Venous Thromboembolism (VTE) Southern New Hampshire Medical Center Lynda Pittenger, RN, CPHQ Kathy Helberg, BSN,RN, CPHQ

188-bed community hospital located in Nashua, NH; part of SNHHS with multi-specialty group practice, Foundation Medical Partners. Level III Trauma Center > 45,000 ED visits /year > 5,500 surgeries / year 24/7 Hospitalist program Minimally invasive surgery program with daVinci 11 Bed ICU Angioplasty / STEMI 2 MRI and 2 CT scanners Magnet (re-designated 2011) American College of Surgeons – Cancer, Breast Center Stroke Program- AHA/GWTG- Gold + award

VTE Measures Tracked and Trended at SNHMC Process Measures: VTE 1: % Inpatients with VTE prevention in place day of or day VTE 2: % ICU Inpatients with VTE prevention in place VTE 3: % VTE patients on coumadin who received overlap therapy VTE 4: % VTE patients on heparin and PTT monitored as per order set VTE 5: % VTE patients received d/c instructions re: coumadin Outcome Measure: VTE 6: % Patients who develop VTE during hospitalization Process Measures; SCIP VTE 1: % surgery patients with recommended VTE prophylaxis ordered SCIP VTE 2: % surgery patients who received appropriate VTE prophylaxis within 24 hours prior to surgery to 24 hours after surgery 3

VTE Tools in Use at SNHMC Prevention: VTE Risk and Prevention Supplemental Order Set for admissions Surgical Order Sets with built in mechanical /pharmacological prevention DVT prevention cue built into EMR to remind staff that if pt is not ambulating, they are at risk. Treatment (for Dx of VTE): Transitional Care Coordinators round on patients with VTE Patient Education Information: – DVT/ PE etiology, care, treatment and prevention – Coumadin Patient Education and Discharge Instruction – Nutrition Guidelines 4

Equipment Barriers Inconsistent use of pneumatic compression stockings Differing opinions by physicians on when to use recommendations - pneumatic + TEDs Not enough equipment Nurses concern with trip factor- may prevent patients from getting OOB. Patient dissatisfaction - comfort Solutions: Medical: Clarified order sets to remove TEDs Surgical: Kept TEDs option on order set and used in conjunction with SCD. Purchased more equipment Promoted a healthy respect for role of pneumatic compression stockings in VTE prevention – Memos, unit rounding and staff education – Enhanced pre-op teaching & expectations for patients

Medication Barriers Variation in med use for chemoprophylaxis: Use of lovenox vs heparin for prevention – $$$$ difference – Daily vs. bid/tid dosing Physician concern with bleeding risk in peri op pts – Some surgeon hold outs – Hospitalists co-managing “twitch” NEW- anticoagulant for arthroscopy-Rivaroxaban Solutions: Endorsed use of SQ heparin for VTE prevention thru P&T Updated VTE evidence based order set Enhanced surgeon & hospitalist partnership Created a new order set in partnership with pharmacy

Medication Barriers cont. Inconsistent use of post op surgical order sets – VTE anticoagulation prophylaxis during off-shifts / weekends. Lack of clarity with overlap – CMS definition states minimum 5 days and INR > than 2 – Physicians reluctant to continue overlap > 48-72H if INR > than 2 Embedded VTE prompts in transfer orders from PACU to nursing units Proposed Solution Provide Physician education Build cue into CPOE Engage Transitional Care Coordinators

SNHMC Performance Measures 8 Quality Measures SNHMC Q SNHMC Q VTE 1: % Inpatients with VTE prevention 100% VTE 2: % ICU Inpatients with VTE prevention 100% VTE 3: % VTE patients on coumadin who received overlap therapy 89%91.6% VTE 4: % VTE patients on heparin and PTT monitored as per order set 100% VTE 5: % VTE patients received d/c instructions re: coumadin 100%90.9% VTE 6: % Patients who develop VTE during hospitalization 21 VTE 1&2: Sample Population VTE 3-6 All Cases

SNHMC SCIP Performance Measures * Source: - a partnership between the Foundation for Healthy CommunitiesFoundation for Healthy Communities and the Northeast Health Care Quality Foundation Q310-Q211 (Composite does not include Card2 or Inf10) (National Average obtained from Hospital Quality Alliance Report)Northeast Health Care Quality Foundation ** Source: Northeast Health Care Quality Foundation - Qtr 4, 2011 (NHCQF Composite score includes the following: 1,2,3,4,6,9,10 VTE1&2, Card2) Quality MeasuresSNHMC Q SNHMC* 2011 SNHMC 2010 SNHMC 2009 NH* Q4 10- Q3 11 National* Average Q4 10- Q3 11 National Benchmark (top 10% of hospitals Q1 11) VTE 1- Recommended VTE Prophylaxis Ordered for Surgery Patients 96% 97% 91%93%98%97%99.9% VTE 2 - Surgery Pts who Received Appropriate VTE Prophylaxis within 24 hrs Prior to Surgery to 24 hrs After Surgery 96% 97% 91%92% 97% 96%99.8%

What Can Others Learn From Our Journey? Engage a physician champion and form a multidisciplinary team Research best practice Create evidence based tools - order sets and checklists Test the tool- round, encourage feedback and make changes – PDCA Roll out to a larger group Implement and include 1:1 feedback ROUND- to scan the environment for opportunities 10