1. The Clot Free Journey Margaret Burns RN, PhD, VP of Patient Services Valley Regional Hospital

2. About Valley Regional Hospital (Subsidiary of Valley Regional Healthcare, Inc.) 25-bed Critical Access hospital located in Claremont, NH, near Vermont border and 35 miles south of DHMC Only hospital located in Sullivan County The only Critical Access Hospital in New Hampshire accredited by The Joint Commission Medical/Surgical Unit; Critical Care Unit; Swing Beds; Emergency Department; Surgical Services; Connecticut Valley Homecare, Hospice, and Day Out Program; Hospital-Owned Practices (primary care, internal medicine, urology, gynecology, orthopedics, general surgery, pediatrics). On-site DHMC Oncology, Cardiology, and Midwifery Practices Pathologists and Radiologists provide specialty services to 4 area hospitals Hospitalist coverage expanded to seven days per week Telemedicine and E-Pharm Pro provide radiology and pharmacy services at night and on weekends 2

3. What Did We Test? Do we provide appropriate VTE prophylaxis for selected patients? During implementation of the EMR, there are several sets of VTE orders. Are physicians utilizing the admitting order set, standing order set, or writing a separate order for VTE? Are physicians documenting reasons for not ordering VTE prophylaxis or are reasons implied (patient is ambulatory, therapeutic on warfarin, or gi bleeding) Do we utilize the NH QA Commission definition for timing (day of or day after admission) versus within 24-hour definition? 3

4. VTE Prophylaxis is routinely considered and administered for all patients. All staff members made a good faith effort to implement the protocol. The timing for VTE prophylaxis can be extended to the day of or day after admission (instead of a more stringent 24-hr timeline) Early Data collection was unorganized, as we reviewed charts for documented reasons for not having VTE ordered, those patients for whom we could imply a reason (ambulatory, therapeutic on Warfarin or with bleeding) would be considered compliant. This created excellent initial results. Double check systems work better than relying solely on the physician to order VTE prophylaxis (standing orders, nurse reminders, retrospective peer review) The nurses had to remind physicians to order VTE prophylaxis initially and physicians would push back It’s burdensome to learn a new EMR and implement the VTE protocol at the same time The Chief Medical Officer is helpful in reinforcing VTE prophylaxis documentation with the medical staff (one-on-one and at staff meetings) NH Quality Commission Toolkit was useful and persuasive in jump-starting the internal hospital work on VTE What Have We Learned So Far? 4

5. What Barriers Did We Encounter? VRH EMR went live on the same day as data collection began for the NH Quality Assurance Initiative. There was no Standard VTE order built in to the new EMR to assist in data collection. Physicians continued to address VTE by ordering prophylaxis if needed, but rarely documented the reason for not ordering. When asked to document reason for exclusion, some felt it was an added and unnecessary burden. Confusion about the timing of VTE (24 hrs. vs. day of admission or day after) A new Hospitalist started in April 2012 and missed occasional opportunities to provide prophylaxis. This caused a drop in our rate of compliance. 5

6. How Did We Overcome These Barriers? VTE orders were added to a Standard Admission order set that included pharmacologic options and reasons for not ordering VTE prophylaxis. MDs were updated in Medical staff meetings about the order sets and agreed to use them. Data collection was simplified and scrutinized more carefully by the QI Coordinator. Routine reporting to the Quality Improvement Patient Safety Committee and Board of Trustees kept us accountable. CMO participation in keeping new members of the medical staff informed was key to improving compliance. 6

7. How Are We Doing Now? 7 There have been no documented, potentially preventable VTE at VRH since data collection began October 1 2011. O c t- 1 1 53/5353/53 10 0 % Nov-11Nov-11 54/5454/54 Jan-12Jan-12 43/4343/43 Feb-12Feb-12 43/4343/43 M a r- 1 2 42/4342/43 98 % A p r- 1 2 64/6764/67 96 % May-12May-12 56/5756/57 98 % Jun-12Jun-12 62/6662/66 94 % Rate of Prophylaxis Oct-1153/53100% Nov-1154/54100% Dec-1153/5498% Jan-1243/43100% Feb-1243/43100% Mar-1242/4398% Apr-1264/6796% May-1256/5798% Jun-1262/6694%

8. What Can Others Learn From Our Journey? New initiatives need to be continuously supported and guided by leadership and quality improvement coach(es) When evidence-based literature is provided, change comes more easily – people want to do the right thing for the patient! Successes and failures are magnified in critical access hospitals due to low numbers 8

9. 9 Do Not Try This At Home (Suggestions for What Not to Do…) Installing an new EMR at the same time as a new initiative Implementing the initiative alone -- nursing, medical staff, quality improvement, and state- wide initiatives are team-based and more effective

10. 10 Questions?