 150kg □ Send patient home with SCD for________________days

For the following patients, Lovenox

should be considered

- Patients whose BMI is over 30 and surgery time > 3 hours - Patients undergoing multiple procedures INCLUDING

Abdominoplasty - Patients with surgery time>5 hours

Houma Outpatient Surgery Center is a physician-owned, ambulatory surgery center that provides quality care for the New Orleans area.

Joseph Caprini, MD

The CapriniRisk Assessment

Increased Focus on Patient Compliance

Discharge Instruction by Cliniciansto follow Physician prescriptions

"is paramount”

8/4/15, 6:11 PMBlood Clot Prevention Is Higher Priority at Hospitals - WSJ

Page 1 of 4http://www.wsj.com/articles/blood-clot-prevention-is-higher-priority-at-hospitals-1438626045

Blood clots, which form when blood doesn’t flow properly, can happento anyone, including travelers on long plane rides in cramped seats,women on birth control drugs, or seemingly healthy people with noknown risk factors.

Almost half of clots strike patients when they are in the hospital orsoon after discharge, ranking them among the most common causes ofpreventable deaths. Guidelines for preventing clots are in place, yetstudies show that 40% to 60% of patients who would benefit don'treceive appropriate treatments. They aren’t given anticlotting drugsbecause hospitals don’t reliably administer them and patientssometimes refuse them.

Now, many hospitals are intensifying their clot-prevention as theyincur more financial penalties in the form of reduced payments fromfederal and state health agencies if patients develop clots while undertheir care. Hospitals are using electronic medical records to moreprecisely identify patients’ risk levels, holding refresher trainingsessions for nurses, and providing patients with educational materialson the dangers of blood clots.

Clots, known by the medical term venous thromboembolism, typicallystart in the deep veins of the leg or arm. Those clots are called deepvein thrombosis. When a part of the clot breaks off and travels to thelung, it can cause a pulmonary embolism, or blockage. There are about900,000 cases of deep vein thrombosis in the U.S. each year, and about30% will become pulmonary embolisms. Of those, about a third arefatal. Democratic presidential candidate Hillary Clinton takes aprescription blood-thinning drug as a result of suffering blood clots in

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http://www.wsj.com/articles/blood-clot-prevention-is-higher-priority-at-hospitals-1438626045

LIFE HEALTH THE INFORMED PATIENT

Blood Clot Prevention Is HigherPriority at HospitalsMany patients don’t receive anticlotting drugs; nurses don’t always give them

| |

Aug. 3, 2015 2:20 p.m. ET

By

LAURA LANDRO

“40% to 60% of patients who would benefit don't

receive appropriate treatments. They aren’t given anticlotting drugsbecause hospitals don’t reliably administer them

and patientssometimes refuse them”.

Curbing Stats

Joint effort (4)

Facilities Leading, Physiciansprescribing, Nursesadministering/educating @ discharge, Patient’s Complying

You could be the next STAR in the fight against VTE

Dikembe Mutombo – “NOT IN MY HOUSE”

We need more stars in each surgery center and hospital across the country