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

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This is the text version of Greg Maynard's slide presentation, Venous Thromboembolism (VTE) Prevention in the Hospital. Select to access the PowerPoint® slide presentation. (2.3 MB). Select for presentation transcript)

Slide 1

Venous Thromboembolism (VTE) Prevention in the Hospital

Greg Maynard M.D., M.Sc.
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

Over the list of Risk Factors for VTE enumerated in slide 3 is written: Most hospitalized patients have at least one risk factor for VTE.

Slide 5

Failure to Do Simple Things Well

• Wash Hands:
  • 60% Reliable.
• Patients Understand Meds / Problems:
  • 40% Reliable.
• Central Lines Placed w/ Proper Technique:
  • 60% Reliable.
• Basal Insulin for Inpt Uncontrolled DM:
  • 40% Reliable.
• VTE Prophylaxis:
  • 50% Reliable.

Slide 6

Registry Data

Highlight the Underuse of Thromboprophylaxis

DVT-free,  RIETE,   Improve:

BAD NEWS!

Only a minority of hospitalized patients receive thromboprophylaxis.

Goldhaber SZ, Tapson VF. Am J Cardiol 2004;93:259-62.
Monreal M, et al. J Thromb Haemost 2004;2:1892-8.
Tapson V, et al. Blood 2004;104:11. Abstract #1762.

Slide 7

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 8

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 9

Why don't we do better?

• Lack of awareness or buy in of guidelines.
• Underestimation of clot risk, overestimation of bleeding risk.
• Lack of validated risk assessment model.
• Translating complicated guidelines into everyday practice is difficult.

Slide 10

E-Alerts Can Increase Prophylaxis

• 2506 hospitalized patients.
• VTE risk score ≥ 4.
• Randomized to intervention or control.

Kucher N, et al. N Engl J Med. 2005;352:969-77.

Slide 11

E-Alerts Decrease VTE

Image: A graph showing the percent of freedom from DVT/PE over 90 days. In the period, for the intervention group, percent of freedom fell from 100 percent to about 95 percent. For the control group, percent of freedom fell from 100 percent to about 91 percent.

Kucher N, et al. N Engl J Med 2005;352:969-977.

Slide 12

Effectiveness can wane over time

Lecumberri R, et al. Thromb Haemost 2008;100:699-704.

Slide 13

Human Alerts Increase Prophylaxis

• 2493 hospitalized patients.
• VTE risk score ≥ 4.
• Randomized to intervention or control.

Piazza G, et al. Circulation. 2009;119:2196-2201.

Slide 14

Human Alerts Decrease VTE

Image: A graph showing the percent of freedom from DVT/PE over 90 days. In the period, for the human alert group, percent of freedom fell from 100 percent to about 97 percent. For the no alert group, percent of freedom fell from 100 percent to about 95 percent.

Wilcoxon P-value: 0.307, Log-rank P-value: 0.309.

Slide 15

Bottom Line—Alerts

• A Useful Strategy.
• E-Alerts and Human Alerts can work.
• Not a panacea.
• Alert fatigue can be a problem.
• Need a multifaceted approach.

Slide 16

Medical Admission Order Sets Can Improve DVT Prophylaxis

Baseline—Only 11% of inpatients on any VTE prophylaxis.

Intervention—A simple prompt for UFH or Mechanical Prophylaxis placed into voluntary admission order sets.

Post intervention: 44 percent on any prophylaxis, 26 percent pharmacologic prophylaxis.

O'Connor C, Adhikari N, DeCaire K, Friedrich Jan. Medical Admission Order Sets to Improve Deep Vein Thrombosis Prophylaxis Rates and Other Outcomes. J Hosp Med 2009.

Slide 17

...but not enough by themselves, and design of the order set matters

• Best practice prophylaxis not defined.

Prompt ≠ Protocol

• No protocol = No guidance at the point of care.

In order set, heparin, mechanical devices, and no prophylaxis presented as equal choices.

• Implementation / Reliability.

At 15 months, only about half of inpatient admissions utilized standardized order set.

Other methods needed to enhance performance!

Slide 18

Education alone is not sufficient

...but it is essential to optimize other strategies that are effective

• Standardized order sets.
• Computerized decision support.
• E-alerts.
• Human alerts.
• Raising situational awareness.
• Audit and feedback.

Slide 19

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 pushes the adequate prophylaxis rates up to 98%. N = 2,944, mean 82 audits/month.

Slide 20

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.

Image: Logos of AHRQ and University of California-San Diego.

Slide 21

UCSD—Decrease in Patients with Preventable HA VTE

Image: Run chart depicts a declining number of preventable VTE as the VTE total prophylaxis rate improves, which affected all services (medicine, surgery, ortho, other, and total) 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 22

Hospital Acquired VTE by Year

# p <0.01 *p <0.001

Maynard GA, et al. J Hosp Med. 2009.

Slide 23

VTE Prevention Guides Modeling a Multifaceted Approach

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

https://www.ahrq.gov/qual/vtguide/

http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_VTE/VTE_Home.cfm

Slide 24

VTE QI Resource Room www.hospitalmedicine.org

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

Slide 25

Collaborative Efforts

• 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 for VTE Prevention—60 sites.
• Effective across wide variety of settings.
  • Paper and Computerized / Electronic.
  • Small and large institutions.
  • Academic and community.

Slide 26

Basic Ingredients for Success

• Institutional support, will to standardize the process.
• Designated multidisciplinary team with physician leadership.
• Specific goals and metrics.
• VTE Protocol guidance built into order sets.
• Education / consensus.
• Alerts / feedback to clinicians in real time.

Slide 27

Enlist Key Groups / Leaders

• Section Heads.
• Hospitalists.
  • (most groups receive some direct support from the hospital).
• Other high volume providers.
• Find some more physician champions.

Slide 28

Educational Detailing—PR

Quote ACCP 8 Guidelines.

Don't use aspirin alone for DVT prophylaxis.

Mechanical prophylaxis is not first line prophylaxis in the absence of contraindications to pharmacologic prophylaxis.

Geerts WH et al. Chest. 2008;133(6 Suppl):381S-453S.

Slide 29

Use the powerful anecdote and data

• Look for VTE case that could have been prevented.
• Personalize the story.
• Enlist a patient / family to help you tell the story.
• Get data on VTE in your medical center
  • (it occurs more often than the doctors think it does).

Slide 30

Questions (Q) and Answers (A)

Q. What is the best VTE risk assessment model?

A. Simple, text based model with only 2-3 layers of VTE Risk.

Q. Who should do the VTE risk assessment?

A. Doctors (via admit transfer order sets), with back up risk assessment by front line nurses or pharmacists, focusing on those without prophylaxis.

Slide 31

Hierarchy of Reliability

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

Slide 32

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 33

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 34

Is your order set in a competition?

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

Slide 35

Too Little Guidance
Prompt ≠ 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 36

No Math!
Critiques of VTE Risk Assessment Model using point scoring techniques

• Point based systems—
  • Low inter-observer agreement in real use.
  • Users stop adding up points.
  • Too large to be modular (collects dust).
  • Point scoring is arbitrary.
  • Never validated.

Slide 37

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

IPC needed if contraindication to AC exists.

Slide 38

Paper Version—"3 Bucket" RAM DVT Prophylaxis Order Set Module

Separate paper version demonstrating 3 bucket model.

Slide 39

Integrate order set as a module

• Make order set even more portable.
• Incorporate module into current heavily used order sets.

Or

Strip out VTE orders from popular order sets and refer to the standardized orders.

Clip orders to all admit / transfer orders.

Slide 40

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 41

Hierarchy of Reliability

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

Slide 42

Measure-vention

Daily measurement drives concurrent intervention (i.e. same as Level 5 in Hierarchy of Reliability)

Identify patients not receiving VTE prophylaxis in real time.

1. Suitable for ongoing assessment, reporting to governing body. Archive-able data (!)
2. Can be used for real time intervention. Actionable data (!)

Slide 43

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 44

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 45

This slide depicts a staggered time series, displaying the quick effect of "measure-vention" is the technique was initiated on 3 wards in two different centers. Protocol implementation had already boosted VTE prophylaxis rates to around 70%, with very quick (in a matter of days) improvement to over 90%.

Effect of Situational Awareness on Prevalence of VTE Prophylaxis by Nursing Unit

UCL = Upper Control Limit.
LCL = Lower Control Limit.

Slide 46

Most Common Mistakes in Measurement of DVT Prophylaxis

• Not doing it at all.
• Not doing it concurrently.
• Failure to make measured poor performance actionable.

Slide 47

Key Points—Recommendations

• QI building blocks should be used.
• Multifaceted approach is needed.
• VTE protocols embedded in order sets.
• Simple risk stratification schema, based on VTE-risk groups (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.

Slide 48

References

Maynard G, Morris T, Jenkins I, Stone S, Lee J, Renvall M, Fink E, Schoenhaus R (2009) Optimizing prevention of hospital acquired venous thromboembolism: prospective validation of a VTE risk assessment model. J Hosp Med 4(7). doi:10.1002/jhm.562.

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, last accessed September 15, 2008 at https://www.ahrq.gov/qual/vtguide/.

Maynard G, Stein J. Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement, version 3.3. Society of Hospital Medicine supplement The Hospitalist August 2008, Vol 12 (8) 1-40.

Maynard G, Stein J. Designing and Implementing Effective VTE Prevention Protocols: Lessons from Collaboratives. J Thromb Thrombolysis DOI 10.1007/s11239-009-0405-4 published online Nov 10, 2009.