Canadian VTE Audit - Information Call

NATIONAL VTE AUDIT CALL TO ACTION

SEPTEMBER 10, 2014 Artemis Diamantouros, Bill Geerts & Virginia Flintoft

Gina Peck, Anne MacLaurin and Alex Titeu

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• Why participate in the VTE audit?

• What did we learn last year?

• How to complete the audit

• Instructions for getting and using your Data Collection Form

Agenda

Why participate in the VTE audit?

What did we learn last year?

How to complete the audit

Instructions for getting your Data Collection Form

Agenda

Bill Geerts, MD, FRCPC

Thromboembolism Specialist, Sunnybrook Health Sciences Centre

Professor of Medicine, University of Toronto

National lead, VTE Prevention, Safer Healthcare Now!



1. Because 60% of all venous thromboembolism (VTE) in the population is hospital-acquired

Burden of Hospital-Acquired VTE

Population of Canada, 2014 35,428,000

Annual VTE rate 35,428

1/1,000/yr

60%

Hospital-acquired VTE rate 21,300/year


1. Because 60% of all VTE in the population is hospital-acquired

2. Because HA-VTE produces substantial patient harm

Harms of Hospital-Acquired VTE

• Symptomatic DVT, PE • Fatal PE • Prolonged hospital stay (or readmission) • Harm of therapeutic anticoagulation • Patient anxiety • Costs of diagnosis and treatment • Future consequences


1. Because 60% of all VTE in the population are hospital-acquired

2. Because HA-VTE produces patient harm

3. Because HA-VTE can be prevented (effectively, safely, inexpensively)


4. Because comprehensive thromboprophylaxis programs are expected by Accreditation Canada and are expected by our PATIENTS


4. Because comprehensive thromboprophylaxis programs are expected by Accreditation Canada and are expected by our PATIENTS

5. Because it is essential to measure our compliance with this safety standard of care

Thromboprophylaxis improves clinically-important outcomes:

4 examples


QI improves Thromboprophylaxis 1

Maynard – J Hosp Med 2010;5:10

54% 67% 80% 90% 98%

QI efforts also reduce VTE

Maynard – J Hosp Med 2010;5:10

2005 P

Patients at risk 9,720 11,207

Appropriate prophylaxis 58% 98% <0.001

Hospital-acquired VTE

131 92 <0.001

Preventable hospital-acquired VTE

44 7 <0.001

1

2

Thromboprophylaxis leads to Fewer Adverse Outcomes

Zeidan – Am J Hematol 2013;88:545

2.5%

1.1%

0%

0.5%

1.0%

1.5%

2.0%

2.5%

Symptomatic VTE

Preventable VTE

Clin

ical

Eve

nts a

t 90

days

Major bleeding

0.7%

0% 0.3%

0.1%

Pre-intervention (N=1,000)

Post-intervention (N=942)

• Medical patients at Johns Hopkins

2

• QI project at King’s College Hospital launched in 2010 (aligned with national VTE program)

• Development of a local VTE Prevention Program • Mandatory, documented VTE risk assessment • VTE prophylaxis guidance • Mandatory VTE education • Identification of hospital-associated VTE • Root cause analysis with targeted QI interventions

Effect of a VTE Prevention Program on Hospital-Assoc VTE

Roberts – Chest 2013;144:1276

3

Patients with a VTE Risk Assessment


% o

f pat

ient

s

• QI project at King’s College Hospital, London, 2010-12

VTE Prevention Program Reduces Hospital-Associated VTE

2010-11 2011-12 p

VTE risk assessment 63% (38-88) 93% (90-97)

HA-VTE Per 1,000 admissions

236 19.7/mo

1.5

189 15.8/mo

1.0

0.014

Potentially preventable HA-VTE

43%

32%

0.005


• All patients admitted to all 163 NHS trusts, 2010-12 • Mandatory reporting of use of the VTE risk tool

Use of the UK National VTE Risk Assessment Tool

Lester – Heart – 2013;99:1734

Rate of VTE risk

assessments performed

[IQR]

100%

0%

50%

July 2010 March 2012

51% [27,71]

93% [91,96]

4

• All 4 million patients admitted to all 163 NHS hospital trusts >3 days, 2010-12

Hospital-Acquired Fatal VTE is Reduced in Adherent Hospitals

Lester – Heart – 2013;99:1734

Fatal VTE <90 days after hospital discharge

Rel Risk for hospitals with VTE risk assessment >90% vs <90%

All 0.85 [0.75-0.96; p=0.01]

Post-discharge 0.81 [0.67-0.79; p=0.03]

Achieving >90% VTE risk assessment is associated with significant lower VTE mortality

National VTE Mortality Data England

Year VTE listed as cause of death

2007 6,121 2008 6,170 2009 6,218 2010 6,282 2011 4,562 2012 4,668

From R. Arya - Office for National Statistics, 2013




• Instructions for getting your Data Collection Form

Agenda

2013 National VTE Audit RESULTS

• Audit April, 2013

• 118 centers, 4,667 patients, 9 provinces coast to coast

• General medical and general surgical patients

• Analyses conducted by CMT with data from Patient Safety Metrics (PS Metrics)

2013 VTE Audit Day

• Overall, thromboprophylaxis use = 81%

- Very good (but with room for improvement)

Thromboprophylaxis Use

Appropriate Thromboprophylaxis - by Province (2013)

% o

f pat

ient

s

100%

65%

Types of Thromboprophylaxis

• Thromboprophylaxis: • LMWH 61% • LMWH or LDH 90% • Mechanical only 4%

• Variability: • By Patient Group:

Medical: LMWH 70% vs LDH 21%

Surgical: LMWH 45% vs LDH 46%

• By province • By region within provinces

• Overall, 19% did not receive appropriate thromboprophylaxis

• Reasons: • No thromboprophylaxis 70% • Delay in start 9% • Wrong dose 8% • Modality varied from SHN recommendation 6%

Reasons for not using Thromboprophylaxis

Reasons for not using Thromboprophylaxis

• Overall, 55% of patients had preprinted order sets

• Huge differences by province (13% 63%) and region

Order set use

Impact of Preprinted Order Sets

N=4,518

Order set used

Order set not used

91%

71%

2014 National VTE Audit




• Instructions for getting your Data Collection Form

Agenda

• When? – October 1 to 15, 2014*

• Purpose: – Obtain a current estimate of national VTE prophylaxis rates – Increase awareness of VTE prophylaxis – Contribute to the first World Thrombosis Day on October

13, 2014 – Improve experience with the VTE Data Collection Tool and

other tools available to support VTE

*Data collected up to Oct. 31st will be accepted

2014 Canadian VTE Audit

• Your commitment: – Approximately 60 minutes

• Your essential contribution: – Helping to improve the delivery of safe and

effective care for patients

Canadian VTE Audit 2014

• The VTE audit will again focus on: – Internal Medicine – General Surgery

• Audit sample can be: – Both Medical AND General Surgical patients

(preferred option) – OR, either Medical or Surgical patients

Patients include

• At least 20 patients from each group (medical, surgical)

• 4 options for determining audit sample: 1. All eligible medical AND general surgical patients 2. All eligible medical OR surgical patients 3. A sample of eligible medical AND surgical patients

(consecutive patients, random sample, 1 or more nursing units)

4. A sample of eligible medical OR a sample of eligible surgical patients

Step 1: Identifying Audit Sample

• Inclusion: – Patients in hospital on Oct. 1 AND with an actual or

expected LOS of more than 2 calendar days – Patients admitted between Oct. 1-15* with an actual or

expected LOS of more than 2 calendar days • Exclusions:

– Patients in hospital >30 calendar days – Patients receiving therapeutic doses of anticoagulants

*May extend to Oct. 31st if required

Eligibility Criteria

• Internal Medicine: – For example, patients admitted with:

• CHF, severe respiratory disease, or confined to bed with active cancer, previous VTE, sepsis, acute neurologic disease, inflammatory bowel disease

• General Surgical Patients: – All general surgical patients are eligible if they meet the

general criteria for eligibility – Exclude Low risk surgical patients

• Non-major surgery and fully mobile and NO additional VTE risk factors

Eligibility Criteria

• Collect data related to 4 questions: 1. Were preprinted orders used on admission or

after surgery? 2. What type of thromboprophylaxis was used? 3. Did the patient receive appropriate

thromboprophylaxis? 4. If no to Q3, why was recommended

thromboprophylaxis not used?

Steps for conducting the audit

• Direct Chart Audit!! – Go to the patient care unit – Determine patient eligibility

• Chart Review/MAR • Report from pharmacy system

– Complete VTE data collection form • More to come . . .

How will you collect the data?

Case 1: No VTE Prophylaxis was ordered – Column 1: answer NO – Column 2: select #12 “No Order” – Column 3: select NO (no appropriate

thromboprophylaxis) – Column 4: select #1 “No Prophylaxis

Ordered”

Reviewing the chart

Case 2: VTE Prophylaxis has been ordered for the patient – Column 1: look at whether an order set was

used to order the VTE prophylaxis • Answer YES or NO in column 1

– Column 2: select the thromboprophylaxis ordered from the list of options

Reviewing the chart

Case 2: VTE Prophylaxis has been ordered for the patient – Column 3: decide whether the VTE

prophylaxis was appropriate for the patient

Reviewing the chart

NB: All patients included in the audit sample are eligible for thromboprophylaxis

• Prophylaxis is considered appropriate if: – It was started within 24 hours (1 calendar day)

of admission or after surgery – Choice is according to evidence-based

anticoagulant prophylaxis – Mechanical thromboprophylaxis if anticoagulant

is contraindicated – patient actively bleeding or at high risk of bleeding)

Determining appropriateness

Case 2: VTE Prophylaxis has been ordered for the patient – Column 4: if you answered NO to column

3, choose the reason(s) why the order was not appropriate

Reviewing the chart

How to participate in the VTE Audit

1. Use your VTE form from last years VTE Audit www.patientsafetymetrics.ca

2. Register for VTE audit day and we will create and email your data collection form http://www.saferhealthcarenow.ca/EN/events/other/VTEAudit/Pages/default.aspx

3. Register for Patient Safety Metrics and create your own Data Collection Tool. www.patientsafetymetrics.ca

Refer to the detailed instructions for more information about each option. http://www.saferhealthcarenow.ca/EN/events/other/VTEAudit/Pages/default.aspx

3 options for getting your form

51

http://www.patientsafetymetrics.ca/

http://www.saferhealthcarenow.ca/EN/events/other/VTEAudit/Pages/default.aspx

http://www.patientsafetymetrics.ca/

http://www.saferhealthcarenow.ca/EN/events/other/VTEAudit/Pages/default.aspx

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How to Request a Data Collection (Audit) Form

Completing Audit Form Request

Patient Safety Metrics An Overview

Features: • Cloud-based data collection and reporting tool • User friendly and simple to navigate • Accessible from website with login details • Tracks >100 process and outcome measures over 14

interventions • Provides real time reporting. • Reduces burden of data collection, entry and analysis • Capacity to customize measures and reports

Patient Safety Metrics

• Data Collection Forms – Patient-level data (de-identified) - daily – Multiple data elements – Print form Collect data Fax form – Automatic roll-up to Measurement Worksheets

• Measurement Worksheets – Aggregate data - monthly – Numerator and Denominator

Worksheets vs Data Collection Forms

PS Metrics can be used to support: • Small and Large Scale Improvement Initiatives

• Roll Up or Drill Down Reports [e.g. Unit Site Program Corporation Region Province Node National]

• Produce automated run charts • Reporting for accountability

• Possible to customize indicators to meet provincial, regional and local reporting needs

Potential applications of the system

Completing Audit Form - #1

Completing Audit Form - #1 Virginia Flintoft 416-946-8350, [email protected]

Access to PS Metrics

60

https://psmetrics.utoronto.ca/metrics/login.aspx

https://psmetrics.utoronto.ca/metrics/Login.aspx?language=french

https://psmetrics.utoronto.ca/metrics/login.aspx

https://psmetrics.utoronto.ca/metrics/Login.aspx?language=french

• Fax form in FINE RESOLUTION (setting on fax machine)

• Use Flat-bed Fax Machines – feeder faxes produce lines

• Do not write or stamp on forms except where allowed • Incorrectly Filled HCP Bubbles(pen, pencil, but

Sharpie is best)

Beware of Common Errors!

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Thank you … Questions?

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Poll Sondage

Thank you!

For any questions, contact:

Virginia Flintoft – 416-946-8350

Artemis Diamantouros– 416-480-6100 x3654 Email: [email protected]

Health & Medicine

Canadian VTE Audit - Information Call