1. Preventing Hospital-Acquired Venous Thromboembolism AHRQ Annual Meeting September 20, 2011 Vicky Agramonte, RN, MSN Project Manager QIO Learning Network

2. Preventing H-A VTE Toolkit Focuses on the basics of quality improvement Focuses on the basics of quality improvement Physician driven QI effort Physician driven QI effort Though development of VTE risk assessment and order sets, preventable H-A VTEs have dropped Though development of VTE risk assessment and order sets, preventable H-A VTEs have dropped Developed based on the research of Dr. Gregory Maynard, in association with the Society of Hospital Medicine Developed based on the research of Dr. Gregory Maynard, in association with the Society of Hospital Medicine

3. VTE Toolkit Comprehensive guide that focuses on the basics of quality improvement Comprehensive guide that focuses on the basics of quality improvement Step-by-step instructions on the development and implementation of an improved VTE prevention protocol Step-by-step instructions on the development and implementation of an improved VTE prevention protocol Hierarchy of Reliability Hierarchy of Reliability Provides sample VTE protocol Provides sample VTE protocol – 3–bucket risk assessment (low, moderate, and high risk) – Sample order set Measurement strategy for continuous improvement Measurement strategy for continuous improvement Protocol = Risk assessment and corresponding order set of pharmacological agents and/or mechanical prophylaxis

4. Toolkit Applicability VTE toolkit is usable in varying provider settings VTE toolkit is usable in varying provider settings – Large hospital settings – Smaller community hospitals – Critical Access Hospitals Usable toolkit for providers that are: Usable toolkit for providers that are: – Have EHR – Paper medical record – Hybrid (both EHR and paper)

5. VTE Toolkit Contents Taking the Essential First Steps Taking the Essential First Steps Laying Out the Evidence and Identify Best Practices Laying Out the Evidence and Identify Best Practices Analyzing Care Delivery Analyzing Care Delivery Tracking Performance with Metrics Tracking Performance with Metrics Layering Interventions Layering Interventions Continuing to Improve Continuing to Improve

6. VTE Toolkit Layer Interventions The VTE protocol serves as the main intervention and focal point for the improvement project The VTE protocol serves as the main intervention and focal point for the improvement project – Keep the protocol simple – Do not interrupt workflow – Design reliability into the process – Pilot interventions on a small scale before attempting wide scale implementation – Monitor use of the protocol Protocol = Risk assessment and corresponding order set of pharmacological agents and/or mechanical prophylaxis

7. Complex VTE Order Set

8. Simple VTE Order Set

9. Simple Order Set

10. Hierarchy of Reliability

11. Situational Awareness and “Measure-vention”- Getting to 95% Identify patients on no anticoagulation Identify patients on no anticoagulation Empower nurses to place mechanical prophylaxis Empower nurses to place mechanical prophylaxis Contact MD if no anticoagulant in place and no obvious contraindication Contact MD if no anticoagulant in place and no obvious contraindication – Template note, text page, etc Back up these interventions Back up these interventions – Physicians can not “shoot the messenger” Maynard G, Stein J. Designing and Implementing Effective VTE Prevention Protocols: Lessons from Collaboratives. J Thromb Thrombolysis 2010 Feb:29(2):159-166.

12. Making the Right Thing to do… …the easy thing to do: …the easy thing to do: – The desired action is the default action (i.e., not doing the desired action requires opting out) – The desired action is prompted by a reminder or a decision aide. – The desired action is standardized into a process – The desired action is scheduled to occur at known intervals – Responsibilities for desired action are redundant – If designed well, the VTE protocol will be an intervention

13. Levels of Risk DVT Risk Without Prophylaxis Suggested Options Low risk Mobile minor surgery patients Fully mobile medical patients <10 % No specific thromboprophylaxis Early and “aggressive” ambulation Moderate risk Most general, open gynecologic or urologic surgery CHF COPD, pneumonia Medically Ill 10-40% LMWH, UFH tid > bid, or fondaparinux High risk Hip or knee arthroplasty, HFS Major trauma, SCI Abdominal/pelvic cancer surgery 40-80% LMWH, fondaparinux, VKA (INR 2-3) Mechanical prophylaxis may be used if risk of bleeding is high; switch to anticoagulants when risk decreases VTE Levels of Risk Adapted from Geerts WH, et al. Chest. 2008;133:381S-453S.

14. ACCP VTE Prophylaxis Guidelines 8 th Edition 1. Every hospital should develop formal strategy to prevent VTE 2. Do not use aspirin alone for prophylaxis 3. Use mechanical prophylaxis primarily for patients at high bleeding risk or as an adjunct to pharmacologic prophylaxis 4. Give thromboprophylaxis for – Major trauma – Spinal cord injury – Acute medical illness – Most ICU patients – Moderate and high risk surgery Geerts WH, et al. Chest. 2008;133:381S-453S.

15. “Patients without risk factors for VTE are called outpatients.” G. Maynard (2010)

16. VTE Prophylaxis Effective, Safe, and Cost-Effective Pharmacologic prophylaxis substantially reduces the risk for VTE Pharmacologic prophylaxis substantially reduces the risk for VTE – Symptomatic and asymptomatic VTE reduced Bleeding complications are rare Bleeding complications are rare HIT is a serious complication of heparin therapy HIT is a serious complication of heparin therapy Cost-effectiveness of VTE prophylaxis well documented Cost-effectiveness of VTE prophylaxis well documented

17. Barriers to Reducing VTE Risk Belief that VTE incidence has declined Belief that VTE incidence has declined VTE not perceived as important VTE not perceived as important Lack of familiarity with guidelines Lack of familiarity with guidelines Underestimation of thrombotic risk Underestimation of thrombotic risk Overestimation of bleeding risk Overestimation of bleeding risk Translation of complicated guidance into simple orders Translation of complicated guidance into simple orders Institutional / structural Institutional / structural

18. Barriers to Reducing VTE Risk Implementation of protocol is flawed Implementation of protocol is flawed Order set not user friendly Order set not user friendly Process creates duplicate work for physicians Process creates duplicate work for physicians Protocol does not fit individual patient Protocol does not fit individual patient Competing order sets Competing order sets

19. VTE Impact Case Study Year 1 Provider Madison Memorial Hospital (MMH) in Rexburg, Idaho developed and implemented a standardized VTE protocol for all hospital admissions based on the recommendations presented in the toolkit. VTE incidence of hospital-associated VTE per 1000 patient days has decreased from a rate of 1.30 to 0.18, an 86% relative improvement, between baseline (4/09-2/10) and remeasurement periods (3/10-11/10). According to team leaders, there also has been significant qualitative impact to their hospital culture and quality performance as a result of the changes made to the VTE protocol: they have implemented the first standardized best practice protocol.

20. VTE Impact Case Study Year 2 Provider A New Mexico hospital entered the project without a VTE protocol in place. As a result of participating in the project, the facility developed a protocol consistent with the toolkit to include a three-level risk-stratified assessment linked to treatment options. The hospital aggressively pursued improvement of its VTE protocol by developing, approving, and implementing a new VTE protocol hospital-wide in less than one month after attending the initial learning session. As a result, compliance with physician use of the protocol is 100 percent, with prevalence of appropriate VTE prophylaxis increasing from 33 to 75 percent between March and July 2011. The facility is now implementing “measure-vention”— concurrent review and interventions of patients in real time--to continue to foster improvement in the prevalence of appropriate VTE prophylaxis.

21. VTE Impact Case Study Year 2 Provider When Memorial Health Care Systems in Seward, Nebraska began the collaborative, Hank Newburn, MD, Family Practice Physician explains, “When we joined the VTE Collaboration in February 2011 Memorial Health Care Systems did not have a risk assessment tool, or protocols for interventions in place. We completed the risk assessment tool which models Dr. Gregory Maynard’s recommendations. Since the inception of the project, we have realized a 5% increase in VTE prophylaxis due to heightening the awareness. I anticipate a significant percentage increase after implementation due to the availability of a consistent risk assessment process, and protocols for interventions. This project has provided great direction for the development of our VTE tools, which will aid us in providing best practice for VTE prophylaxis consistently, promoting increased safety for our patients.”

22. Key Points Expert Recommendations VTE protocols embedded in order sets VTE protocols embedded in order sets Simple risk stratification schema, based on VTE-risk groups (2-3 levels of risk should do it) Simple risk stratification schema, based on VTE-risk groups (2-3 levels of risk should do it) Institution-wide if possible (a few carve outs ok) Institution-wide if possible (a few carve outs ok) Local modification is OK Local modification is OK – Details in gray areas not that important Use “measure-vention” to accelerate improvement Use “measure-vention” to accelerate improvement Maynard G, Stein J. Designing and Implementing Effective VTE Prevention Protocols: Lessons from Collaboratives. J Thromb Thrombolysis 2010 Feb:29(2):159-166.

23. Collaborative Efforts AHRQ / QIO (NY, IL, IA) - 40 sites AHRQ / QIO (NY, IL, IA) - 40 sites AHRQ / QIO 2 and AHRQ / QIO 3 - 33 & 28 sites AHRQ / QIO 2 and AHRQ / QIO 3 - 33 & 28 sites ASHP Advantage collaborative - 6 sites ASHP Advantage collaborative - 6 sites CHW with CIIS - 2 sites CHW with CIIS - 2 sites IHI Expedition for VTE Prevention - 50 sites IHI Expedition for VTE Prevention - 50 sites SHM VTE Prevention Collaborative I - 25 sites SHM VTE Prevention Collaborative I - 25 sites SHM VTE Prevention Collaborative III - 30 sites SHM VTE Prevention Collaborative III - 30 sites SHM / VA Pilot Group - 6 sites PLUS SHM / VA Pilot Group - 6 sites PLUS SHM / Cerner Pilot Group - 6 sites SHM / Cerner Pilot Group - 6 sites Vancouver Hospital Medicine - 25 sites Vancouver Hospital Medicine - 25 sites

24. QIO Learning Network Activity

25. Resources Preventing HA VTE- a guide for effective quality improvement http://www.ahrq.gov/QUAL/vtgui de/ Preventing HA VTE- a guide for effective quality improvement http://www.ahrq.gov/QUAL/vtgui de/ http://www.ahrq.gov/QUAL/vtgui de/ http://www.ahrq.gov/QUAL/vtgui de/ Society of Hospital Medicine VTE Collaborative http://www.hospitalmedicine.org Society of Hospital Medicine VTE Collaborative http://www.hospitalmedicine.org http://www.hospitalmedicine.org

26. Reference 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 http://www.ahrq.gov/qual/vtguide/. http://www.ahrq.gov/qual/vtguide/ Society of Hospital Medicine: http://www.hospitalmedicine.org http://www.hospitalmedicine.org Maynard G, Stein J. Designing and Implementing Effective VTE Prevention Protocols: Lessons from Collaboratives. J Thromb Thrombolysis 2010 Feb:29(2):159-166. Geerts et al. Prevention of Venous Thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest June 2008 133:381S453S; 10.1378/chest.08-0656

27. Contact Information AHRQ QIO Learning Network Project Team Vicky Agramonte, RN, MSN Project Manager IPRO AHRQ QIO Learning Network 518-426-3300 or 1-800-233- 0360 Ext.115 vagramonte@ipro.org Sheryl Ruhland Contract Coordinator IPRO AHRQ QIO Learning Network 518-426-3300 or 1-800-233- 0360 Ext.114 sruhland@ipro.org