1. Hospital-Acquired VTE: What We Have Learned Martha J. Radford, MD Chief Quality Officer NYU Langone Medical Center September 2009

2. VTE Prevention in the USA 2005 2006 2007 2008 2009 2010 SCIP Measures SCIP on Intranet POAHAC Chest Guidelines Ortho Guidelines AHRQ PSIs

3. VTE Prevention in the USA 2005 2006 2007 2008 2009 2010 SCIP Measures SCIP on Intranet POAHAC Chest Guidelines Ortho Guidelines AHRQ PSIs AHRQ Validation

4. VTE Prevention at NYULMC 2005 2006 2007 2008 2009 2010 SCIP Measures SCIP on Intranet POAHAC Chest Guidelines Ortho Guidelines AHRQ PSIs Internal SCIP SCIP VTE in P4P 2010 Goal: No Preventable VTE VTE Prophy in CPOE Dept VTE Standards HAC Review

5. We Learned from AHRQ Validation: Our Coding Needs Improvement Of the 17 2006 VTE PSI cases we reviewed for the AHRQ validation study, our coding was incorrect for 5 (29%). This began a focus on VTE coding quality that continues today. The appearance of VTE following ortho procedures as a HAC has solidified the need for accurate VTE coding.

6. NYULMC VTE Coding Accuracy

7. Coding Errors at NYULMC One fourth to one third: no evidence for VTE Two thirds to three fourths: VTE was present on admission – If date of study demonstrating VTE was after the date of admission, VTE not coded as “present on admission”.

8. Coding Interventions at NYULMC Outreach to coders about impact of their coding on quality and safety assessment. Ongoing feedback to coders about coding errors Organizational focus on clinical documentation, clinical documentation specialists interact frequently with coders.

9. Actual Hospital-Acquired VTE

10. VTE Prevention at NYULMC 2005 2006 2007 2008 2009 2010 SCIP Measures SCIP on Intranet POAHAC Chest Guidelines Ortho Guidelines AHRQ PSIs Internal SCIP SCIP VTE in P4P 2010 Goal: No Preventable VTE VTE Prophy in CPOE Dept VTE Standards HAC Review

11. Department Standards for VTE Prophylaxis 2006: Medicine department 2007: Surgery departments (8) 2008: Departments’ CPOE order sets 2009: Required order module (medicine) 2010: Organization-wide goal to eliminate preventable VTE:  ACCOUNTABILITY

12. Department Standards Risk assessment Documentation of contraindications to VTE prophylaxis VTE prophylaxis ordering options

13. At first Purely Optional Medicine Admission Order Set

14. Medicine Admission Order Set: VTE Compulsory

15. You cannot enter entire order set unless either a VTE order is entered or you have documented why VTE prophylaxis is not indicated Medicine Admission Order Set: VTE Compulsory

16. Surgical Department Standards and Order Sets Challenges include: Bleeding risk of great concern Start VTE prophylaxis on admission, or postop? What happens with epidural anesthesia? Conflicting guidelines: orthopedics ALL surgical services place intermittent compression devices before or in the OR, but this may not be sufficient for some patients at particularly high risk.

17. Increasing Accountability Every quarter we send to all department chairs a “quality safety score card” that displays the department’s performance on a variety of quality performance measures: – Administrative measures: admissions, hospital mortality, length of stay, 30-day readmissions. – Nationally-reported quality performance measures. – AHRQ patient safety indicators. – Internal quality and safety measures.

18. Department Quality-Safety Score Card AHRQ Patient Safety Indicators (green = at or below UHC median; red = above UHC median) rate per 1000 DepartmentNYULMC Complications of anesthesia - PSI01 0.00.3 Death in low mortality DRG - PSI02 0.0 Decubitus ulcer - PSI03 5.95.1 Death among inpatients with serious treatable complications - PSI04 16.789.7 Iatrogenic pneumothorax - PSI06 0.00.5 Infections due to medical care - PSI07 2.41.7 Post-operative hip fracture - PSI08 0.0 Post-operative hemorrhage or hematoma - PSI09 0.02.0 Post-operative physiologic/metabolic - PSI10 0.00.2 Post-operative respiratory failure - PSI11 6.410.5 Post-operative PE or DVT - PSI12 17.99.9 Post-operative sepsis - PSI13 6.28.6 Post-operative wound dehiscence - PSI14 0.0 Accidental puncture/ laceration - PSI15 1.73.0 Birth trauma - PSI17 3.7 OB trauma - vaginal with instrument - PSI18 157.5 OB trauma - vaginal w/o instrument - PSI19 25.7 OB trauma - cesarean section - PSI20 1.4

19. Department Score Card: Numerator Cases Also included: – Patient identifiers – Attending physician

20. Analytic Report from EMR

21. Internal Quality Report Posted on Intranet

22. What Have We Learned? Accurate coding needs attention from clinicians. Computerized order entry with decision support can be harnessed to improve VTE prophylaxis. Decreasing the rate of hospital-acquired VTE— real and apparent—is possible.

23. What Do Hospitals Need from Measures? Actionable performance data: Timely, reliable measures With “drill down” to the “unit of actionability” – For VTE prophylaxis at NYULMC, this is the department

24. What Has AHRQ Learned? What is the variability in hospital coding practice? Are the AHRQ PSIs sufficiently reliable as safety measures to permit fair hospital comparison?