The Surgical Care Improvement Project: VTE Measures

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The Surgical Care Improvement Project VTE
Measures

• Masspro
• June 21, 2007

This material was prepared by Masspro, the
Medicare Quality Improvement Organization for
Massachusetts, under contract with the Centers
for Medicare Medicaid Services (CMS), an agency
of the U.S. Department of Health and Human
Services. The contents presented do not
necessarily represent CMS policy.
8sow-ma-hosp-07-76 SCIP-VTEMeasures-june
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Objectives

• Review the science / medicine
• Share improvement strategies and tools
• Discuss the performance measures and key data
  elements
• Review frequently asked questions
• Respond to new and unanswered questions

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VTE References

• Anderson Frederick, PhD
• University of Massachusetts
• Bratzler Dale, DO, MPH
• HI QIOSC Medical Director
• Dalton Vanessa MD
• American College of Obstetricians and
  Gynecologists
• DePalma Ralph, MD
• National Director of Surgery, Acute Care
  Strategic Healthcare Group, Dept of Veterans
  Affairs
• Flum David, MD
• University of Washington
• Geerts William, MD
• Canada chairs the ACCP Consensus committee on
  VTE prevention

• Heit John, MD
• Mayo Clinic, Rochester
• Hyman Neil, MD
• American Society of Colon and Rectal Surgeons
• Kresowik Timothy, MD
• Society for Vascular Surgery
• Lieberman Jay R, MD
• American Academy of Orthopedic Surgeons
• Padberg Frank, MD
• Chief, Vascular Surgery, Dept of Veterans Affairs
• Raskob Gary, PhD
• University of Oklahoma, Dean of College for
  Public Health
• Sidawy Anton, MD

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VTE References

• Prevention of venous thromboembolism the Seventh
  ACCP Conference on Antithrombotic and
  Thrombolytic Therapy.
• Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen
  MR, Colwell CW, Ray JG.
• Chest. 2004 Sep126(3 Suppl)338S-400S.
• From the Seventh American College of Chest
  Physicians Conference, this article provides
  guidelines for the prevention of venous
  thromboembolism in hospitalized patients and
  represents an update of the guideline published
  in 2001.

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VTE 101

• A venous thromboembolism (VTE) is a formation,
  development, or existence of a blood clot or
  thrombus within the venous system.
• Virchows Triad
• Vascular wall abnormality
• Venous stasis
• Activation of coagulation
• Symptoms include
• None
• Calf / Thigh pain
• Leg swelling
• Dyspnea, chest pain, hemoptysis

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Risk Factors for VTE

• Surgery
• Trauma (major or lower extremity)
• Immobility, paresis
• Malignancy
• Cancer therapy
• Previous DVT
• Increasing age
• Pregnancy and the postpartum period
• Estrogen-containing oral contraceptives or
  hormone replacement therapy

• Selective estrogen receptor modulators
• Acute medical illness
• Heart or respiratory failure
• Inflammatory bowel disease
• Nephrotic syndrome
• Myeloproliferative disorders
• Parxysmal nocturnal hemoglobinuria
• Obesity
• Smoking
• Varicose veins
• Central venous catheterization
• Inherited or acquired thrombophilia

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VTE and the Hospitalized Patient

• Venous thromboembolism (VTE) includes deep vein
  thrombosis (DVT) and pulmonary embolism (PE)
• VTE is one of the most common complications of
  the hospitalized patient
• Thromboemboloic complications
• Excess length of stay
• Excess mortality
• Excess hospital charges
• PE is the most common preventable cause of
  hospital death

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Absolute Risk of DVT

• Patient Group
• Medical patients
• General surgery
• Major gynecologic surgery
• Major urologic surgery
• Neurosurgery
• Stroke
• Hip or knee arthroplasty, hip fracture surgery
• Major trauma
• Spinal cord injury
• Critical care patients

• DVT Prevalence,
• 10 20
• 15 40
• 15 40
• 15 40
• 15 40
• 20 50
• 40 60
• 40 80
• 60 80
• 10 80

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Clinical Evidence for VTE Prophylaxis

• Hundreds of randomized trials
• Over 20 published evidence-based guidelines
  showing clear evidence of benefits and safety
• Reductions in
• Incidence of DVT
• Incidence of PE
• All-cause mortality
• Costs

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VTE Prophylaxis Grade 1 Recommendations
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VTE Prophylaxis Grade 1 Recommendations
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VTE Prophylaxis Grade 1 Recommendations
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VTE Prophylaxis Grade 1 Recommendations
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Rational for Thromboprophylaxis

• High prevalence of VTE
• Adverse consequences of unprevented VTE
• Efficacy and Effectiveness of thromboprophylaxis
• Without prophylaxis, deep vein thrombosis occurs
  in 25 and pulmonary embolism occurs in 7 of all
  major surgical procedures. Despite the
  well-established efficacy and safety of
  preventive measures, studies show that
  prophylaxis is often underused or inappropriately
  used.

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Improvement Strategies and Tools

• Incorporate into routine patient care
• Develop a written policy on VTE prophylaxis
• Recognize the role of nursing staff
• Pre-printed orders sensible prophylaxis
• Computer reminders with CPOE (Computerized
  Physician Order Entry)
• Audit and feedback

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VTE Measures

• VTE 1 - Surgery patients with recommended venous
  thromboembolism prophylaxis ordered
• VTE 2 - Surgery patients who received appropriate
  venous thromboembolism prophylaxis within 24
  hours prior to surgery to 24 hours after surgery
• VTE 3 - Intra- or postoperative pulmonary
  embolism (PE) diagnosed during index
  hospitalization and within 30 days of surgery
• VTE 4 - Intra- or postoperative deep vein
  thrombosis (DVT) diagnosed during index
  hospitalization and within 30 days of surgery.

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Version 2.2b Exclusions

• Patients who are less than 18 years of age
• Procedures performed entirely by laparoscope
• Procedures where total surgery time is minutes
• Length of stay
• Burn patients
• Patients on Warfarin prior to admission
• Patients with contraindication to both mechanical
  and pharmacological prophylaxis
• Principal procedure occurred prior to the date of
  admission

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Key Data Elements VTE Prophylaxis

• Documentation of venous thromboembolism (VTE)
  prophylaxis ordered anytime during this
  admission.
• 1 Low dose unfractionated heparin (LDUH)
• 2 Low molecular weight heparin (LMWH)
• 3 Intermittent pneumatic compression devices
  (IPC)
• 4 Graduated compression stockings (GCS)
• 5 Factor Xa Inhibitor
• 6 Warfarin
• A None of the above / not documented / UTD

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Key Data Elements VTE Prophylaxis

• IPCs include
• AE pumps
• DVT boots
• EPC cuffs / stockings
• Flotron / Flotron DVT system
• Impulse pump
• Plexipluse
• Sequential compression device
• Sequential TEDS
• Venodyne boots

• GCS include
• Anti-embolism stockings
• Anti-thrombosis stockings
• Elastic support hose
• Graduated compression elastic stockings
• Jobst stockings
• Surgical hose
• Ted hose (TEDS)
• Thrombo-guard
• White hose
• Thrombosis stockings

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Key Data Elements VTE Timely

• Documentation of venous thromboembolism (VTE)
  prophylaxis received within 24 hours prior to
  Surgical Incision Time to 24 hours after Surgery
  End Time.
• If VTE prophylaxis was ordered and administered
  within the defined time frame, select Yes
• If VTE prophylaxis was ordered and not
  administered, select No
• If VTE prophylaxis was ordered and not
  administered within the defined time frame,
  select No

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Key Data Elements Contraindication

• Documentation by a physician / advanced nurse
  practitioner / physician assistant of
  contraindications to both pharmacological and
  mechanical venous thromboembolism (VTE)
  prophylaxis.
• In order to select Yes, patients must have
  documentation of contraindications to both
  mechanical and pharmacological prophylaxis
• Documented Bleeding Risk is not a
  contraindication to all types of VTE prophylaxis

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Key Data Elements Bleeding Risk

• Documentation by a physician / advanced nurse
  practitioner / physician assistant of a risk for
  bleeding that contraindicates an order for
  pharmacological VTE prophylaxis.
• If the physician / APN / PA documents that the
  patient is at risk for bleeding or that
  pharmacological prophylaxis is not being ordered
  due to bleeding, select Yes
• If there is documentation of a bleeding risk, the
  patient may still be eligible for mechanical
  prophylaxis

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Newport Hospital Initiative 2004

• Absolute Contraindication
• Active hemorrhage
• Epidural/indwelling spinal catheter placement
  or removal
• Heparin or warfarin use in patients with
  heparin-induced thrombocytopenia (HIT)
• Severe trauma to head, spinal cord, or
  extremities with hemorrhage within the last 4
  weeks
• Warfarin use in the first trimester of pregnancy

• Relative contraindication
• Active intracranial lesions / neoplasms /
  monitoring devices
• Coagulopathy (PT 18 sec)
• Craniotomy within 2 weeks
• GI / GU hemorrhage within the last 6 months
• Hx of cerebral hemorrhage
• Proliferative retinopathy
• Thrombocytopenia
• Uncontrolled HTN (SPB200, DBP120, or both)
• Vascular access / biopsy site inaccessible to
  hemostatic control

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Key Data Elements Neuraxial Anesthesia

• Documentation that the patient received neuraxial
  anesthesia for the surgical procedure.
• Neuraxial anesthesia is medication administered
  into the epidural space (epidural) or spinal
  canal (spinal) to block sensations of pain
• An epidural catheter whether for anesthesia or
  pain management is consistent with neuraxial
  anesthesia and this data element should be
  answered Yes

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Key Data Elements Preadmission Warfarin

• Documentation that the patient was on Warfarin
  prior to admission.
• If there is documentation that warfarin was a
  home or current medication, select Yes
• If warfarin was listed as a home or current
  medication, but placed on hold prior to surgery,
  select Yes
• If there is no documentation that the patient was
  on warfarin prior to admission, select No

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Key Data Elements Laparoscope

• Documentation that the surgical procedure was
  performed entirely with a laparoscope.
• If there is documentation the surgical procedure
  was performed entirely by laparoscope, select
  Yes
• If there is documentation the surgical procedure
  was not performed entirely by laparoscope, select
  No
• If unable to determine, select UTD
• If the only incision that is made is to introduce
  the laparoscope or thorascope, the operation is
  laparoscopic only

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SCIP VTE Measures

• Frequently Asked Questions

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SCIP VTE Measures

• New and Unanswered Questions