Guide Available for Deep Vein Thrombosis (Text Version)

On September 15, 2009, Greg Maynard made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (1.1 MB).

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Slide 1

Guide Available for Deep Vein Thrombosis

• Developed from Partnerships in Implementing Patient Safety program toolkit
• Based on quality improvement initiatives undertaken at the University of California, San Diego Medical Center and Emory University Hospitals
• Assists quality improvement practitioners in preventing one of the most important problems facing hospitalized patients - DVT / PE (VTE) 

Slide 2

Why build a toolkit for VTE Prevention?

• VTE is a common source of inpatient M&M
  • Jumbo jet crash / day- > Breast CA, HIV, MVA combined
  • May be # 1 preventable source of hospital death
• Effective and safe methods of prevention exist
  • Large "implementation gap" - best practice? current practice
• These methods are grossly underutilized
  • Awareness, difficulty implementing, no validated risk assessment
• P4P, 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 

Slide 3

To Achieve Improvement

• Real institutional support / prioritization
• Will to standardize
• Physician leadership
• Measurement of process / outcomes
• Protocol, integrated into order sets
• Education
• Continued refinement / tweaking- PDSA

SHM and AHRQ Guides on VTE Prevention 

Slide 4

Hierarchy of Reliability

Level		Predicted Prophylaxis rate
1	No protocol* ("State of Nature")	40%
2	Decision support exists but not linked to order writing, or prompts within orders but no decision support	50%
3	Protocol well-integrated (into orders at point-of-care)	65-85%
4	Protocol enhanced (by other QI / high reliability strategies)	90%
5	Oversights identified and addressed in real time	95+%

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

Slide 5

The Essential First Intervention

VTE Protocol

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

Challenges:
Make it easy to use ("automatic")
Make sure it captures almost all patients
Trade-off between guidance and ease of use / efficiency

Slide 6

Example from UCSD
Keep it Simple - A "3 bucket" model

Low	Medium	High
Ambulatory with no other risk factors. Same day or minor surgery	CHF COPD / Pneumonia Most Medical Patients Most Gen Surg Patients Everybody Else	Elective LE arthroplasty Hip/pelvic fx Acute SCI w/ paresis Multiple major trauma Abd / pelvic CA surgery
Early ambulation	UFH 5000 units q 8 h (5000 units q 12 h if > 75 or weight <50 kg) LMWH Enox 40 mg q day Other LMWH CONSIDER add IPC	Enox 30 mg q 12 h or Enox 40 q day or Other LMWH or Fondaparinux 2.5 mg q day or Warfarin INR 2-3 AND MUST HAVE IPC

IPC needed if contraindication to AC exists

Slide 7

Map to Reach Level 3
Implementing an Effective VTE Prevention Protocol

• Examine existing admit, transfer, periop order sets with reference to VTE prophylaxis.
• Design a protocol-driven DVT prophylaxis order set (w/ integrated risk assessment)
• Vette / Pilot - PDSA
• Educate / consensus building
• Place new standardized DVT order set 'module' into all pertinent admit, transfer, periop order sets.
• Monitor, tweak - PDSA

Slide 8

Percent of Randomly Sampled Inpatients with Adequate VTE Prophylaxis

In press, Maynard, Morris et al, J Hosp Med

Image of line graph from Q1 2005 to Q4 2007.  It shows baseline; consensus building; order set implementation and adjustment; and real time ID and intervention.

Slide 9

UCSD - Decrease in Patients with Preventable HA VTE

Image of line graph from Q1 2005 to Q1 2007.  There are separate graphs for different departments including: medicine, surgery, ortho, other and then total of all.

Slide 10

Hierarchy of Reliability

Level		Predicted Prophylaxis rate
1	No protocol* ("State of Nature")	40%
2	Decision support exists but not linked to order writing, or prompts within orders but no decision support	50%
3	Protocol well-integrated (into orders at point-of-care)	65-85%
4	Protocol enhanced (by other QI / high reliability strategies)	90%
5	Oversights identified and addressed in real time	95+%

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

Slide 11

Map to Reach Level 5
95+ % prophylaxis

• Use MAR or Automated Reports to Classify all patients on the Unit as being in one of three zones:
  
  GREEN ZONE - on anticoagulation
  YELLOW ZONE - on mechanical prophylaxis only
  RED ZONE - on no prophylaxis

Act to move patients out of the RED!

Slide 12

Situational Awareness and Measure-vention: Getting to Level 5

• Identify patients on no anticoagulation
• Empower nurses to place SCDs in patients on no prophylaxis as standing order (if no contraindications)
• Contact MD if no anticoagulant in place and no obvious contraindication
  • Templated note, text page, etc
• Need Administration to back up these interventions and make it clear that docs can not "shoot the messenger"

Slide 13

Collaborative Efforts and Kudos

• SHM VTE Prevention Collaborative I - 25 sites
• SHM / VA Pilot Group - 6 sites
• SHM / Cerner Pilot Group - 6 sites
• AHRQ / QIO (NY, IL, IA) - 60 sites
• IHI Expedition to Prevent VTE - 60 sites
• SHM Team Improvement Award
• NAPH Safety Net Award
• Venous Disease Coalition