IHI Expedition 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 VTE Expedition Kick Off Call July 21, 2009

Teams will be able to: Identify VTE Risk Factors Describe processes others use to assess patients on admission for VTE risk Implement reliable process for assessment of VTE risk in hospitalized patients ….and learn practical methods enabling you to track the effectiveness of your efforts

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

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.

Risk Factors for VTE Stasis Age > 40 Immobility CHF Stroke Paralysis Spinal Cord injury Hyperviscosity Polycythemia Severe COPD Anesthesia Obesity Varicose Veins Hypercoagulabilit y 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. Bick RL & Kaplan H. Med Clin North Am 1998;82:409. Most hospitalized patients have at least one risk factor for VTE

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

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: Monreal M, et al. J Thromb Haemost 2004;2: Tapson V, et al. Blood 2004;104:11. Abstract #1762.

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.

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.

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

11 Baseline Consensus building Order Set Implementation & Adjustment Real time ID & intervention Baseline Consensus building Order Set Implementation & Adjustment Real time ID & intervention N = 2,944 mean 82 audits / month In press, JHM 2009

12 Level 5 Oversights identified and addressed in real time 95+%

In press, JHM 2009

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

VTE Prevention Guides

VTE QI Resource Room

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 Effective across wide variety of settings –Paper and Computerized / Electronic –Small and large institutions –Academic and community

Q and 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. Q. What are the features of successful efforts?

Team Success Factors Strong team-based improvement capacity Designated team, ideally to include a nurse working on the testing unit or able to lead the work, an internal quality/performance improvement expert, and a physician champion Sponsorship and support from hospital leadership Clear commitment to the goal and the process IHI website, accessed July 2009

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

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

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

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)

Hierarchy of Reliability No protocol* (“State of Nature”) Decision support exists but not linked to order writing, or prompts within orders but no decision support Protocol well-integrated (into orders at point-of-care) Protocol enhanced (by other QI / high reliability strategies) (by other QI / high reliability strategies) Oversights identified and addressed in real time Level Predicted Prophylaxis rate 40% 50% 65-85% 90% 95+% * Protocol = standardized decision support, nested within an order set, i.e. what/when

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

26 Is your order set in a competition?

Medical vs. Surgical Surgical Patients often higher risk High Risk Surgery / Ortho patients already have prophylaxis at high levels, however. Trauma patients often with contraindications to pharmacologic prophylaxis Medical patients often represent largest opportunity Inclusive approach: one protocol for the great majority of med / surg patients 27

The Essential First Intervention 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 28 VTE Protocol

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

Too Much Guidance Not Practical in Use, Point Based Systems

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

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 32 IPC needed if contraindication to AC exists Example from UCSD Keep it Simple – A “3 bucket” model

34 VTE Risk LowModerateHigh Contraindications NoneRelativeAbsolute Preferred (default) choices  LMWH q day  UFH 5000 q 8 hours ( ± SCDs)

35 VTE Risk LowModerateHigh Contraindications NoneRelativeAbsolute Preferred (default) choices  LMWH q day  Warfarin AND SCDs  Arixtra

Paper Version – “3 Bucket” RAM DVT Prophylaxis Order Set Module

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

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

Hierarchy of Reliability No protocol* (“State of Nature”) Decision support exists but not linked to order writing, or prompts within orders but no decision support Protocol well-integrated (into orders at point-of-care) Protocol enhanced (by other QI / high reliability strategies) (by other QI / high reliability strategies) Oversights identified and addressed in real time Level Predicted Prophylaxis rate 40% 50% 65-85% 90% 95+% * Protocol = standardized decision support, nested within an order set, i.e. what/when

Map to Reach Level % 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!

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 (!) 41 Measure-vention

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”

43 Effect of Situational Awareness on Prevalence of VTE Prophylaxis by Nursing Unit Hospital A, 1 st Nursing Unit Baseline Post-Intervention UCL: 93% 104% Mean: 73% 99 % (p < 0.01) LCL: 53% 93% Hospital A, 2 nd Nursing Unit Baseline Post-Intervention UCL: 90% 102% Mean: 68% 87% (p < 0.01) LCL: 46% 72% Hospital B, 1 st Nursing Unit Baseline Post-Intervention UCL: 89% 108% Mean: 71% 98% (p < 0.01) LCL: 53% 88%_______________________ UCL = Upper Control Limit LCL = Lower Control Limit Hospital Days Intervention

Most Common Mistakes in Measurement of DVT Prophylaxis Not doing it at all Not doing it concurrently Failure to make measured poor performance actionable

Key Points - Recommendations VTE protocols embedded in order sets Simple risk stratification schema, based on VTE- risk groups (3 levels of risk should do it) Hierarchical design of orders –User’s response to VTE Risk Level and Contraindication drive default choices for prophylaxis 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 45