1. AHRQ / QIO Venous Thromboembolism (VTE) Prevention in the Hospital Greg Maynard MD, MSc Clinical Professor of Medicine and Chief, Division of Hospital Medicine University of California, San Diego

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

3. Risk Factors for VTE Stasis Age > 40 Immobility CHF Stroke Paralysis Spinal Cord injury Hyperviscosity Polycythemia Severe COPD Anesthesia Obesity Varicose Veins Hypercoagulability Cancer High estrogen states Inflammatory Bowel Nephrotic Syndrome Sepsis Smoking Pregnancy Thrombophilia Endothelial Damage Surgery Prior VTE Central lines Trauma Anderson FA Jr. & Wheeler HB. Clin Chest Med 1995;16:235.

4. Risk Factors for VTE Stasis Age > 40 Immobility CHF Stroke Paralysis Spinal Cord injury Hyperviscosity Polycythemia Severe COPD Anesthesia Obesity Varicose Veins Hypercoagulabilit y Cancer High estrogen states Inflammatory Bowel Nephrotic Syndrome Sepsis Smoking Pregnancy Thrombophilia 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

5. ENDORSE Results 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.

6. The “Stick” is coming…. NQF endorses measures already 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 CMS – DVT or PE with knee or hip replacement reimbursed as though complication had not occurred.

7. 2005 – AHRQ grant to: –Design and implement VTE prevention protocol –Monitor impact on VTE prophylaxis and HA VTE –Validate a VTE risk assessment model / protocol Attempt to use portable methodology, build toolkit to allow others to accomplish the same thing

8. Percent of randomly sampled inpatients with adequate vte prophylaxis 8 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

9. UCSD – Decrease in patients with preventable ha vte 9 Level 5 Oversights identified and addressed in real time 95+%

10. UCSD VTE Protocol Validated Easy to use, on direct observation – a few seconds Inter-observer agreement – –150 patients, 5 observers- Kappa 0.8 and 0.9 Predictive of VTE 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 Effective – 40% reduction in HA VTE –86% reduction in risk of preventable VTE

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

12. VTE QI Resource Room www.hospitalmedicine.org VTE QI Resource Room

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

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

15. 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 15 VTE Protocol

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

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

18. Too Little Guidance Prompt ≠ Protocol DVT PROPHYLAXIS ORDERS  Anti thromboembolism Stockings  Sequential Compression Devices  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

19. Most Common Mistakes in VTE Prevention Orders Point based risk assessment model 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 Too many categories of risk Allowing non-pharm prophy too much Failure to pilot, revise, monitor Linkage between risk level and prophy choices are separated in time or space

20. 20 Is your order set in a competition?

21. 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 <50 kg) LMWH Enox 40 mg q day 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 21 IPC needed if contraindication to AC exists Example from UCSD Keep it Simple – A “3 bucket” model

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

23. 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: GREEN ZONE - on anticoagulation YELLOW ZONE - on mechanical prophylaxis only RED ZONE – on no prophylaxis Act to move patients out of the RED!

24. Situational Awareness and Measure-vention: Getting to Level 5 Identify patients on no anticoagulation 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 –Templated note, text page, etc Need Administration to back up these interventions and make it clear that docs can not “shoot the messenger”

25. Summary of Key Strategies 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 Active monitoring for non-adherents to protocol, intervene in real time