Venous Thromboembolism (VTE) Prevention in the Hospital (Text Version)

On September 16, 2009, Greg Maynard made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (1.68 MB).

---

Slide 1

AHRQ / QIO Venous Thromboembolism (VTE) Prevention in the Hospital

Greg Maynard MD, MSc
Clinical Professor of Medicine and Chief,
Division of Hospital Medicine
University of California, San Diego 

Slide 2

VTE: A Major Source of Mortality and Morbidity

• 350,000 to 650,000 with VTE per year
• 100,000 to > 200,000 deaths per year
• Most are hospital related.
• VTE is primary cause of fatality in half-
  • More than HIV, MVAs, Breast CA combined
  • Equals 1 jumbo jet crash / day
• 10% of hospital deaths
  • May be the #1 preventable cause
• Huge costs and morbidity (recurrence, post-thrombotic syndrome, chronic PAH)

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

Slide 3

Risk Factors for VTE

Stasis

• Age > 40
• Immobility
• CHF
• Stroke
• Paralysis
• Spinal Cord injury
• Hyperviscosity
• Polycythemia
• Severe COPD
• Anesthesia
• Obesity
• Varicose Veins

Hypercoagulability

• Cancer
• High estrogen states
• Inflammatory Bowel
• Nephrotic Syndrome
• Sepsis
• Smoking
• Pregnancy
• Thrombophilia

Endothelial Damage

• Surgery
• Prior VTE
• Central lines
• Trauma 

Anderson FA Jr. & Wheeler HB. Clin Chest Med 1995;16:235.

Slide 4

Risk Factors for VTE

Image of previous slide with the following words over it: Most hospitalized patients have at least one risk factor for VTE.

Slide 5

ENDORSE Results

• Out of ~70,000 patients in 358 hospitals, appropriate prophylaxis was administered in:
  • 58.5% of surgical patients
  • 39.5% of medical patients

Cohen, Tapson, Bergmann, et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet 2008; 371: 387-94. 

Slide 6

The "Stick" is coming..

• NQF endorses measures already
• Public reporting and TJC measures coming soon:
  • Prophylaxis in place within 24 hours of admit or risk assessment / contraindication justifying it's absence
  • Same for critical care unit admit / transfers
  • Track preventable VTE
• CMS - DVT or PE with knee or hip replacement reimbursed as though complication had not occurred. 

Slide 7

 

• 2005 - AHRQ grant to:
  • Design and implement VTE prevention protocol
  • Monitor impact on VTE prophylaxis and HA VTE
  • Validate a VTE risk assessment model / protocol

Attempt to use portable methodology, build toolkit to allow others to accomplish the same thing.

In press, JHIM 2009. 

Slide 8

Percent of Randomly Sampled Inpatients with Adequate VTE Prophylaxis

A run chart showing rates of adequate VTE prophylaxis rates at UCSD, based on randomly selected inpatients. Baseline rate = about 50%, consensus building and education phase shows improvement to 70%, order set implementation gets the rate of adequate prophylaxis to 80 - 90%, and real time identification push the adequate prophylaxis rates up to 98%. 

Slide 9

UCSD - Decrease in Patients with Preventable HA VTE

Run charts depicts a declining number of preventable VTE as the VTE prophylaxis rate improves, which affected all services. 10-13 preventable VTE per quarter were occurring at baseline in the first quarter of 2005, whereas this became 2 per quarter at times after implementation. 

Slide 10

UCSD VTE Protocol Validated

• Easy to use, on direct observation - a few seconds
• Inter-observer agreement -
  • 150 patients, 5 observers- Kappa 0.8 and 0.9
• Predictive of VTE
• Implementation = high levels of VTE prophylaxis
  • From 50% to sustained 98% adequate prophylaxis
  • Rates determined by over 2,900 random sample audits
• Safe - no discernible increase in HIT or bleeding
• Effective - 40% reduction in HA VTE
  • 86% reduction in risk of preventable VTE 

Slide 11

VTE Prevention Guides

Image: Two images are shown. One is the cover of the Preventing Hospital-Acquired Venous Thromboembolism, A Guide for Effective Quality Improvement - Version 3.0. The other cover is Preventing Hospital-Acquired Venous Thrombeenbolism, A guide to Effective Quality Improvement. 

Slide 12

VTE QI Resource Room www.hospitalmedicine.org

Screen shot of web page: Society of Hospital Medicine title at the top, with a blue banner labelled Quality Improvement Resource Rooms across the middle of the page. A gold box on the right of the screen shot has "Venous Thromboembolism outlined with a red rectangle. 

Slide 13

Slide 13. Collaborative Efforts and Kudos

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 (Honorable Mention)
• Venous Disease Coalition 

Slide 14

To Achieve Improvement

SHM and AHRQ Guides on VTE Prevention

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

Slide 15

The Essential First Intervention

VTE Protocol

1) a standardized VTE risk assessment, linked to...
2) a 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 16

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 17

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 model [RAM])
• 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 18

Too Little Guidance Prompt is Not Equal to Protocol

DVT PROPHYLAXIS ORDERS

• Anti thromboembolism Stockings
• Sequential Compression Devices
• UFH 5000 units SubQ q 12 hours
• UFH 5000 units SubQ q 8 hours
• LMWH (Enoxaparin) 40 mg SubQ q day
• LMWH (Enoxaparin) 30 mg SubQ q 12 hours
• No Prophylaxis, Ambulate

Slide 19

Most Common Mistakes in VTE Prevention Orders

• Point based risk assessment model
• Improper Balance of guidance / ease of use
  • Too little guidance - prompt? protocol
  • Too much guidance- collects dust, too long
• Failure to revise old order sets
• Too many categories of risk
• Allowing non-pharm prophy too much
• Failure to pilot, revise, monitor
• Linkage between risk level and prophy choices are separated in time or space

Slide 20

Is your order set in a competition?

A photo of a table top with 15-20 order sets spread all over it is depicted.

Slide 21

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

Low	Medium	High
Ambulatory with no other risk factors.  Same day or minor surgery Early ambulation	CHF COPD / Pneumonia Most Medical Patients Most Gen Surg Patients Everybody Else 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	Elective LE arthroplasty Hip/pelvic fx Acute SCI w/ paresis Multiple major trauma Abd / pelvic CA surgery 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 22

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 23

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 24

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 25

Summary of Key Strategies

• Basic Building Blocks
  • Institutional support, team, education, protocol, metrics, PDSA
• Physician performs VTE risk assessment within easy to use order sets, which captures all admits / transfers
• Active monitoring for non-adherents to protocol, intervene in real time