Guide Available for Deep Vein Thrombosis

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Guide Available for Deep Vein Thrombosis

• Developed from Partnerships in Implementing
  Patient Safety program toolkit
• Based on quality improvement initiatives
  undertaken at the University of California, San
  Diego Medical Center and Emory University
  Hospitals
• Assists quality improvement practitioners in
  preventing one of the most important problems
  facing hospitalized patients - DVT / PE (VTE)

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Why build a toolkit for VTE Prevention?

• VTE is a common source of inpatient MM
• Jumbo jet crash / day- gt Breast CA, HIV, MVA
  combined
• May be 1 preventable source of hospital death
• Effective and safe methods of prevention exist
• Large implementation gap - best practice ?
  current practice
• These methods are grossly underutilized
• Awareness, difficulty implementing, no validated
  risk assessment
• P4P, public reporting, and core measures

Geerts WH, et al. Chest. 2008133381S-453S. Cohen
, Tapson, Bergmann, et al. ENDORSE study Lancet
2008 371 38794. Surgeon Generals Call to
Action to Prevent DVT and PE 2008 DHHS
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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
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Hierarchy of Reliability
Predicted Prophylaxis rate
Level

• 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)
• Oversights identified and addressed in real time

1
40
50
2
3
65-85
4
90
5
95
Protocol standardized decision support,
nested within an order set, i.e. what/when
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The Essential First Intervention
VTE Protocol

• 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

5
6
Low Medium High
Example from UCSD Keep it Simple A 3 bucket
model
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IPC needed if contraindication to AC exists
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Map to Reach Level 3Implementing 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)
• Vette / Pilot PDSA
• Educate / consensus building
• Place new standardized DVT order set module
  into all pertinent admit, transfer, periop order
  sets.
• Monitor, tweak - PDSA

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N 2,944 mean 82 audits / month
In press, JHM 2009
In press, Maynard, Morris et al, J Hosp Med
Real time ID intervention
Order Set Implementation Adjustment
Consensus building
Baseline
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9
9
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Hierarchy of Reliability
Predicted Prophylaxis rate
Level

• 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)
• Oversights identified and addressed in real time

1
40
50
2
3
65-85
4
90
5
95
Protocol standardized decision support,
nested within an order set, i.e. what/when
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Map to Reach Level 595 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!

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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

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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
• Venous Disease Coalition