1. Reducing Hospital-Acquired Venous Thromboembolisms (VTE): Interventions That Work Wednesday, September 16, 2009 8:00 am - 9:30 am AHRQ Annual Conference Bethesda North Marriott Rockville, Maryland

2. Preventing VTEs Web Conference Series Partners: Partners: – Agency for Healthcare Research and Quality – IPRO – Illinois Foundation for Quality Health Care – Iowa Foundation for Medical Care Subject matter expert: Subject matter expert: – Dr. Greg Maynard, Univ. of California San Diego Tool: Tool: – AHRQ Preventing VTEs in the Hospital Toolkit Duration: Duration: – 7 Web conferences from Sept. 2008 to May 2009

3. Web Conference Series Overview Approach Approach – 7 interactive Web conferences with participating hospitals Several featured expert review of draft protocol Several featured expert review of draft protocol – Assignments between Web conferences Identify physician champion, Identify physician champion, Audit VTE prophylaxis rates Audit VTE prophylaxis rates Changes in protocol Changes in protocol – 1 additional “train-the-trainer” event for QIO staff 44 hospitals participated (at least 3 events) 44 hospitals participated (at least 3 events) – Iowa: 12 hospitals – Illinois: 14 hospitals – New York: 18 hospitals

4. Early Results Outreach to hospitals to gauge impact is ongoing Outreach to hospitals to gauge impact is ongoing To date, out of 32 hospitals queried: To date, out of 32 hospitals queried: – 19 revised existing protocols – 5 developed a new protocol (did not have an existing protocol) Of the 24 new/revised protocols: Of the 24 new/revised protocols: – 15 have passed all stages of hospital review – 9 have been implemented (others expected to be implemented by end of year)

5. Reducing Hospital-Acquired Venous Thromboembolisms (VTE): Interventions That Work Greg Maynard MD, MSc Clinical Professor of Medicine and Chief, Division of Hospital Medicine University of California, San Diego

6. VTE: A Major Source of Mortality and Morbidity 350,000 to 650,000 with VTE per year 350,000 to 650,000 with VTE per year 100,000 to > 200,000 deaths per year 100,000 to > 200,000 deaths per year Most are hospital related Most are hospital related VTE is primary cause of fatality in half- VTE is primary cause of fatality in half- – More than HIV, motor vehicle accidents, breast cancer combined – Equals 1 jumbo jet crash / day 10% of hospital deaths 10% of hospital deaths – May be the #1 preventable cause Huge costs and morbidity (recurrence, post- thrombotic syndrome, chronic PAH) Huge costs and morbidity (recurrence, post- thrombotic syndrome, chronic PAH) Surgeon General’s Call to Action to Prevent DVT and PE 2008 DHHS

7. Risk Factors for VTE Stasis Age > 40 ImmobilityCHFStrokeParalysis Spinal Cord injury HyperviscosityPolycythemia Severe COPD AnesthesiaObesity Varicose Veins HypercoagulabilityCancer High estrogen states Inflammatory Bowel Nephrotic Syndrome SepsisSmokingPregnancyThrombophilia Endothelial Damage Surgery Prior VTE Central lines Trauma Anderson FA Jr. & Wheeler HB. Clin Chest Med 1995;16:235.

8. Risk Factors for VTE Stasis Age > 40 ImmobilityCHFStrokeParalysis Spinal Cord injury HyperviscosityPolycythemia Severe COPD AnesthesiaObesity Varicose Veins HypercoagulabilityCancer High estrogen states Inflammatory Bowel Nephrotic Syndrome SepsisSmokingPregnancyThrombophilia 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

9. ENDORSE Results Out of ~70,000 patients in 358 hospitals, appropriate prophylaxis was administered in: 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.

10. The “Stick” is coming…. National Quality Forum endorses measures already National Quality Forum endorses measures already Public reporting and TJC measures coming soon: 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 Centers for Medicare & Medicaid Services (CMS) – deep vein thrombosis (DVT) or pulmonary embolism (PE) with knee or hip replacement reimbursed as though complication had not occurred Centers for Medicare & Medicaid Services (CMS) – deep vein thrombosis (DVT) or pulmonary embolism (PE) with knee or hip replacement reimbursed as though complication had not occurred

11. 2005 AHRQ Grant 2005 – AHRQ grant to: 2005 – AHRQ grant to: – Design and implement VTE prevention protocol – Monitor impact on VTE prophylaxis and hospital- acquired (HA) VTE – Validate a VTE risk assessment model / protocol Attempt to use portable methodology, build toolkit to allow others to accomplish the same thing Attempt to use portable methodology, build toolkit to allow others to accomplish the same thing

12. Percent of Randomly Sampled Inpatients with Adequate VTE Prophylaxis 12 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

13. UCSD – Decrease in Patients with Preventatble HA VTE 13 Level 5 Oversights identified and addressed in real time 95+%

14. UCSD VTE Protocol Validated Easy to use, on direct observation – a few seconds Easy to use, on direct observation – a few seconds Inter-observer agreement – Inter-observer agreement – – 150 patients, 5 observers- Kappa 0.8 and 0.9 Predictive of VTE Predictive of VTE Implementation = high levels of VTE prophylaxis 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 Safe – no discernible increase in HIT or bleeding Effective – 40% reduction in HA VTE Effective – 40% reduction in HA VTE – 86% reduction in risk of preventable VTE

15. http://ahrq.hhs.gov/qual/vtguide/ http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_VTE/VTE_Home.cfm VTE Prevention Guides

16. VTE QI Resource Room www.hospitalmedicine.org

17. Collaborative Efforts and Kudos SHM VTE Prevention Collaborative I - 25 sites SHM VTE Prevention Collaborative I - 25 sites SHM / VA Pilot Group - 6 sites SHM / VA Pilot Group - 6 sites SHM / Cerner Pilot Group – 6 sites SHM / Cerner Pilot Group – 6 sites AHRQ / QIO (NY, IL, IA) - 44 sites AHRQ / QIO (NY, IL, IA) - 44 sites IHI Expedition to Prevent VTE – 60 sites IHI Expedition to Prevent VTE – 60 sites SHM Team Improvement Award SHM Team Improvement Award NAPH Safety Net Award (Honorable Mention) NAPH Safety Net Award (Honorable Mention) Venous Disease Coalition Venous Disease Coalition

18. To Achieve Improvement Real institutional support / prioritization Real institutional support / prioritization Will to standardize Will to standardize Physician leadership Physician leadership Measurement of process / outcomes Measurement of process / outcomes Protocol, integrated into order sets Protocol, integrated into order sets Education Education Continued refinement / tweaking - PDSA Continued refinement / tweaking - PDSA SHM and AHRQ Guides on VTE Prevention

19. The Essential First Intervention 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 19 VTE Protocol

20. Hierarchy of Reliability Level Predicted Prophylaxis Rate 1 No protocol* (“State of Nature”) 40% 2 Decision support exists but not linked to order writing, or prompts within orders but no decision support 50% 3 Protocol well-integrated (into orders at point-of-care) 65%-85% 4 Protocol enhanced (by other quality improvement / high reliability strategies) 90% 5 Oversights identified and addressed in real time 95+% * Protocol = standardized decision support, nested within an order set, i.e. what/when

21. Map to Reach Level 3 Map to Reach Level 3 Implementing an Effective VTE Prevention Protocol Examine existing admit, transfer, perioperative order sets with reference to VTE prophylaxis Examine existing admit, transfer, perioperative order sets with reference to VTE prophylaxis Design a protocol-driven DVT prophylaxis order set (with integrated risk assessment model [RAM]) Design a protocol-driven DVT prophylaxis order set (with integrated risk assessment model [RAM]) Vet / Pilot – Plan Do Study Act (PDSA) Vet / Pilot – Plan Do Study Act (PDSA) Educate / consensus building Educate / consensus building Place new standardized DVT order set ‘module’ into all pertinent admit, transfer, periop order sets Place new standardized DVT order set ‘module’ into all pertinent admit, transfer, periop order sets Monitor, tweak - PDSA Monitor, tweak - PDSA

22. Too Little Guidance Prompt ≠ Protocol DVT Prophylaxis Orders  Anti thromboembolism Stockings  Sequential Compression Devices (SCD)  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

23. Most Common Mistakes in VTE Prevention Orders Point based risk assessment model Point based risk assessment model Improper balance of guidance / ease of use 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 Failure to revise old order sets Too many categories of risk Too many categories of risk Allowing non-pharmacologic prophylaxis too much Allowing non-pharmacologic prophylaxis too much Failure to pilot, revise, monitor Failure to pilot, revise, monitor Linkage between risk level and prophylaxis choices are separated in time or space Linkage between risk level and prophylaxis choices are separated in time or space

24. 24 Is your order set in a competition?

25. 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 75 or weight <50 kg)LMWH Enox 40 mg q day Enox 40 mg q day Other LMWH 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 25 IPC needed if contraindication to AC exists Example from UCSD Keep it Simple – A “3 bucket” model

26. Hierarchy of Reliability Level Predicted Prophylaxis Rate 1 No protocol* (“State of Nature”) 40% 2 Decision support exists but not linked to order writing, or prompts within orders but no decision support 50% 3 Protocol well-integrated (into orders at point-of-care) 65%-85% 4 Protocol enhanced (by other quality improvement / high reliability strategies) 90% 5 Oversights identified and addressed in real time 95+% * Protocol = standardized decision support, nested within an order set, i.e. what/when

27. Map to Reach Level 5 95+ % prophylaxis Use MAR or Automated Reports to classify all patients on the unit as being in one of three zones: 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!

28. Situational Awareness and Measure-vention: Getting to Level 5 Identify patients on no anticoagulation Identify patients on no anticoagulation Empower nurses to place SCDs in patients on no prophylaxis as standing order (if no contraindications) 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 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” Need administration to back up these interventions and make it clear that docs can not “shoot the messenger”

29. Summary of Key Strategies Basic Building Blocks Basic Building Blocks – Institutional support, team, education, protocol, metrics, PDSA Physician performs VTE risk assessment within easy to use order sets, which captures all admits / transfers Physician performs VTE risk assessment within easy to use order sets, which captures all admits / transfers Active monitoring for non-adherents to protocol, intervene in real time Active monitoring for non-adherents to protocol, intervene in real time

30. Questions?

31. Reducing Hospital-Acquired Venous Thromboembolisms (VTE): Interventions That Work Lisa Clark, RN, BSN Clinical Reviewer Performance Improvement Department Catskill Regional Medical Center Harris, New York

32. How did we know that we had a problem? Existing in-house committee to review VTE issues chaired by MD champion Existing in-house committee to review VTE issues chaired by MD champion Recognized need for house-wide protocol to promote more uniform practice Recognized need for house-wide protocol to promote more uniform practice Sought to reduce physician confusion and clarify prophylaxis needs Sought to reduce physician confusion and clarify prophylaxis needs

33. What do we aim to do about it? What is our goal? What is our goal? – To achieve adequate universal prophylaxis by risk factors / orders to promote patient safety What are we doing to get there? What are we doing to get there? – Protocol revision, continue to build institutional support for universal prophylaxis, look to other options besides education

34. How has our VTE prevention protocol changed? Changes in Protocol Changes in Protocol – Before: Our facility set out to make it the most inclusive best point -based protocol ever to cover ALL ANGLES of VTE prophylaxis Our facility set out to make it the most inclusive best point -based protocol ever to cover ALL ANGLES of VTE prophylaxis End product was experience with a move to a different protocol End product was experience with a move to a different protocol – After: Found it was too busy and difficult to use Found it was too busy and difficult to use Streamlining is the key !!! Streamlining is the key !!! Formatted more to look like usual order set Formatted more to look like usual order set

35. Old VTE prevention protocol

36. New VTE Prevention protocol

37. What other changes are we making? Changes in Measurement Changes in Measurement – Before: Monthly retroactive review of those coming up with a diagnosis of DVT/PE and sent letters to MDs who fell out. – After: D o daily real time reviews for orders and have started to make calls as well. D o daily real time reviews for orders and have started to make calls as well. Other Process Changes Other Process Changes – Before: No protocol at all No protocol at all – After: Protocol revised and in place Protocol revised and in place

38. Where are we in the process of implementation? Stage of Implementation Stage of Implementation – Revise orthopedic protocol – Change format of ongoing protocol to a carbonated form with more emphasis on chart flow as currently a stand alone Implementation Team Implementation Team – Multidisciplinary with Staff Development, MDs, PI, Nursing, Dietary and Pharmacy

39. Are we making progress?

40. What were our challenges and how did we overcome them? Protocol revision Protocol revision Increased buy-in Increased buy-in Orthopedic more on board with ordering Orthopedic more on board with ordering More physician awareness with order writing once protocol was out More physician awareness with order writing once protocol was out

41. Biggest revelations? Introduction of the new orders spurred MDs to order prophylaxis even if they wrote their own orders Introduction of the new orders spurred MDs to order prophylaxis even if they wrote their own orders Need to promote the orders for risk factor choices but 1:1 intervention very helpful Need to promote the orders for risk factor choices but 1:1 intervention very helpful Education of various groups despite best efforts is not enough Education of various groups despite best efforts is not enough

42. In retrospect, what would we do differently? Initiate 1:1 intervention sooner Initiate 1:1 intervention sooner Discover a more effective way to incorporate the stand alone order set in your process Discover a more effective way to incorporate the stand alone order set in your process Identify your champion group early and engage them as much as possible (e.g., hospitalists) Identify your champion group early and engage them as much as possible (e.g., hospitalists)

43. Reducing Hospital-Acquired Venous Thromboembolisms: Interventions That Work Marcia Kruse, RN, BA, CPHQ Director Case Management Fort Madison Community Hospital Fort Madison, Iowa

44. FMCH’s Journey Journey began in 2005 Journey began in 2005 Iowa Hospitals – 113 out of 116 (97%) were involved in a Survey of the National Quality Forum 30 Safe Practices-aimed at measuring Iowa hospital’s engagement in implementing strategies endorsed by NQF Iowa Hospitals – 113 out of 116 (97%) were involved in a Survey of the National Quality Forum 30 Safe Practices-aimed at measuring Iowa hospital’s engagement in implementing strategies endorsed by NQF Sponsored by Iowa Healthcare Collaborative and Texas Medical Institute of Technology Sponsored by Iowa Healthcare Collaborative and Texas Medical Institute of Technology Risk assessment and appropriate prophylaxis for VTE was one of the safe practices Risk assessment and appropriate prophylaxis for VTE was one of the safe practices

45. How did we know that we had a problem? Listened to the first webinar Listened to the first webinar Decided we were way ahead of the game Decided we were way ahead of the game Later QIO petitioned hospitals for data- I sent ours! Later QIO petitioned hospitals for data- I sent ours! QIO asked for protocol and asked if they could share with Dr. Maynard QIO asked for protocol and asked if they could share with Dr. Maynard

46. What did we aim to do about it? What was our goal? What was our goal? – To revise current protocol, simplify the process, physician driven What did we do to get there? What did we do to get there? – Discussed with Chief of Adult Medicine – Slide presentation to our Adult Medicine Committee – Revised Risk Assessment/Protocol and implemented June 1st – Placed on all admissions-flagged – To be completed in 24 hours

47. Moving on… Risk Assessment/Orders taken to Surgery Committee Risk Assessment/Orders taken to Surgery Committee Post op VTE prophylaxis is embedded in post op order sets Post op VTE prophylaxis is embedded in post op order sets Voted to use the new forms – box checked when already ordered Voted to use the new forms – box checked when already ordered

48. How has our VTE prevention protocol changed? Changes in Protocol Changes in Protocol – Before: Nurses completed the assessment on line and auto printed for physicians to complete Nurses completed the assessment on line and auto printed for physicians to complete Auto scored by point system Auto scored by point system complicated order set complicated order set – After: Simple risk groups - Low, Medium and High Simple risk groups - Low, Medium and High Response to risk level and contraindications drive default choices Response to risk level and contraindications drive default choices

49. Lots of Choices-Old Version

50. New Version-Simplified

51. What other changes are we making? Changes in Measurement Changes in Measurement – Monitored quarterly in past-random records – Reported to Adult Med Committee – Monitors showed good compliance – Basically monitored if the form was signed-not appropriateness – Did not do metrics for DVT, PE incidence New monitors New monitors – Baseline determined-on appropriate orders – Weekly, now monthly-watch for appropriate orders

52. Monitors for Old Version

53. New Monitor

54. Barriers Occasionally form not available Occasionally form not available Risk not assessed appropriately Risk not assessed appropriately Form not completed accurately Form not completed accurately

55. What is Next?? Post op DVT/PE already go to MSQRC Post op DVT/PE already go to MSQRC Hospital Acquired will go to MSQRC? Hospital Acquired will go to MSQRC? Address at peer review level those doctors not using form appropriately Address at peer review level those doctors not using form appropriately Investigate ER Doctors/Clinical Pharmacist initiating orders Investigate ER Doctors/Clinical Pharmacist initiating orders Monitor incidence of hospital acquired VTE/PE Monitor incidence of hospital acquired VTE/PE

56. Next Steps Monitoring implementation Monitoring implementation Continued support through QIOs on: Continued support through QIOs on: – Protocol development – Measurement – Identifying physician champion – Securing buy-in from administration, surgeons/physicians, nurses, others

57. Q&A Panelists Panelists – Denise Faulkner-Cameron, IPRO – Greg Maynard, UCSD – Lisa Clark, Catskill Regional Medical Center – Marcia Kruse, Fort Madison Community Hospital