1. VTE PREVENTION UPDATE, WA (May 2010) Dr Helen van Gessel Office of Safety and Quality Luke SlawomirskiPerformance Activity & Quality Division Delivering a Healthy WA

2. Safety and Quality Investment for Reform (SQuIRe) Program Since 2006/07 $8M each year across WA Health 8 quasi-collaboratives addressing priority clinical practice improvement areas –IHI “bundles”, process improvement focus –Central OSQ department “scaffolding” –Not voluntary –Area Health Services (x4) determine resource allocation and implementation www.safetyandquality.health.wa.gov.au/squire/index.cfm

3. SQuIRe VTE prevention AIM –prevent VTE by performing risk assessment and correct prophylaxis (based on VTE Working Gp evidence summary – NB no formal state policy) PROCESSES TO MEASURE AND IMPROVE –% patients risk assessment –% patients at risk receiving correct prophylaxis Aligned with QUM indicator def n and sampling method Suggested initial focus surgical patients

4. Mid 2009 progress Estimated coverage 20% inpatients ; All hospitals have “VTE team”; Moves to sustainable process monitoring; Range of achievement

5. 2010 aim – generate a “sense of urgency” Visit by NHS experts February 2010 Created WA VTE Prevention Network - 3 meetings, evolving interprofessional community of practice –“bring outside in” (Kotter) –Share ideas, experiences, learnings –Generate stories and new ideas –Generate data and talk about it in a meaningful way

6. Ideas progressing / testing NIMC risk assessment and mechanical prophylaxis prescription incorporation “signal” event investigation State VTE prevention policy State risk assessment tool Craft group – specific prophylaxis guidelines ?via Clinical Networks / professional Investigating value of coded data Talking to RFDS for country patient transfer diagnoses

7. Estimating Iatrogenic VTE Burden WA UK 12 000 000 adult admissions; 311 000 inpatient VTE in untreated pts; 124 400 deaths/yr in untreated pts (UK Parliamentary Report) WA 400 000 adult admissions; 10 366 inpatient VTE in untreated pts; 4 146 deaths/yr in untreated pts Est. 25 VTE untreated pts / 1000 separations

8. Iatrogenic VTE Incidence - Literature Gallagher et al (2009): 2.57 cases / 1000 CWS http://qshc.bmj.com/content/18/5/408.full http://qshc.bmj.com/content/18/5/408.full Leibson et al (2008): 2.59 / 1000 ‘encounters’ http://journals.lww.com/lww- medicalcare/Abstract/2008/02000/Identifying_In_Hospital_Venous_Thromboembolism.5.aspx

9. VTE Incidence Data WA Request to Epidemiology Branch for 3 years’ VTE morbidity and mortality data ICD-10-AM codes (based Access Economics study 2008) COF (c-prefix) not used (WA: since July 2008) Aims: –Gauge extent of incidence and burden – ‘URGENCY’ –Validate VTE coding sensitivity & specificity (case note r/v, radiology, RFDS) –Calculate extended LOS and additional cost of VTE

10. Codes (preliminary list) WA DoH RequestAccess Economics Study 2008 I26 pulmonary Embolism I26.0 pulmonary Embolism with mention of acute cor pulmonale I26.8 iatrogenic pulmonary embolism I26.9 pulmonary Embolism without mention of acute cor pulmonale I63.1 cerebral infarction due to embolism of pre-cerebral arteries I63.4 cerebral infarction due to embolism of cerebral arteries I74 arterial embolism and thrombosis I80.2 deep vein thrombosis not otherwise specified I80.3 embolism or thrombosis of lower extremity I82.2 embolism and thrombosis of vena cava I82.3 embolism and thrombosis of renal vein I82.8 embolism and thrombosis of other specified veins I82.9 embolism and thrombosis of unspecified vein I26 pulmonary Embolism I26.0 pulmonary Embolism with mention of acute cor pulmonale I26.8 iatrogenic pulmonary embolism I26.9 pulmonary Embolism without mention of acute cor pulmonale I63.1 cerebral infarction due to embolism of pre-cerebral arteries I63.4 cerebral infarction due to embolism of cerebral arteries I74 arterial embolism and thrombosis I82 other venous embolism and thrombosis I82.2 embolism and thrombosis of vena cava I82.3 embolism and thrombosis of renal vein I82.8 embolism and thrombosis of other specified veins I82.9 embolism and thrombosis of unspecified vein

11. Preliminary Administrative Data Extract WA Area Health Service; July 2009 – March 2010 Total separations ~ 147,000 ICD-10-AM codes from prev. slide COF* 1 & 2 = 832 cases (5.6 per 1000 separations) Est. 50% healthcare associated = 416 (2.8 / 1000 seps) COF 1 only = 107 cases * see next 2 slides for definitions

12. Condition onset Flag (COF) http://meteor.aihw.gov.au/content/index.phtml/itemId/354816 COF 1 Condition with onset during the episode of admitted patient care a condition which arises during the episode of admitted patient care and would not have been present on admission Includes: –Conditions resulting from misadventure during medical or surgical care during the episode of admitted patient care. –Abnormal reactions to, or later complication of, surgical or medical care arising during the episode of admitted patient care. –Conditions arising during the episode of admitted patient care not related to surgical or medical care (for example, pneumonia).

13. COF 2 Condition not noted as arising during the episode of admitted patient care a condition present on admission such as the presenting problem, a comorbidity, chronic disease or disease status. a previously existing condition not diagnosed until the episode of admitted patient care. Includes: –In the case of neonates, the conditions present at birth. –A previously existing condition that is exacerbated during the episode of admitted patient care. –Conditions that are suspected at the time of admission and subsequently confirmed during the episode of admitted patient care. –Conditions that were not diagnosed at the time of admission but clearly did not develop after admission (for example malignant neoplasm). –Conditions where the onset relative to the beginning of the episode of admitted patient care is unclear or unknown.

14. COF 1 & 2 dataset (n=832)

15. Follow-up work to assess utility of admin data sources Larger data set pending Case note review validation –Sample of code – positive and code-negative records

17. COF 1 dataset (n=107)