Preventable Harm from Venous Thromboembolism (VTE) – A New Metric for Quality of Care

by

Elliott R. Haut, MD, FACS

A dissertation submitted to Johns Hopkins University in conformity with the requirements for the degree of Doctor of Philosophy

Baltimore, Maryland April, 2014

© 2013 Elliott R. Haut All Rights Reserved

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ABSTRACT

Venous thromboembolism (VTE), comprised of deep venous thrombosis (DVT)

and pulmonary embolism (PE), is an underappreciated public health concern. According

to the United States’ Surgeon’s General “Call to Action to Prevent Deep Vein

Thrombosis and Pulmonary Embolism,” VTE affects between 350,000-600,000

Americans each year, causing over 100,000 deaths annually.

Even with overwhelming evidence of benefit, many hospitalized patients do not

receive adequate VTE prophylaxis. The Agency for Healthcare Research and Quality

(AHRQ) has called VTE prevention the number one strategy to improve patient safety in

hospitals. As a consequence, many governmental agencies, accrediting bodies, and

patient safety organizations have made improving VTE prophylaxis a priority and VTE is

suggested as an ideal target for public reporting. However, VTE rates alone are not

reliable as quality indicators. We suggest a more palatable and reliable measure of

preventable harm from VTE.

Chapter 1 shows how publicly reported VTE process and outcome measures fail

to correlate and are not valid to benchmark hospitals. Chapter 2 explains how

surveillance bias limits the role of VTE outcome reporting and offers a better solution-

linking VTE process and outcome data into a single measure to define preventable harm.

Chapter 3 summarizes published approaches to improve VTE prophylaxis for

hospitalized patients. Chapter 4 offers perspectives on lessons learned while

implementing a mandatory computerized clinical decision support tool to improve VTE

prevention at our academic medical center. Chapters 5 and report data showing how our

tool decreased preventable harm from VTE (using our definition) in adult trauma and

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medicine patients. Chapter 7 presents a real-world example of the feasibility of linking

VTE prevention process and outcome measures.

The work of this dissertation has already influenced national policy. By inclusion

in The Centers for Medicare and Medicaid Services financial incentives programs for the

“meaningful use” of certified electronic health record (EHR) technology to improve

patient care. VTE-6 is defined as patients diagnosed with confirmed VTE who did not

receive VTE prophylaxis" This definition followed our suggestion that “performance

measures could link a process of care with adverse outcomes when defining incidences of

preventable harm.” We posed the question; CMS now requires that all participating

hospitals answer our query.

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PREFACE/ACKNOWLEDGEMENTS

Thank you to everyone who has supported me and/or helped with all the work

involved in creating this final dissertation. If there were such a thing as a team PhD, this

would be the perfect example.

My Family

Thank you all so much for putting up with the long hours which too often take

away from family time. This dissertation and all the work I do would not be possible

without the loving support of my amazing wife, Jayne Gerson. Olive juice. My wonderful

kids, Arenal and Fletcher, may not truly understand it yet, but they are the inspiration and

drive for everything I do. My life has changed so much for the better with them in it.

Since I was a young child, my parents, Rosalie and Michael, encouraged me in every way

and instilled within me a love of learning. My mother has always unconditionally

supported everything I do. I am so sorry my dad didn’t live to see this final culmination

of my PhD.1 He was the most wonderful role model for me as a physician and a father. I

truly cherish the time we shared during my training at Pennsylvania Hospital. I still miss

him every day.

Dissertation Readers Serving on Final Oral Examination Committee • Ellen MacKenzie, PhD Examining Committee Chair • Peter Pronovost, MD, PhD Thesis Research Mentor • Dorry Segev, MD, PhD GTPCI Academic Advisor • Jodi Segal, MD, MPH • Michael Streiff, MD Alternate Dissertation Readers • Dale Needham, MD, PhD • Albert Wu, MD, MPH

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The Johns Hopkins Venous Thromboembolism (VTE) Collaborative The most wonderful group of multi-disciplinary collaborators that I could imagine • Michael B. Streiff, MD • Deborah B. Hobson, BSN, RN • Peggy S. Kraus, PharmD • Brandyn D. Lau, MPH, CPH • Kenneth M. Shermock, PharmD, PhD • Howard Carolan, MPH, MBA • Dauryne Shaffer MSN, RN, CCRN • Hasan M. Shihab, MBChB, MPH Collaborators/Mentors from the Armstrong Institute for Patient Safety and Quality For always pushing the science of safety alongside the human touch • Peter Pronovost, MD, PhD • Renee Demski, MSW, MBA • Sean M. Berenholtz, MD, MHS Resident/Fellow/Student Collaborators/Mentees Mentorship is a two way street. Every one of them have taught me so much. • Jonathan K. Aboagye, MD, MPH • Matthew M. Boelig, MD • Anthony Dat, MD • Stacy Elder, PharmD, BCPS • Awori J. Hayanga, MD, MPH • Eric A. JohnBull, MPH • Shahrzad Kardooni, MD, MPH • Franca Kraenzlin, MHS • M. Francesca Monn, MD, MPH • Matthew J. Newman, PharmD • Charles A. Pierce, DO, MPH • Jessica J. Rosenberg, MHS • Rishav Shrestha, MD, MPH • Kyle Van Arendonk, MD, PhD • Eric S. Weiss, MD, MPH • Adrian Wong, PharmD • Amer M. Zeidan, MBBS The Graduate Training Programs in Clinical Investigation (GTPCI) • N. Franklin Adkinson, Jr., MD • Charles W. Flexner, MD • Cristina A. DeNardo, M.Ed.

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Division of Acute Care Surgery at Johns Hopkins Medicine I truly appreciate the understanding of my colleagues as my research and schoolwork has impacted all of the clinical work we do. You have all helped me immensely over the years and I could not have done it without you. • Edward E. Cornwell, 3rd, MD • David T. Efron, MD • Adil H. Haider, MD, MPH • Kent A. Stevens, MD, MPH • Albert Chi, MD • Amy P. Rushing, MD • Catherine G. Velopulos, MD, MHS Department of Surgery at Johns Hopkins Medicine • Julie A. Freischlag, MD, the Chair of Surgery who hired me for my first faculty position and supported my academic surgical career over the past ten years • Eric B. Schneider, PhD, a long-term collaborator on projects in various areas of clinical research Trauma/ Acute Care Surgery Fellows They are the future leaders of clinical and academic trauma and acute care surgery. It has been a pleasure and honor to help guide this step of their clinical training. • Preeti Rebecca John, MD, MPH • Alicia Nicole Kieninger, MD • George Koenig, Jr., DO • Nicholas Jaszczak, MD • Amy Page Rushing, MD • Catherine Garrison Velopulos, MD, MHS • Luis J. Garcia, MD • Leigh Ann Slater, MD • Marcie Feinman, MD • William “Rob” Leeper, MD

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Sources of Funding 7/1/2009-6/30/2013 “Does Screening Variability Make DVT an Unreliable Quality Measure of Trauma Care?” Agency for Healthcare Research and Quality (AHRQ) http://www.ahrq.gov/funding/training-grants/grants/active/kawards/Kawdsumhaut.html Mentored Clinical Scientist Development Award K08 1K08HS017952-01 PI: Elliott R. Haut 75% effort 7/1/2013-present “Preventing Venous Thromboembolism: Empowering Patients and Enabling Patient-Centered Care via Health Information Technology” The Patient-Centered Outcomes Research Institute (PCORI) http://www.pcori.org/pfaawards/preventing-venous-thromboembolism-empowering-patients-and-enabling-patient-centered-care-via-health-information-technology/ CE-12-11-4489 PI: Elliott R. Haut 25% effort 7/1/2011-present The Hopkins Sommer Scholars Program The Johns Hopkins Bloomberg School of Public Health http://www.jhsph.edu/admissions/scholarships/institutional-scholarships/sommer-scholars/

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TABLE OF CONTENTS Front Matter Title page i Abstract ii Preface, including acknowledgments iv Table of Contents, with titles and page references viii List of Tables, titles and page references ix List of Figures, titles and page references x Text Introduction 1 Chapter 1 6 Hospital-Reported Perioperative Venous Thromboembolism Prophylaxis is not Associated with Outcome Rates in Publicly Reported Data Chapter 2 Surveillance Bias in Outcomes Reporting 10 Chapter 3 15 Prevention of Venous Thromboembolism: Brief Update Review Chapter 4 25 Lessons from the Johns Hopkins Multi-Disciplinary Venous Thromboembolism (VTE) Prevention Collaborative Chapter 5 37 Improved Prophylaxis and Decreased Rates of Preventable Harm With the Use of a Mandatory Computerized Clinical Decision Support Tool for Prophylaxis for Venous Thromboembolism in Trauma Chapter 6 53 Impact of a Venous Thromboembolism (VTE) Prophylaxis “Smart Order Set”: Improved Compliance, Fewer Events Chapter 7 68 Linking Processes and Outcomes: A Key Strategy to Prevent and Report Harm from Venous Thromboembolism in Surgical Patients Conclusions 73 Future Directions 75 References Bibliography 82 Brief Biography 104 Curriculum Vitae 105

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LIST OF TABLES, TITLES AND PAGE REFERENCES Table Title Page Table 3.1 Prevention of Venous Thromboembolism: 24

Brief Update Review Summary Table 5.1 Characteristics of 1599 Hospitalized Adult 43

Trauma Patients Table 5.2 Trauma Patients With Venous Thromboembolism 47

(VTE) Events From 2007-2010 Table 6.1 Definitions Used for Data Collection 59 Table 6.2 Demographics and Baseline Characteristics 60 Table 6.3 VTE Prophylaxis Before and After Implementation 62

of the “Smart Order Set” Table 6.4 Clinical Outcomes 64 Table 7.1 Proportion of Surgical Patients With vs. Without VTE 70

Who Were Prescribed Risk-Appropriate VTE Prophylaxis Stratified by Risk Status

x

LIST OF FIGURES, TITLES AND PAGE REFERENCES Figure Title Page Figure 1.1 Risk-Adjusted AHRQ PSI-12 Postoperative VTE 8

Rate vs. Percentage of Patients Who Received SCIP VTE-2 Prophylaxis

Figure 1.2 Risk-Adjusted AHRQ PSI-12 Postoperative Venous 8 VTE Rate vs. Percentage of Patients Who Received SCIP VTE-2 Prophylaxis, by Quintile

Figure 4.1 Example of paper order set for prevention of venous 28 thromboembolism in surgery departments (includes general surgery, surgical oncology, urology, and vascular surgery)

Figure 4.2 Example of computer algorithm for prevention of venous 31 thromboembolism in general surgery department

Figure 4.3 Changes in venous thromboembolism (VTE) risk 33 assessment for medical and surgical inpatients at key points in the implementation of a clinical decision support tool for VTE risk stratification

Figure 4.4 Changes in venous thromboembolism (VTE) risk 34 assessment for medical and surgical inpatients since implementation of a computerised clinical decision support tool for VTE risk stratification

Figure 5.1 Algorithm for risk-appropriate VTE prophylaxis in 40 hospitalized trauma patients

Figure 5.2 Trends in venous thromboembolism (VTE) prophylaxis 44 and events in hospitalized adult trauma patients

Figure 5.3 Proportion of hospitalized adult trauma patients who 45 received venous thromboembolism (VTE) prophylaxis

Figure 5.4 Compliance rates among hospitalized adult trauma 46 patients, stratified by those with or without documented contraindications to pharmaceutical prophylaxis for venous thromboembolism

Figure 6.1 Flow chart describing the major components of the 56 “smart order set”: the major risk factors for VTE, the contraindications, and decision-making algorithm

Figure 7.1 The percentage of patients with postoperative venous 71 thromboembolism (VTE), deep vein thrombosis (DVT), and pulmonary embolism (PE) who were prescribed risk-appropriate VTE prophylaxis compared with those who were not. The vast majority of VTE events occurred in patients prescribed risk-appropriate prophylaxis.

1

INTRODUCTION

Venous thromboembolism (VTE), comprised of deep venous thrombosis (DVT)

and pulmonary embolism (PE), is an underappreciated public health concern. According

to the United States’ Surgeon’s General “Call to Action to Prevent Deep Vein

Thrombosis and Pulmonary Embolism,” VTE is estimated to affect between 350,000-

600,000 Americans each year.2 PE causes over 100,000 deaths annually in the United

States, more than from motor vehicle crashes, breast cancer and AIDS combined. VTE is

a significant cause of unnecessary healthcare expenditures. The annual direct cost of

treating post-thrombotic syndrome adds $200 million to the annual cost of hospitalization

nationally.3 The overall costs to the US economy have been estimated at greater than $1.5

billion dollars.4

Although VTE occurs in the outpatient setting, hospitalization is known to confer

significant added risk. Every hospitalized patient is at increased risk while some patient

populations (e.g., trauma, surgery, orthopedics) raise the risk dramatically, others are

only moderate higher risk (e.g., medicine, obstetrics oncology), and some remain at

lower, but non-zero, risk (e.g., pediatrics, psychiatry). Many individual patient risk

factors have been studied and risk prediction and scoring systems (i.e., Caprini5, 6,

Padua7) have been validated in some patient populations.

The benefit of VTE prophylaxis is well established. Thousands of clinical studies

have been published describing pharmacologic and mechanical approaches to VTE

prevention. Many leading national and international organizations provide evidence

based guidelines regarding the appropriate use of VTE prevention. The American College

of Chest Physicians (ACCP) is one of the most well-known for providing guidance on

2

VTE prophylaxis for broad patient populations.8-10 Other specialty societies (e.g., Eastern

Association for the Surgery of Trauma [EAST],11 American College of Obstetricians and

Gynecologists [ACOG]12, American College of Physicians [ACP]13) give focused

recommendations for more narrow patient populations.

Unfortunately, even with the overwhelming evidence of benefit, many

hospitalized patients do not receive adequate VTE prophylaxis. In one United States

study of 2,726 patients in whom DVT was diagnosed in the hospital, only 42% had

received any prophylaxis before their diagnosis.14 A large multi-national study of 68,183

patients in 358 hospitals across 32 countries found that only 59% of surgical and 40% of

medical patients were prescribed ACCP-recommended VTE prophylaxis.15 In 2003, Dr.

Samuel Z. Goldhaber stated in an American Public Health Association white paper that

“the disconnect between evidence and execution as it relates to DVT prevention amounts

to a public health crisis.”16 Since 2001, the Agency for Healthcare Research and Quality

(AHRQ) has called VTE prevention in patients the number one strategy to improve

patient safety in hospitals.17, 18

As a consequence, many governmental agencies, accrediting bodies, and patient

safety organizations have made improvement in VTE prophylaxis practice a top priority.

The AHRQ plays a major role in determining quality measures and has listed

postoperative VTE as one of its Patient Safety Indicators (PSI -12). The Joint

Commission has mandated risk stratification for VTE for all patients upon admission to

the hospital and upon admission to an intensive care unit (ICU) setting. The National

Quality Forum (NQF) has endorsed many VTE related measures including some for both

specific (e.g., stroke) and general (e.g., all discharged hospital inpatients) patient cohorts.

3

The Centers for Medicare and Medicaid Services (CMS) has included multiple VTE

related elements in its financial incentives programs for the “meaningful use” of certified

electronic health record (EHR) technology to improve patient care.

In 2008, The Centers for Medicare and Medicaid Services (CMS) announced that

hospitals would no longer be reimbursed for certain “reasonably preventable” events.

Under this new “zero tolerance” policy, certain conditions, such as wrong site surgery,

retained foreign bodies after surgery, and death/disability associated with incompatible

blood, would not be reimbursed if they occur after hospital admission.19 CMS included

VTE in orthopedic surgery (total knee replacement and hip replacement) patients to this

list. While the NQF had gone through a rigorous process to obtain consensus and define

“never events,” CMS did not follow the NQF’s list directly. Michael Streiff and I joined

the numerous clinicians and safety researchers to publish peer-reviewed evidence to help

overturn their unwise decision. We summarized data from many large randomized

controlled trials of VTE prophylaxis in orthopedic joint replacement surgery, showing

that even with best practice measures and optimal prophylaxis, thromboembolic

complications still occurred.20

The theme above exemplifies the problem in which implementation of pay for

performance and public reporting of supposed quality of care is moving more rapidly

than the science of measuring quality. Pronovost et. al. have suggested that the true

analytical science behind measures of quality may be lagging behind the reality of the

public’s quest for knowledge and their desire to go to the “best” hospitals.21 Identifying

valid measures of quality remains difficult and continues to result in significant

controversy.

4

VTE is an ideal target as a quality metric, mainly because most in-hospital events

and their subsequent sequelae are preventable with appropriate prophylaxis. VTE can be

approached as a quality measure in all three of the classic Donabedian methods of quality

assessment: structure, process and outcome. However, these methods are not as

straightforward as they seem at first glance. Which structural item (i.e., physical

equipment and facilities) impact VTE? How can we choose the ideal process of care to

measure? Simply measuring outcomes, such as VTE rates, is more complicated than it

appears. Even the denominator (number patients at risk) is often not abundantly clear.22

Most importantly, the impact of surveillance bias on VTE outcomes is significant.

For over eight years, I have chaired the Performance Improvement Committee for

the Level 1 Adult trauma Center at The Johns Hopkins Hospital. In approximately 2005,

we received a letter from The Maryland Institute for Emergency Medical Services

Systems (MIEMSS), the verifying agency for trauma centers in our state. The letter

informed us that our hospital had the highest DVT rate for trauma patients in the state,

implying we were providing low quality trauma care. My trauma surgery colleagues and I

were shocked and dismayed since we felt that we were ahead of the curve in providing

optimal care for preventing VTE in trauma patients. We had fought hard for approval to

build best practice VTE prophylaxis into our admission ordersets, even though the

medications were significantly more costly than what the data proved were inferior

options. Based on published literature and national guidelines, we had also included a

local guideline for frequent duplex ultrasound screening for DVT in high risk

asymptomatic trauma patients into our policy, procedure, and education manuals.

5

This letter sparked my interest and prompted us to generate a hypothesis for a

possible cause for our alleged low quality of care. We were performing frequent testing

for DVT at our trauma center, but perhaps other centers in the state were not. Could this

have influenced DVT rates? After much thought, we asked the question- “Are we being

penalized because we look harder and therefore find more DVTs?” With this quality

reporting question, our research group embarked on what has turned into my research

niche with wide national influence. This seemingly simple query has shaken up the world

of pay for performance as it relates to trauma care. Since then, we have published

numerous papers confirming the presence of surveillance bias in DVT reporting in

trauma specifically.23-27 These projects were summarized in our paper in JAMA

“Surveillance Bias in Outcomes Reporting” which is chapter two of this dissertation.28

As clinicians, we must help define quality measures using valid data and correct

rationale rather than waiting for these measures to be defined for us by administrators,

insurers, and legislators. We have to truly understand the ways in which we are

measured, benchmarked, and eventually paid. We have to make sure they are valid and

meaningful based on the combination of our clinical knowledge and reliable science. If a

measure does not hold face validity amongst the clinicians, then it will, and should, never

be accepted. We must be involved in the quality improvement process at every step along

the way. We need to identify issues, help define meaningful measurement criteria, and

prove that we are making progress with scientifically rigorous studies. Top-quality data is

only the first step; true progress comes from policy changes at the highest level driven by

those data.29

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CHAPTER 1

No Association Between Hospital-Reported Perioperative Venous Thromboembolism Prophylaxis and Outcome Rates in Publicly Reported Data30

(reprinted with permission from JAMA-Surgery)

Introduction

Venous thromboembolism (VTE), consisting of deep vein thrombosis (DVT) and

pulmonary embolism, is an important cause of postoperative mortality and long-term

morbidity. Because many events are preventable, VTE prophylaxis performance and

postoperative VTE are used as measures of hospital quality of care and patient safety.

Two such metrics are reported on the Centers for Medicare & Medicaid Services Hospital

Compare website (http://www.medicare.gov/hospital-compare/search.html) with the

stated goal of helping consumers make decisions about where to receive their health care.

The Surgical Care Improvement Project (SCIP) VTE-2, a process measure,

captures the percentage of a hospital’s surgical patients who received any VTE

prophylaxis within 24 hours of surgery. Previous studies have shown that performance on

the SCIP VTE-2 measure is not associated with VTE among Medicare patients in 6 high-

risk surgical procedures,31 nor with outcomes in a Veterans Affairs cohort.32 In October

2011, Hospital Compare made additional VTE outcomes data available to consumers. We

hypothesized that there is no association between the process measure (SCIP VTE-2) and

the outcome (Agency for Healthcare Research and Quality Patient Safety Indicator

[PSI]–12, a risk-adjusted postoperative VTE rate based on administrative data).

Methods

The SCIP VTE-2 and PSI-12 data were downloaded from the Centers for

Medicare & Medicaid Services website. Average annual prophylaxis performance was

7

linked to the 2-year VTE rate for each hospital (from July 1, 2009, to June 30, 2011). The

PSI-12 is adjusted for age, sex, age × sex interactions, diagnosis-related group, and

modified comorbidity index prior to public reporting. Simple linear regression was used

to test for an association between VTE prophylaxis and VTE rate. Sensitivity analyses

were performed that excluded outliers and that used a log-transformed VTE rate because

the data were not normally distributed. Hospitals were categorized by quintile of

prophylaxis performance, and VTE rates were compared using a nonparametric Kruskal-

Wallis rank test and Bonferroni-corrected rank sum tests for multiple pairwise

comparisons. Hospitals with 100% prophylaxis performance were compared to the lowest

quintile using a rank sum test. Statistical analyses were conducted using Stata version

11.2 (StataCorp).

Results

There were 3040 hospitals with complete prophylaxis and VTE data. Average

annual prophylaxis performance was negatively skewed (median rate, 94.5%). The

median risk-adjusted VTE rate was 4.13 per 1000 surgical discharges. Prophylaxis

performance was not associated with VTE rate (P = .13) on linear regression (Figure 1.1).

Regression results were unchanged in sensitivity analyses that excluded outliers (P = .51)

and that used a log-transformed VTE rate (P = .90). Among quintiles, the VTE rates

appeared to be similar (Figure 1.2). Although the global Kruskal-Wallis test was

significant (P = .04), no pairwise comparison by quintile was statistically significant.

Hospitals reporting 100% VTE prophylaxis performance (n = 141) and hospitals in the

bottom quintile of prophylaxis performance (n = 618) had nearly identical median VTE

outcome rates (4.18 vs 4.17; P = .98, determined by rank sum test).

8

Figure 1.1 Risk-Adjusted AHRQ PSI-12 Postoperative VTE Rate vs. Percentage of

Patients Who Received SCIP VTE-2 Prophylaxis

Figure 1.2 Risk-Adjusted AHRQ PSI-12 Postoperative Venous VTE Rate vs.

Percentage of Patients Who Received SCIP VTE-2 Prophylaxis, by Quintile

9

Discussion

Our findings show that there is no association between reported VTE prophylaxis

and outcome rates for surgical patients, when compared across the range of process

measure performance. There was no difference in quintiles, or between extremes at 100%

performance and the lowest quintile. This may reflect the current low, minimum standard

for VTE prophylaxis because the SCIP VTE-2 gives credit for even the most basic,

suboptimal prophylaxis. Perhaps a more rigorously applied benchmark to report

adherence to optimal, risk-appropriate prophylaxis would have a greater chance of

differentiating hospitals and improving outcomes. Furthermore, VTE rates are greatly

influenced by surveillance bias,28 which likely weakens any association between process

and outcome.

To be useful to consumers, hospital quality measures should be associated with

important patient outcomes.33 Biased information, presented as evidence of hospital

quality, should not inform the decision-making process. Hospital Compare–reported

SCIP VTE-2 prophylaxis rates are of little value to consumers choosing a hospital for

surgical treatment. Our results suggest a need to explore alternate public-reporting

strategies or metrics, such as those that combine process and outcome to identify

preventable harm20, 34 and quantify VTE-related quality of care.

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CHAPTER 2

Surveillance Bias in Outcomes Reporting28

(reprinted with permission from JAMA - Journal of the American Medical Association)

The prevalence and extent of public reporting of adverse medical outcomes are

increasing. Many private, public, and government Web sites rank hospitals and report

scores on selected quality measures. Health care consumers, including referring

physicians, individual patients, and insurers, can use these data to inform decision

making by selecting hospitals with better outcomes. However, the science of outcome

reporting is young and lags behind the desires of the public in this information age.

Reporting quality measures may have benefits but also may pose risks from unintended

consequences.20

When validating outcome measures, the main focus has been strict definitions for

numerators to clearly identify cases and for denominators to identify patients at risk.22

Standardized surveillance for events within the population of those at risk has received

little attention, and as a result, surveillance bias is likely an important source of error in

currently reported outcome measures.

Surveillance bias, a nonrandom type of information bias, refers to the idea that

“the more you look, the more you find.”23 It occurs when some patients are followed up

more closely or have more diagnostic tests performed than others, often leading to an

outcome diagnosed more frequently in the more closely monitored group. In an article on

biases inherent to clinical research, Sackett35 used the phrase “unmasking (detection

signal) bias” to explain how “an innocent exposure may become suspect if, rather than

causing a disease, it causes a sign or symptom which precipitates a search for the

11

disease.” As a result, differences in outcomes may be related to surveillance bias rather

than differences in quality. If ignored, flawed causal inferences could be suggested from

differential rates identified between groups. Surveillance bias is a well-known concept in

epidemiology yet is seldom considered in published clinical studies.36

For example, deep vein thrombosis (DVT) is a significant cause of preventable

harm and a commonly monitored quality-of-care measure. DVT is a common, life

threatening complication among patients who have sustained trauma.22 Because injured

patients are at increased risk for DVT, some clinicians use duplex ultrasound to screen

high risk asymptomatic trauma patients for DVT. Other clinicians argue this approach is

neither clinically necessary nor cost-effective and therefore do not routinely screen for

DVT in trauma patients. This clinical uncertainly leads to variability in the use of

screening duplex ultrasound, creating variability in rates of DVT identified and reported-

a typical example of surveillance bias.25

Evidence for surveillance bias in DVT reporting after trauma is well documented.

For instance, after implementation of a DVT screening guideline at one trauma center,

duplex ultrasound rates increased 4-fold and DVT rates increased 10-fold.24 Within the

National Trauma Data Bank, DVT rates were 7-fold higher at hospitals in the highest

quartile of use of vascular ultrasound,23 and patients treated at hospitals that performed

more duplex ultrasounds were twice as likely to have DVT reported, even controlling for

other patient risk factors.26

Surveillance bias also is an important factor in other high profile publicly reported

outcome measures. For example, rates of central line-associated bloodstream infections

(BSIs) increased 3-fold with the use of computer automated surveillance, suggesting that

12

“surveillance practice may complicate interinstitutional comparisons of publicly reported

central line–associated BSI rates.”37 The hazard of error caused by surveillance bias will

likely increase with increasing use of penalties and rewards for performance on quality

measures.

Surveillance bias also has the potential to pose significant harms. For instance,

patients may be harmed because clinicians will not know if quality of care is improving,

and incentives to improve outcomes may encourage clinicians to avoid appropriate

diagnostic testing to minimize reported complications. Because performance measures do

not specify surveillance, outcomes that are not sought ordinarily will not be detected.

This potential for unintended consequences was summarized in a comment by Alam and

Velmahos as: “No screening, no DVT, no punishment.”23 Thus, patients with DVT may

remain untreated, potentially sustaining a fatal pulmonary embolism.

Moreover, with pay for performance and public reporting, there may be

significant economic and reputational risks to hospitals and clinicians. Without

standardized surveillance, performance is likely determined by how thoroughly clinicians

look rather than the quality of care provided, unjustly penalizing and rewarding

hospitals.24 Surveillance bias may become extensive, leading to erroneous, undeserved

payments for these biased measures of higher or lower quality. For example, the

occurrence of DVT or pulmonary embolism after some orthopedic procedures has been

labeled a never event by the Centers for Medicare & Medicaid Services, and as such,

hospitals will no longer be compensated for providing care necessary to treat this

complication, a clear incentive to avoid diagnosing this event. Publicly reported

outcomes also drive overall hospital and university reputation, which is a crucial element

13

in the competition for patient-care and clinical revenue dollars, as well as research

funding.

There is broad bipartisan and public support for measuring outcomes, yet these

measurements must be made accurately, guided by principles of measurement from

clinical research. To do otherwise would be reckless and unjust. To be done

appropriately, quality measurement is expensive; key decisions involve who will pay

these expenses and whether certain measurements are worth these financial investments.

Which outcomes to evaluate must be determined and then they must be measured

accurately, rather than squandering resources on measuring many outcomes inaccurately.

Several steps can help reduce the error caused by surveillance bias.

First, those developing and reviewing outcome measures should ensure that the

methods for surveillance are clearly explicated. Ideally, evidence-based clinical

guidelines should specify which patients at risk should be studied and clearly convey

exact testing modalities and frequency. Important considerations include the methods

used to identify events and patients at risk, the sensitivity and specificity of screening

tests, and the net risks and benefits associated with false-positive results. Policy makers

must also address the costs for surveillance and decide who will pay the costs if the tests

are not routinely obtained for clinical care.

Second, policy makers need to examine the costs and benefits of proposed

outcome measures to enable rational prioritization of which measures to mandate. Formal

analysis such as the value of information analysis may help prioritize which outcome

measures to collect and evaluate whether the costs of collecting a specific outcome

measure are worth the benefits. In addition, policy makers could require a formal post

14

hoc review evaluating the risks, benefits, and harms of the outcome measures after

implementation.

Third, performance measures could link a process of care with adverse outcomes

when defining incidences of preventable harm.38 When standardized surveillance is too

costly or risky, processes of care among those sustaining the outcome could be examined.

For example, what percentage of patients who develop a DVT (outcome) received

appropriate risk assessment and prophylaxis (process)?25 This approach may be

particularly useful when many (but not all) events are preventable and for cases in which

high-quality evidence shows a direct link between the process (i.e., DVT prophylaxis)

and outcome (i.e., DVT).

Performance measurement is essential for improving quality and reducing costs of

medical care. However, most outcome measures in use do not sufficiently standardize

surveillance for events and those at risk for events, likely introducing substantial

measurement error. If outcome measurement is to fulfill its purpose, greater attention to

surveillance bias is needed.

15

CHAPTER 3

Prevention of Venous Thromboembolism: Brief Update Review39

(reprinted with permission from “Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices.” March 2013. Agency for Healthcare Research and Quality [AHRQ])

Introduction

Deep venous thrombosis (DVT) refers to occlusion within the venous system,

most commonly of the lower extremities, which can lead to pulmonary embolism (PE), or

embolism to the pulmonary vasculature. Venous thromboembolism (VTE), comprising

PE and DVT, is estimated to account for 5 to 10 percent of all deaths among hospitalized

patients,9, 40 and also is associated with significant morbidities. In 2008, the United States

Surgeon General issued a Call to Action to Prevent DVT and PE. The report brings to

light the huge numbers of patients afflicted by DVT (350,000-600,000) and killed by PE

(>100,000) every year in the United States.2 Even though high quality evidence exists for

safe and effective strategies to reduce the risk of VTE, studies continue to show that

many hospitalized patients are not given risk- appropriate VTE prophylaxis. One recent

study across 32 countries found that only 59 percent of at-risk surgical and 40 percent of

at-risk medical patients received guideline-recommended VTE prophylaxis15and a United

States registry study found that only 42 percent of patients diagnosed with DVT during a

hospitalization had received prophylaxis.14

The Agency for Healthcare Research and Quality (AHRQ) has indicated that

delivery of appropriate VTE prophylaxis is an essential patient safety practice and one

that can prevent in- hospital death.17 As of 2011, the National Quality Forum (NQF) has

10 VTE-related standards and endorsed outcomes measures.41 Evidence-based best

16

practice prophylaxis varies by primary service (e.g. medicine, surgery, trauma,

orthopedics) and patient risk factors. Risk of VTE among hospitalized patients varies

based on several risk factors including medical condition, type of surgery, trauma, cancer,

age, immobility, hypercoagulable state, and previous history of VTE. Most hospitalized

patients have one or more VTE risk factors, and well-developed guidelines are available

that specify which types of patients should receive prophylaxis measures, and which

specific measures are most appropriate.9

The original report, Making Health Care Safer, reviewed the effectiveness, safety,

cost- effectiveness, and indications for VTE prophylaxis. This review concluded that

whereas VTE prophylaxis shows clear benefits for a number of conditions and minimal

concerns regarding adverse events, the practice remains underused. A small number of

interventions aimed at improving use of prophylaxis were reviewed. The current review

provides an update on the most effective VTE prophylaxis regimens as well as on

interventions aimed at improving adherence to guidelines on the use of these preventive

strategies. A MEDLINE search was conducted from 2001 to 2011 to identify studies that

assessed the effectiveness and safety of VTE preventive measures as well as those aimed

at improving their use.

What Are the Practices for Preventing Venous Thromboembolism?

Both pharmacologic and mechanical prophylactic interventions have been

demonstrated to be effective in preventing many VTE events and have been evaluated for

their appropriateness for certain types of patients (medical vs. surgical) with certain risk

factors.9, 42 Pharmacologic prophylaxis includes low dose unfractionated heparin; low-

molecular weight heparins, including enoxaparin, dalteparin, and fondaparinux; warfarin;

17

and aspirin, along with newer classes of anti- thrombotic agents. Mechanical prophylaxis

includes anti-embolic stockings and intermittent pneumatic compression devices.

Because the underlying approach of all prophylaxis medications is to decrease clotting,

they may increase the risk of bleeding. The balance between bleeding and clotting must

be considered in every patient, and the benefits and harms must be weighed before

administering these drugs. For this reason, patient risk stratification is paramount to

ensure that only at-risk patients are treated and that they receive the right prophylaxis.

Ongoing clinical research and evidence-based medicine reviews suggest that blanket

approaches that give the same medication to all patients without risk stratification may

not be beneficial and may even cause more harm than benefit.13, 43, 44

New Medications for VTE Prophylaxis

New versions of low molecular weight heparins (LMWH) are being brought to

market, with additional newly approved indications by the U.S. Food and Drug

Administration (FDA). In addition, other medications with different pathways of action

are being researched and approved. Most recently in July 2011, rivaroxiban, an oral direct

Factor Xa inhibitor, was approved by the FDA for prophylaxis of DVT/PE in adults

undergoing hip and knee replacement surgery. Dabigitran, an oral direct thrombin

inhibitor, is FDA approved for prevention of stroke in patients with non-valvular atrial

fibrillation. Although it is not currently approved for VTE prophylaxis in the United

States, it is being used in this capacity in some European countries and Canada. A recent

systematic review and meta-analysis of three novel oral agents, dabigatran, apixaban and

rivaroxaban, for VTE prophylaxis after total hip and total knee replacement surgery

found no difference in net clinical benefit. In fact, this review reported that success in

18

prevention of VTE was inversely associated with clinically relevant bleeding.45 These

findings are indicative of the diminishing returns associated existing medications

developed to prevent VTE and highlight the need to improve prescription of the best-

practice medications currently available.46

Inferior Vena Cava Filters

New technologic advances in devices to prevent DVT from becoming PE via

mechanically trapping the clot in the inferior vena cava before they can reach the heart

and lungs may be beneficial in some patient populations. Although originally designed

for permanent use, multiple approved devices can now be placed for temporary (also

known as “optional” or “retrievable”) prophylaxis and then removed at a later date.

However, the evidence to support the use of this technology is unclear.

For example, the placement of inferior vena cava filers (IVCFs) is rapidly

increasing among trauma patients47 for primary prophylaxis against PE even in patients

without proven DVT. Clinical uncertainty remains about whether prophylactic IVCFs

should be used in trauma. Current guidelines from the American College of Chest

Physicians (ACCP)9 and the Eastern Association for the Surgery of Trauma (EAST)48

have diametrically opposed opinions on the use of IVCFs for primary PE prophylaxis. An

ongoing AHRQ sponsored Evidence-based Practice Center Systematic Review Protocol

entitled “Comparative Effectiveness of Pharmacologic and Mechanical Prophylaxis of

Venous Thromboembolism among Special Populations” will assess the role of IVCFs in

the prevention of pulmonary embolism in trauma and other special populations (including

those patients undergoing bariatric surgery).

19

What Approaches Have Been Used To Improve Appropriate VTE Prophylaxis?

Evolution of information technology is enabling development of more

sophisticated clinical decision support systems to improve compliance with guidelines.

Several recent examples are described below.

Lesselroth et al,49 developed a clinical decision support-enabled order menu in

their computerized patient record system (CPRS) to recommend appropriate VTE

prophylaxis at the time medication orders are written at the Portland Oregon VA Medical

Center. After identifying and addressing some key initial limitations (providers could

unintentionally or intentionally bypass the order menu and recommended guidelines), use

of the order menu increased from 20 percent to 80 percent. This study underscores the

need for interventions to integrate well into provider workflow and ideally be mandatory

without any possibility of ignoring or bypassing the VTE algorithm. Alerts and systems

are only effective if they consistently reach their intended target.

In the study by Beeler et al,50 an electronic alert was displayed in the medical

chart of every hospitalized medical patient who did not have pharmacological or

mechanical VTE prophylaxis ordered within 6 hours after admission and had documented

VTE risk. Rates of thromboprophylaxis orders among medical patients significantly

increased from pre-implementation rates of 43.4 percent to 66.7 percent (p<0.0001)

during the 4 months after implementation. The following year, thromboprophylaxis

orders increased further to 73.6 percent (p=0.011).

Kucher et al,51 proactively searched for hospitalized patients at risk for developing

VTE who were not prescribed prophylaxis (pharmacological or mechanical). Electronic

alerts were sent to providers of patients randomized to the intervention group that their

20

patient was at risk for VTE. Patients in the intervention group were significantly more

likely to receive mechanical prophylaxis (p<0.001) and significantly more likely to

receive prophylactic doses of unfractionated heparin (p<0.001). There were no significant

changes to orders of enoxaparin (p=0.18) or warfarin (p=0.11) between intervention and

control groups. In addition, patients in the intervention group were significantly more

likely to be free from DVT or PE after 90 days (p<0.001). This approach is reactive – it

identifies patients who were not initially ordered prophylaxis and then attempts to correct

the patient safety problem, rather than suggesting and improving rates of prophylaxis at

the appropriate time of initial treatment.

In 2008, a mandatory, computerized decision support-enabled VTE risk

stratification order set was implemented in the computerized provider order entry system

at the Johns Hopkins Hospital to recommend ACCP guideline-appropriate, service-

specific (e.g. medicine, general surgery, trauma, etc.) prophylaxis for an individual

patient’s risk stratum.52 Within the first year, adherence to guideline-appropriate VTE

prophylaxis increased significantly hospital-wide and rates of VTE have been on a

decreasing trend. This system overcomes the downsides of the Kucher approach since it

requires proactive risk stratification during the completion of the admission order set for

all admitted patients and therefore is nearly 100 percent effective at forcing providers to

assign an appropriate risk stratum to all patients within 24 hours of hospital arrival.53

However, this system remains fallible since the guideline-suggested VTE prophylaxis is

merely a recommendation; it is not mandatory and may be ignored.

21

What Have We Learned About These Practices?

What Are the Beneficial Effects of VTE Prophylaxis?

The original “Making Health Care Safer” report focused on the evidence for

effectiveness of specific clinical interventions (i.e. medications and mechanical

prophylaxis) for specific clinical situations, and concluded that there was extensive

evidence supporting their effectiveness and low cost, particularly after certain types of

surgical procedures, trauma, and medical conditions such as cerebrovascular accidents.18

Quality improvement-related interventions such as practice guidelines, clinical decision

support systems, and educational interventions to change provider behavior were

addressed in separate chapters in the original support. A few studies found beneficial

effects of clinical decision support systems and educational interventions, both separately

and combined.

The updated evidence for VTE prophylaxis in selected patients has been well-

described in a variety of recent evidence-based clinical guidelines and systematic

reviews.9, 11, 13 The evidence for clinical interventions for VTE prophylaxis remains

strong in specified populations, and prophylaxis is recommended by practice guidelines

for those patients, although it should not be applied universally. Since the availability of

medications and condition-specific evidence is rapidly evolving and these guidelines are

regularly updated, this evidence is not summarized here, and the remainder of this section

focuses on interventions intended to improve compliance with risk-appropriate VTE

prophylaxis among different patient populations.

22

Interventions to Improve Prophylaxis Adherence

A systematic review of interventions to improve VTE prophylaxis use in

hospitals, based on literature searches from 1996-2003, found 30 eligible studies; only

one was an RCT and only three had concurrent controls. Strategies included passive

dissemination, which had little effect (50% compliance), single-strategy studies (12

studies—audit and feedback, documentation aids, and quality assurance activities all

produced about 80% compliance), and clinical decision support systems approached 100

percent compliance. Twelve studies incorporated two or more strategies, usually

including an educational component, and all demonstrated improvements in use of VTE

prophylaxis. In addition to the types of strategies used in the single-strategy studies, these

studies also included strategies such as advertising, appointment of specific

implementation staff, and recruitment of local change agents or opinion leaders. Most

studies evaluated change in provider behavior, not patient outcomes, and no study that

evaluated outcomes demonstrated a reduction in DVT or PE rates, often due to lack of

adequate power.54

Interventions to improve adherence to prophylaxis include implementation of

clinical decision support tools, financial disincentives, and outcomes reporting. Clinical

decision support tools have the potential to improve adherence to guideline-appropriate

prophylaxis ordering55, 56 which may then have a sustained impact on clinical outcomes.

While this method has classically taken the form of paper-based order-sets, as

computerized provider order entry systems are adopted in hospitals across the country, an

opportunity exists to build electronic clinical decision support into these systems to

23

evaluate, risk stratify patients based on individual patient risk factors and recommend the

appropriate VTE prophylaxis strategies.

Outcomes reporting is another approach to improve VTE prophylaxis, through

feedback and public reporting or the financial incentive of nonpayment for VTE events.

The Centers of Medicare and Medicaid Services (CMS) placed VTE after orthopedic

hip/knee replacement on their list of “never events” for which providers will not be

reimbursed. However, even with best practice, not all VTE events can be prevented;27 it

has been estimated that best practice prophylaxis may reduce incidence of DVT by up to

70 percent.1 Another potential limitation to the use of DVT/PE rates alone to measure

quality is the significant issue of surveillance bias- because many DVTs are clinically

silent and therefore go undetected without routine screening.28 For example, in the field

of trauma surgery, clinical ambiguity persists regarding the clinical and cost effectiveness

of the screening of high-risk asymptomatic trauma patients for DVT with duplex

ultrasound.28 As a result, certain providers and hospitals report higher DVT rates due

entirely to higher rates of diagnostic testing- a classic example of surveillance bias.23, 24, 26

Because of these issues- and variation in patient risk- unadjusted VTE rates are

likely not appropriate for public reporting. A better definition of preventable harm may

be obtained by combining an outcome and process measure rather than relying on an

outcome alone. For example, it has been suggested that only VTE events occurring in

patients who did not receive adequate prophylaxis should be labeled a “preventable

VTE.”28This approach and specific definition has been incorporated as one of the six

Meaningful Use Quality Measures related to VTE,18 although this measure has not yet

been evaluated for its impact on VTE prophylaxis compliance.

24

Conclusions and Comment

Strong evidence from numerous high-quality trials supports the effectiveness of

VTE prophylaxis for specific populations, although there are significant risks and risk

stratification is necessary to ensure that prophylaxis is targeted to appropriate patients.

However, rates of VTE prophylaxis are suboptimal, and VTE remains a difficult and

elusive crisis in patient safety. Less evidence exists on which interventions are effective

for increasing rates of VTE prophylaxis in appropriate populations. As with other patient

safety interventions, educating providers on the benefits of appropriate VTE prophylaxis

alone is not an effective strategy to improve appropriate use of VTE prophylaxis.

Evidence, although mostly low-quality, non-randomized studies without concurrent

controls, supports that education combined with other quality improvement strategies,

and information technology approaches such as mandatory computerized clinical

decision support, appear to offer the most effective approaches to promote best practice

prophylaxis use and prevent patient harm resulting from VTE. A summary table is

located below. (Table 3.1)

Table 3.1 Prevention of Venous Thromboembolism: Brief Update Review Summary

Scope of the Problem Targeted by the PSP (Frequency/Severity)

Strength of Evidence for Effectiveness of the PSPs

Evidence or Potential for Harmful Unintended Consequences

Estimate of Cost

Implementation Issues: How Much do We Know? / How Hard Is it?

Common/Moderate High Moderate (bleeding)

Low Little/Moderate

25

CHAPTER 4

Lessons from the Johns Hopkins Multi-disciplinary Venous Thromboembolism (VTE) Prevention Collaborative52

(reprinted with permission from BMJ – British Medical Journal)

Background

Venous thromboembolism (VTE) is a silent health risk for many inpatients,

causing deaths, complications, and increased medical costs.57, 58 In the US almost

800,000 patients have a VTE and 25% die from pulmonary embolism before medical

intervention every year.59 Treatment is expensive; each deep venous thrombosis or

pulmonary embolism costs an estimated $10,000 (£6,466; €8,076) and $16,000 (£10,345;

€12,921), respectively.60 Complications such as post-thrombotic syndrome affect as many

as 60% of patients with deep venous thrombosis and result in annual socioeconomic costs

of $200m.3, 61

Evidence based consensus guidelines recommend prophylaxis for many

hospitalised patients to prevent VTE. 8Assessment of each patient’s risk for bleeding and

thrombosis is essential to ensure selection of the optimal prophylaxis strategy.

Anticoagulant prophylaxis should be selectively administered given the associated risk of

bleeding, cost, and modest benefits for some patients.13, 62 In the UK, the National

Institute for Health and Clinical Excellence (NICE) has established guidelines for risk

adjusted VTE prevention. However, many patients who would benefit from prophylaxis

do not receive it. In a multinational study, only 58.5% of surgical patients and 39.5% of

medical patients received appropriate VTE prophylaxis.15Another study found that only

42% of patients with deep venous thrombosis had received prophylaxis before its

diagnosis.14 A 2012 study reported that only 40% of Austrian patients in intensive care

26

received prophylaxis in line with guidelines.63 Some agencies are measuring VTEs as

preventable complications to drive quality and pay for performance. The NICE quality

standard requires that “all patients, on admission, receive an assessment of VTE and

bleeding risk” using their criteria,64 although this requirement is controversial.65 Not all

VTEs are preventable,20 which raises concern about using VTE rates as a measure of

healthcare quality.28

In September 2005, patient safety and quality leaders at the Johns Hopkins

Hospital conducted a random chart audit in several high risk patient populations and

found that only 33% of 322 patients received appropriate VTE prophylaxis. The Venous

Thromboembolism (VTE) Prevention Collaborative was established to improve the use

of risk-appropriate prophylaxis at the Johns Hopkins Hospital. This paper describes the

VTE Prevention Collaborative and the methods used to develop and implement a clinical

decision support tool for VTE prophylaxis.

Strategy for change

This prospective quality improvement activity was conducted by a

multidisciplinary team comprised of a haematologist, trauma surgeon, critical care

intensivist, intensive care nurse, pharmacist, several information technology specialists,

an administrative coordinator, and several quality and safety clinical researchers. The

Johns Hopkins Center for Innovation in Quality Patient Care helped coordinate the

collaboration and involvement of all clinical departments. The Johns Hopkins University

Institutional Review Board approved the retrospective collection and analysis of data

from this quality improvement project.

27

The VTE Prevention Collaborative applied the “translating research into practice”

(TRIP) model66 to implement a mandatory clinical decision support tool for VTE risk

stratification and risk-appropriate prophylaxis for all adult inpatients. The TRIP model

has four steps: summarise the evidence, identify local barriers to implementation,

measure performance, and ensure patients receive the interventions.

Step 1. Summarise the evidence and identify quality improvement interventions

After reviewing the VTE prevention guidelines of the American College of Chest

Physicians (ACCP)9 and the Eastern Association for the Surgery of Trauma (EAST),11

the collaborative team identified three pertinent prevention practices: identification of

patient risk factors for VTE and bleeding, stratification of patients into VTE risk

categories with corresponding recommendations for prophylaxis, and provision of

alternatives for patients with contraindications to drug prophylaxis.

Checklists have proved effective in other areas of healthcare, having helped

improve safety attitudes and evidence based practices for infection control and reduce

postoperative complication rates and infection rates.67, 68 Thus, in early 2006, paper order

sets were developed to standardise the VTE prevention process. (Figure 4.1) A one page

paper order set was created for each of six clinical services with high patient throughput

(such as orthopaedics, medicine, surgery, trauma, and neurology and neurosurgery) that

were willing to participate in the collaborative. We hypothesised that specific forms for

each service would increase provider buy-in. Clinician researchers from the VTE

collaborative met with representatives from each clinical service to explain the

collaborative’s aims and gain consensus from both administrative and frontline staff.

28

Figure 4.1 Example of paper order set for prevention of venous thromboembolism

in surgery departments (includes general surgery, surgical oncology, urology, and

vascular surgery)

29

Step 2. Identify local barriers to implementation through pilot testing

The paper order set for surgery was pilot tested in 2006 to determine the

feasibility and usability of the form. The form guided clinicians through the risk

stratification process and recommended appropriate VTE prophylaxis. Once completed,

the sheet was deposited in a designated box for collection by the collaborative’s

coordinator. Some surgical services required individual physicians to complete the form,

whereas others designated one provider to complete all the forms. Although the latter

strategy ensured consistent risk assessments, this approach also posed problems. For

example, order set compliance was nearly 100% on one service where a single, dedicated

nurse practitioner assessed patients, but this plummeted to nearly zero compliance when

she was on vacation.

Clinicians found the paper order set time consuming to locate and complete, and it

was not part of their normal workflow for order entry. Also the collaborative team found

it resource intensive to track provider performance given the large patient volume. The

paper forms were visually challenging for users given the large number of risk factors for

VTE and bleeding and the corresponding variety of prophylaxis options (Figure 4.1). In a

systematic review, Tooher et al concluded that a combination of active reminders and

prophylaxis recommendations was the most effective strategy to increase the use of VTE

prophylaxis.54

Given this information and the hospital’s transition to computerised physician

order entry (CPOE), the collaborative team approached the hospital’s information

technology department in 2006 to design a CPOE based clinical decision support tool.

The VTE clinical decision support tool included a forcing function to make risk

30

assessment mandatory, a default feature that recommended risk-appropriate prophylaxis,

and an auto-populate feature that displayed relevant medical information from the

patient’s electronic medical record (such as age, weight, haemostatic parameters,

estimated creatinine clearance). We made the VTE prophylaxis module a mandatory field

in CPOE admission and transfer order sets because evidence suggests technology based

change is difficult if it is not hardwired into the clinical workflow.49 Once risk

stratification is complete, clinicians can order the recommended prophylaxis or a

different prophylaxis option. As some physicians had complained that the paper order

sets were too general for their specialised patient population, we developed 16 evidence

based, specialty specific VTE order sets in collaboration. (Figure 4.2 shows the general

surgery module).

The first VTE prophylaxis order set was pilot tested in July 2007 on the

orthopaedic spine surgery service. The order sets for internal medicine, general surgery,

trauma surgery, orthopaedic hip and knee replacement, orthopaedic shoulder

replacement, and orthopaedic trauma were activated in December 2007. Subsequent order

sets for cardiac surgery, otolaryngology, neurology, neurosurgery, and obstetrics and

gynaecology were debuted at three month intervals throughout 2008. Medical oncology

was brought online in 2009. From an informatics and user perspective, the collaborative

found it much easier to develop and implement multiple specialty-specific order sets

rather than one large complex order set. For example, if one large surgery order set was

designed, we found that the risk stratification process would be too cumbersome and time

consuming for providers. Designing specialty-specific order sets allowed us to customise

and condense the risk stratification and prophylaxis selection process.

31

Figure 4.2 Example of computer algorithm for prevention of venous

thromboembolism in general surgery department

Step 3. Measure performance

The collaborative team initially focused on measuring process measures such as

the percentage of patients risk stratified within 24 hours of admission and ordered risk-

appropriate VTE prophylaxis. Reports were generated monthly and distributed to

departmental leaders and quality management staff. To facilitate data analysis and

distribution, a web based VTE prophylaxis database was constructed that allowed

performance assessments on institutional, departmental, divisional, service, and

individual provider levels.

32

Step 4. Ensure patients receive the intervention by engaging staff, executing the

intervention, and evaluating performance

The collaborative used multiple methods to engage and educate stakeholders

throughout the organisation. Departmental meetings were held to summarise the evidence

for VTE prophylaxis and to demonstrate the order sets. Annual hospital-wide symposia

were held featuring world renowned VTE experts, personal stories from individual

patients with VTE, and the latest results from the Johns Hopkins VTE Prevention

Collaborative. The collaborative has worked closely with local service champions (such

as in hospital medicine, plastic surgery, medicine) to catalyse improvement on a local

level. For example, the physician champion from hospital medicine has developed a “pay

for performance” initiative linking individual performance on VTE prophylaxis with

bonus compensation. On the medicine service, the physician champion has organised a

competition among the house staff services, awarding a pizza party to the service with the

best VTE prophylaxis performance at year’s end. On a departmental level, monthly audits

of VTE prophylaxis performance were conducted to motivate continual performance

improvement.

Changes after interventions

The paper based order sets increased VTE risk assessment and risk-appropriate

prophylaxis. (Figure 4.3) Among surgical patients, orders for risk-appropriate

prophylaxis increased from 26% (42/161 patients sampled) at baseline to 68% (178/262)

over a 12 month period. In 2008, the first year after the CPOE modules were installed,

risk-appropriate prophylaxis was ordered for 72% of surgery patients and 80% of

medicine patients. (Figure 4.3) In 2011 risk-appropriate prophylaxis was ordered for

33

80.2% (5159/6433) of surgery patients and 92.2% (10,162/11,024) of medicine patients.

A more than threefold improvement in prophylaxis compliance was seen between

baseline and the most recent year (2011) of the computerised decision support tool. In a

recently published before and after study of adult trauma patients, we showed that

compliance increased significantly (66.2% v 84.4%, P<0.0001) and preventable harm

from VTE decreased dramatically (1.0% v 0.17%, P=0.037).53

Figure 4.3 Changes in venous thromboembolism (VTE) risk assessment for medical

and surgical inpatients at key points in the implementation of a clinical decision

support tool for VTE risk stratification

Figure 4.4 displays the steadily increasing effect of continuous data and

performance feedback to clinicians and managers for medicine and surgery from 2008

through 2011. Similar to other studies,50 we saw a temporary decline in process measure

performance during the initial implementation phase when physicians were learning to

use the computerised decision support tool.

34

Figure 4.4 Changes in venous thromboembolism (VTE) risk assessment for medical

and surgical inpatients since implementation of a computerised clinical decision

support tool for VTE risk stratification

Lessons learnt and next steps

We found that the key ingredient to sustained performance improvement in a

large healthcare organisation was a core team of dedicated multidisciplinary professionals

who were willing to work with frontline clinicians to develop a VTE prophylaxis strategy

that integrated seamlessly into the existing process for healthcare delivery. While top-

down VTE prophylaxis interventions have improved compliance in UK hospitals, we

found that a bottom-up approach was more effective and sustainable in our work

environment.

We also learnt that institution-wide involvement was imperative because of the

large number of patients at risk for VTE. This necessitated a team with broad and varied

expertise (including administration, informatics, medicine, patient safety, and quality

35

leaders) and buy-in from all levels of the organisation, from frontline care providers to

the president of the hospital and chief executive officer of the health system. Our

multidisciplinary collaborative team allowed us to garner the necessary support from

leadership and provided the credibility to engage providers and convince them of the

need for change across the organisation. We engaged clinical champions in each specialty

to ensure that our prevention strategies were congruent with current clinical practice and

best practices.

We found that education helped convince providers of the need for change, but a

forcing function was also necessary to ensure consistent performance. The VTE

prophylaxis order sets had to be efficient, evidence based, user friendly, and firmly

integrated into routine workflow, and had to allow for real-time performance assessment

and feedback. The paper order sets provided standardisation of VTE prevention but were

labour intensive for users, lacked a forcing function, and made compliance assessment

difficult. These shortcomings were eliminated with our computerised VTE prophylaxis

order sets.

Moving forward, we will continue to monitor the literature on VTE prophylaxis to

ensure our decision support modules remain current. We are also considering switching

from an “opt in” system (prophylaxis is suggested and provider must select it) to an “opt

out” system (provider must actively decline the default prophylaxis and possibly give a

reason) in an attempt to further increase compliance with risk-appropriate prophylaxis.

Opt out orders have increased compliance rates with evidence based guidelines in other

inpatient settings. We are also considering the feasibility of reminder alerts to prompt

providers who initially documented contraindications to drug prophylaxis to reconsider

36

these contraindications at a later point in the hospital stay and perhaps start drug

prophylaxis. In addition, we plan to roll out the computerised VTE prophylaxis modules

to other hospitals in Johns Hopkins Medicine.

Future research will focus on evaluating the impact of our modules on risk-

appropriate prophylaxis, rates of symptomatic VTE, and cost savings. VTE in

hospitalised patients is a global health issue, and standardised methods of risk assessment

and appropriate prophylaxis are needed. We implemented a VTE prevention

collaborative in a large academic medical centre that was adequately resourced to

develop and implement a computer based tool. We are confident this model would work

in similar hospitals around the world. Smaller hospitals and hospitals with limited

resources could use mandatory paper based order sets.

37

CHAPTER 5

Improved Prophylaxis and Decreased Rates of Preventable Harm With the Use of a Mandatory Computerized Clinical Decision Support Tool for Prophylaxis for Venous Thromboembolism in Trauma53

(reprinted with permission from JAMA-Surgery)

Introduction

Venous Thromboembolism (VTE), which includes pulmonary embolism (PE) and

deep vein thrombosis (DVT), is one of the most common22 and deadly complications

among trauma patients. Although some VTE events are unavoidable,20 data suggest that

most events are preventable with proper prophylaxis.10, 11 Studies,14, 15 however, have

repeatedly shown that most hospitalized patients are not given appropriate DVT

prophylaxis. Goldhaber equates the “disconnect between evidence and execution as it

relates to DVT prevention . . . to a public health crisis.”16 The Agency for Healthcare

Research and Quality suggests that appropriate VTE prophylaxis is the number one

patient safety initiative needed to prevent in-hospital death.17

Many strategies have been attempted to improve adherence to evidence-based

VTE prophylaxis in different patient populations, thereby trying to improve the quality of

medical care. A systematic review of these strategies showed that passive dissemination

and education alone are unlikely to improve VTE prophylaxis. They suggested that a

reminder to clinicians to assess the patient for VTE risk and help with their selection of

the appropriate prophylaxis would likely be the strategy to achieve the best outcomes.54 A

preemptive reminder to use VTE prophylaxis in surgical patients did increase adherence

rates, but it did not change VTE outcomes.69 A computerized alert system that warns

38

physicians after prophylaxis has been omitted has shown some benefit; however, this

system reacts to, rather than defends against, a potential error.51

Clinical decision support (CDS) tools improve the application of evidence-based

medicine to patient care,70 including within the realm of VTE prevention specifically.55,

56 However, the Director of the Agency for Healthcare Research and Quality notes that

“despite their clear advantages, uptake and motivation to acquire CDS systems remain

low.”71 The widespread application of computerized provider order entry (CPOE)

systems is an appropriate platform in which to build a CDS tool that targets VTE

prevention. However, these systems must be seamlessly integrated into provider

workflow to be successful.71, 72 Our study evaluates the effect of a CPOE based

mandatory CDS module on physician compliance with evidence-based VTE prophylaxis

and on VTE outcomes in an adult trauma patient population. We hypothesized that

implementation of the VTE CDS module would increase the proportion of trauma

patients receiving evidence-based VTE prophylaxis, would decrease the proportion of

VTE events, and would decrease the rate of preventable harm from VTE.

Methods

Study Design and Setting

Our study retrospectively analyzed the effect of a mandatory CPOE-based, CDS-

enabled VTE order set on provider compliance with prophylaxis guidelines and on

outcomes among adult trauma patients. The computerized VTE order set was

implemented on December 17, 2007, at the Johns Hopkins Hospital and a specific

module was used for trauma patients.52 The Johns Hopkins Hospital is part of an

academic medical center, with a state-designated level 1 trauma center, serving an urban

39

community in Baltimore, Maryland. We searched the Johns Hopkins Hospital Adult

Trauma Center registry (Collector Trauma Registry, Digital Innovation, Inc.) for patients

who were admit- ted directly to the adult trauma service between January 1, 2007, and

December 31, 2010, and hospitalized for more than 1 day. Patients admitted in 2007

served as our baseline group, and we compared them with patients in the post

implementation group (i.e., patients admitted between 2008 and 2010). Our study was

approved by the Johns Hopkins University School of Medicine institutional review board.

VTE Order Set

The mandatory CPOE-based, CDS-enabled VTE order set was developed to

improve compliance with best practice VTE prophylaxis for all hospitalized patients.

Once the ordering provider entered the CPOE, they had to complete short checklists of

VTE risk factors and contraindications to pharmacologic VTE prophylaxis. The order set

then deployed an evidence-based algorithm to identify the patient’s risk stratification

level and recommended the appropriate VTE prophylaxis regimen. (Figure 5.1)

Prophylactic enoxaparin sodium (low- molecular-weight heparin) was the preferred drug

suggested for the majority of trauma patients without a documented contra indication to

pharmacologic prophylaxis. Mechanical prophylaxis with sequential compression devices

was suggested for trauma patients with contraindications to pharmacologic prophylaxis.

(Figure 5.1) Providers were not required to follow the CDS suggested order. The

algorithm was initially developed using previous iterations of evidence-based guidelines8,

11 and has been re- examined and modified as guidelines are updated.10

40

Figure 5.1 Algorithm for risk-appropriate VTE prophylaxis in hospitalized trauma

patients

VTE Risk Factors Spinal cord injury Lower extremity fracture Pelvic fracture Severe head injury (AIS>2) Injury Severity Score >8 Shock at admission (SBP<90) Surgical procedure (>30 mins) Age > 40 Femoral venous line insertion Prolonged immobility Prior DVT/PE

Contraindications High risk of bleeding Traumatic Brain Injury Solid organ injury Pelvic/Retroperitoneal hematoma Ocular Injury with hemorrhage Active bleeding Systemic anticoagulation INR ≥ 1.5 or aPTT ratio ≥ 1.3 Platelet count < 50,000

Specific contraindication to enoxaparin

Indwelling epidural catheter Renal insufficiency (CrCl <30)

*VTE Risk Factors

Yes

No

Yes

No No

Yes

Yes

No

Yes No

Yes

No

Yes

No

*Contraindications

Use TEDs/SCDs until contraindication is no longer present. Perform serial duplex surveillance.

Consider vena caval (temporary) filter in high-risk patients.

*Contraindications

Freely Ambulatory

*Contraindications

No pharmacologic prophylaxis needed. Use TEDs/SCDs

No pharmacologic prophylaxis needed. Use TEDs/SCDs

*Specific contraindication to enoxaparin

*Specific contraindication to enoxaparin

Use TEDs/SCDs until contraindication is no longer present. Perform serial duplex surveillance.

Consider vena caval (temporary) filter in high-risk patients.

Unfractionated Heparin 5000 units sc q8h

Plus TEDs/SCDs Perform serial duplex surveillance.

Unfractionated Heparin 5000 units sc q8h

Plus TEDs/SCDs Perform serial duplex surveillance.

Enoxaparin 30 mg sc q12h Plus TEDs/SCDs

Perform serial duplex

Enoxaparin 30 mg sc q12h Plus TEDs/SCDs

Perform serial duplex surveillance.

41

Data Collection

We extracted the following variables for all patients from the adult trauma

registry: demographics (age, race, and sex), injury characteristics (Injury Severity Score,

Glasgow Coma Scale score at admission; trauma type [blunt or penetrating]; whether

there was shock at admission, which was defined as a systolic blood pressure of <90 mm

Hg; and Abbreviated Injury Scale score by body region), admitting service, hospital

length of stay, and VTE events.

For the baseline period (2007), one researcher (F.S.K.) re- viewed each patient’s

medical record to collect the following VTE-related variables: provider documentation of

VTE risk stratification, patient VTE risk factors, contraindications to pharmacological

prophylaxis, and written orders for prophylaxis (pharmacological and/or mechanical)

within 24 hours of ad- mission. For the post implementation period (2008-2010), these

variables were extracted directly from the CPOE system. Compliance with appropriate

best practice VTE prophylaxis was de- fined as adherence to our trauma service-specific

VTE prevention algorithm.

Statistical Analysis

Descriptive data were summarized as proportions. We compared the

demographic characteristics, injury characteristics, and VTE prophylaxis data (risk

stratification, appropriate prophylaxis order, and type of prophylaxis) of patients during

the baseline period with those of patients during the post implementation period, using

the 2-sided χ2 test for categorical variables and unpaired t tests for continuous variables;

interquartile ranges were reported for the Injury Severity Score and hospital length of

stay. Because VTE event rates were relatively small, we used the 2-sided Fisher exact test

42

to compare proportions of patients with VTE, DVT, and/or PE during the baseline period

with proportions of patients with VTE, DVT, and/or PE during the post implementation

period.

We defined the incidence of a potentially preventable VTE as a DVT or PE event

occurring in a patient who was not ordered the guideline-appropriate prophylaxis for their

specific VTE risk factors. This definition was based on the Centers for Medicare and

Medicaid Services requirements for meaningful use of Electronic Health Record systems

and other suggested approaches for reporting preventable harm.28, 38, 73 Using this

definition is well accepted by clinicians and in quality/safety research. Providers are not

penalized for VTE cases that occur in patients who were ordered best practice

prophylaxis measures because it is well accepted that VTE events occur in this

population.20 Quality/safety experts are able to identify reasonable targets for

improvement, and the goal of zero “preventable harm” is reasonable.

Data from the trauma registry were linked to results from the manual chart review

(baseline) and results from the CPOE (post implementation) using a relational database

(Microsoft Access; Microsoft, Inc.), matching the patient’s first and last names, medical

record number, and admission date (±1 day). All statistical analyses were performed

using STATA version 11.0 (StataCorp).

Results

We identified 1603 hospitalized adult trauma patients meeting our study criteria

between 2007 and 2010. The paper medical records for 4 patients from 2007 (baseline)

were not available, resulting in a total 1599 patients being included in our analysis. The

trauma patient populations in the baseline and post implementation periods were similar

43

in mean age, distribution by race, the majority being male, the proportion with blunt

trauma, the proportion presenting in shock or with a decreased Glasgow Coma Scale

score, and hospital length of stay. (Table 5.1)

Table 5.1 Characteristics of 1599 Hospitalized Adult Trauma Patients

VTE Risk Stratification

Documentation of VTE risk stratification within the first 24 hours of admission

was identified in only 3.0% of the baseline group (12 of 399 patients). This proportion

increased dramatically to 97.8% (1174 of 1200 patients) in the post implementation

group (P < .001).

Compliance with Evidence-Based VTE Prophylaxis

The compliance rate for evidence-based VTE prophylaxis was 66.2% at baseline

compared with 84.4% for the overall post implementation period (P < .001). (Figure 5.2)

The compliance rate decreased to 46.7% in the first post implementation quarter

(compared with 72.2% in the first quarter in 2007 [P < .001]) and then increased to more

44

than 90.0% by the third quarter of 2008 (P < .001). The highest quarterly compliance rate

(95.6%) occurred in 2009.

Figure 5.2 Trends in venous thromboembolism (VTE) prophylaxis and events in

hospitalized adult trauma patients

The overall percentage of patients who received enoxaparin (the preferred

prophylaxis for most trauma patients) was 35.8% at baseline compared with 48.8% for

the post implementation period (P < .001). (Figure 5.3) In the post implementation

period, the rate increased from 43.4% in 2008 to 52.6% in 2010 (P < .001). Orders for

sequential compression devices were high for the entire study period. One exception was

the first quarter of 2008, when the rate dropped below 50% (data not shown).

45

Figure 5.3 Proportion of hospitalized adult trauma patients who received venous

thromboembolism (VTE) prophylaxis

In 2007, 2.8% of hospitalized trauma patients were not ordered any prophylaxis.

The number of patients not ordered any prophylaxis increased in 2008 to 10.4%, and this

increase occurred almost entirely during the first quarter post implementation period

(44.4%). For the remainder of 2008, 99.1% of patients were ordered some form of

prophylaxis (P = .13), and this number increased in 2009 and 2010 to 99.7% and 99.5%,

respectively (P < .001).

When examining trauma patients with and without documented contraindications

to pharmacologic prophylaxis, we found that the compliance rates remained high for

46

those with a documented contraindication during the entire study period (Figure 3). In

patients without a documented contraindication, compliance rates increased from 40.6%

at baseline to 74.2% for the post implementation period (P < .001). (Figure 5.4)

Figure 5.4 Compliance rates among hospitalized adult trauma patients, stratified by

those with or without documented contraindications to pharmaceutical prophylaxis

for venous thromboembolism

47

VTE Events

Of 1599 patients, 35 (2.18%) had experienced VTE events; 12 patients (0.75%)

experienced PE-only events, and 21 patients (1.31%) experienced DVT-only events. Two

patients in the post implementation period experienced both DVT and PE events. The

proportion of VTE events were 3.0% at baseline compared with 1.25% for the final post

implementation year (P = .23). (Table 5.2) The PE rate remained relatively constant

during the study period, whereas the DVT rate decreased from 2.26% at baseline to

0.25% for the final post implementation year (i.e., 2010) (P = .02).

Table 5.2 Trauma Patients With Venous Thromboembolism (VTE) Events From

2007-2010

Potentially Preventable VTE Events

In the baseline year, 4 patients (1.00%) experienced potentially preventable VTE

events (a patient with VTE was not ordered risk-appropriate prophylaxis) compared with

2 patients (0.17%) who experienced potentially preventable VTE events during the 3-year

post implementation period, representing an 83% relative risk reduction in preventable

harm (P = .04). (Table 5.2) All 4 events in 2007 were DVT events (2 large symptomatic

and 2 asymptomatic), and both patients who experienced preventable VTE harm in 2010

had a symptomatic PE. There were no potentially preventable VTE events identified in

2008 and 2009.

48

Comment

We found that implementation of a CPOE-based, mandatory CDS module

significantly improved compliance with evidence-based VTE prophylaxis orders for

hospitalized adult trauma patients. The majority of this improvement stemmed from

increased compliance rates among patients without contraindications to pharmacologic

prophylaxis. Patients with contraindications were consistently ordered sequential

compression devices, resulting in high compliance rates. We also found a decrease in

VTE events over time after the tool was implemented, with a 36% relative risk reduction

in VTE events and an 83% relative risk reduction in preventable harm, defined as VTE

events occurring in patients not ordered appropriate prophylaxis.

Despite evidence demonstrating the beneficial effects of prophylaxis, VTE

prophylaxis remains underutilized across many patient populations.15 Trauma patients are

at very high risk,1 and we should be vigilant about prophylaxis. Few large studies have

looked at VTE compliance in trauma. In a retrospective review of data from 18 level

1 trauma centers across the United States, we noted about an 80% prophylaxis

compliance rate.74, 75 This finding is in stark contrast to another study that reported

prophylaxis orders in 25% of patients within 48 hours after receiving trauma.76 These

data and our baseline compliance rate suggest that trauma patients may be getting VTE

prophylaxis at higher rates than other medical and surgical patients.14, 15 Perhaps a well-

defined protocol for trauma care, which has been shown to improve outcomes in

trauma,77, 78 also helps to increase compliance with VTE prophylaxis. In our study, we

observed nearly a 2-fold improvement in prophylaxis orders among patients with no

contraindications to enoxaparin. This group likely benefitted the most from the computer-

49

based CDS module. These rates, however, are still well below the 100% goal of

providing appropriate prophylaxis for all patients that we should strive to achieve.

Although many types of interventions have attempted to increase the use of

prophylaxis, our proactive, mandatory approach has been shown to be one of the most

effective. More passive strategies, such as laminated cards or educational efforts, are

likely familiar to many providers but were found to be relatively ineffective in increasing

prophylaxis compliance rates.54 Computer-generated alerts that search for omitted

prophylaxis orders have shown some improvement51; however, this still provides a

window of time wherein the patient remains at risk for a VTE event. The CDS VTE order

set at our hospital was a mandatory field in the CPOE system, forcing providers to

complete the VTE risk stratification module. The only way to avoid completing the

module was to abandon the entire admission order set. The CDS tool then suggests the

correct prophylaxis regimen and makes ordering easy. We saw significant increases in

prophylaxis orders once the CPOE-based module was implemented. We mandate risk

stratification (a joint commission mandate at the time of implementation) for all admitted

adult patients during the initial ordering process at admission.

The cost of quality improvement interventions must always be considered when

deciding on where to expend time, energy, and financial resources. We recognize that our

approach requires the existence or implementation of an electronic health record system,

which is the largest expense. The development of specific VTE prophylaxis algorithms

for different patient populations would result in a relatively small incremental cost above

that of the electronic health record base system. This proof-of-concept shows a glimpse

into the future at how computerized CDS can effect other areas of quality, patient safety,

50

and efficiency.79Implementation of this successful CDS tool would satisfy one of the core

measures of meaningful use, enabling health care organizations to take advantage of

financial incentives, perhaps offsetting the cost of implementing such a system.73

Paper-based CDS has a clinically beneficial history in health care, but a

computerized tool is likely a far superior approach. The Director of the Agency for

Healthcare Research and Quality has suggested that CDS systems “help clinicians make

better decisions by increasing adherence to evidence-based knowledge and reducing

variations in clinical practice.”71 As CPOE systems are promulgated across the country,

integrating CDS is a natural and more efficient next step. Inpatient computerized CDS

has improved some process measures.80 We demonstrated similar improvements in

process measures, including risk stratification for VTE and ordering of appropriate

prophylaxis. Moreover, we went further to show clinical outcome benefits with

significantly lower preventable VTE event rates. Not many studies have shown

improvements in specific clinical outcomes, particularly an outcome that is clinically

relevant and currently reported nationally in many regards as an accepted quality

measure.

Even with all the suggested benefits, there are some inherent limitations in the

design, implementation, and effectiveness of computerized CDS. Our study, similar to

others,49, 50 saw a temporary worsening in process measure compliance during the

learning phase when the CDS tool was first implemented. Nonetheless, compliance re-

bounded and improved to well above baseline levels. In addition, our data suggest that

compliance waned slightly with time, prompting our group to reinstitute an ongoing

educational program about the importance of VTE prophylaxis. Our findings support the

51

systematic review showing that a combination of methods is the best approach.54 We

chose to link the patient type to the parent order set used, which provided specific

prophylaxis recommendations, rather than having the provider choose the exact patient

type (e.g., trauma, surgery, medicine, orthopedics, or obstetrics). Physicians treating

trauma patients could have chosen another order set (e.g., general surgery), which could

give different prophylaxis suggestions; some providers may have ordered an alternative

prophylaxis (i.e., unfractionated heparin) that was considered noncompliant for trauma.

When the VTE CDS tool was being designed, we initially hoped to implement a program

in which the suggested VTE prophylaxis would be automatically ordered, while giving

the provider a chance to opt out. However, some clinicians and administrators thought

this would remove too much clinician autonomy, and we were forced to use a different

approach that gave a suggestion that the provider could choose to accept or ignore.

Ultimately, the decision to order VTE prophylaxis remains entirely with the ordering

provider. Perhaps this opt-in approach is less effective.75, 81

There were several limitations to our study. First, our baseline data collection

required paper chart review, wherein there was no prompt to document VTE risk

stratification (which is shown by the 3% documentation rate of VTE risk assessment).

Second, overall VTE rates remained too low to provide sufficient power to detect

statistically significant decreases in PE, DVT, or overall VTE events. Third, surveillance

bias exists when considering reporting of DVT after trauma. There is wide variation in

practice patterns regarding the use of surveillance duplex ultrasound in high-risk

asymptomatic trauma patients, which has affected the DVT rate identified after major

trauma.23-25, 28, 77 Although this is a known limitation in many studies of DVT as an

52

outcome, our study is partially protected from this bias because it was performed at a

single institution with a well-established standardized protocol to screen high-risk

asymptomatic trauma patients for DVT. This protocol was instituted years before the

beginning of this study. Moreover, there was no change in protocol that would suggest

that we found higher rates of DVT because we looked more aggressively in certain

patient populations.24

Rates of VTE have been used and suggested as a measure of quality of medical

care; however, there are potential pitfalls in their use.20, 28 Although some complications

(e.g., central line–associated bloodstream infections) can be eliminated with the adoption

of best practices and simple interventions, such as checklists,21, 33 VTE is inherently

different. The prevention for VTE (i.e., the use of low-dose anticoagulants) comes with

associated risks and cannot simply be used for all patients. In addition, even these

medications are not 100% effective at pre- venting all VTEs.20 We agree that continued

improvements in prophylaxis are needed to decrease rates of DVT and PE, but VTE

cannot be classified as a “never event.” Newer definitions of preventable harm that link

an adverse event to a lapse in best practices is the preferred approach.20, 27, 38 This

methodology has been adopted by the US government in their “meaningful use” for

health care information technology when describing VTE.73 This definition of

preventable harm places VTE in patients not receiving prophylaxis in the numerator and

all patients in the denominator, giving a proportion with “preventable harm,” which we

agree can have a goal of zero. Using this definition, we demonstrated a dramatic decrease

in preventable harm from VTE (1.0%-0.17%; P = .04) for admitted adult trauma patients,

including 2 full years with no preventable harm VTE events.

53

CHAPTER 6

Impact of a Venous Thromboembolism Prophylaxis “Smart Order Set”: Improved Compliance, Fewer Events82

(reprinted with permission from American Journal of Hematology)

Introduction

Venous thromboembolism (VTE), a disease entity that includes deep venous

thrombosis (DVT) and pulmonary embolism (PE), is estimated to affect over 700,000

Americans each year.59 Although VTE is often associated with major surgery in the

minds of many healthcare providers, medical patients constitute the majority of patients

who suffer an episode of VTE.14, 59, 83-86 Numerous randomized clinical trials and

systematic reviews have documented the efficacy of pharmacologic VTE prophylaxis in

medical inpatients.9, 62, 87-91

Despite these data, many hospitalized patients, particularly medical inpatients, do

not receive risk-appropriate VTE prophylaxis.14, 92, 93 Since PE is a common cause of

potentially preventable mortality in hospitalized patients 94, 95, patient safety advocates,

healthcare accrediting organizations and regulatory agencies, including the office of the

US Surgeon General, have made VTE prevention a priority.2, 57 In fact, the Agency for

Healthcare Research and Quality (AHRQ) has placed “interventions to improve

prophylaxis for VTE” on its list of “strongly encouraged patient safety practices” in its

Updated Critical Analysis of the Evidence for Patient Safety Practices.96, 97

A number of strategies have been employed to improve VTE prophylaxis

practices including educational programs, consultation services, and clinical decision

support (CDS) tools in the form of electronic alerts as well as computerized provider

order entry (CPOE)-based VTE prophylaxis order sets.51, 53, 80, 98-101 In 2005, we launched

54

a multidisciplinary effort to improve VTE prophylaxis at the Johns Hopkins Hospital

after noting suboptimal VTE prophylaxis practices among healthcare providers. To

address this care deficit, we developed a series of evidence-based, specialty-specific

“smart order sets” that were embedded in admission and transfer order sets in the CPOE

system as a mandatory field.52 The purpose of this study is to examine the impact of our

“smart order set” on VTE prophylaxis and events in medical inpatients.

Materials and Methods

Development of an evidence-based specialty-specific “smart order set” for VTE

prophylaxis in Internal Medicine inpatients

As part of a hospital-wide quality improvement project to improve VTE

prevention, we developed and implemented a VTE risk stratification and prophylaxis

recommendation tool for all admitted medically ill patients. A mandatory CDS tool was

embedded within all admission and transfer order sets within our CPOE system; it

requires providers to complete two simple checklists to assess every patient’s VTE risk

factors and contraindications to pharmacologic prophylaxis. Based upon provider

responses, the order set shows the optimal risk-appropriate choice for VTE prophylaxis

and an order grid positioned immediately below the text box facilitates rapid risk-

appropriate VTE prophylaxis ordering. The “opt-in” order set recommends but does not

mandate prophylaxis selection; the ordering provider is free to order any prophylaxis, or

omit prophylaxis altogether. Once VTE prophylaxis orders are placed, the “smart order

set” saves all the information in data tables for analysis. The Internal Medicine “smart

order set” for VTE prophylaxis was activated on December 17, 2007. Detailed methods

55

of the implementation of this intervention hospital-wide have been previously

published.52, 53

Major risk factors for VTE were selected based on study entry criteria for three

major randomized controlled trials of VTE prophylaxis for medically ill patients

(PREVENT, MEDENOX, and ARTEMIS) and the American College of Chest

Physicians guideline.9, 62, 89, 102 In hospitalized medical patients with one or more major

VTE risk factors and no contraindications to pharmacological VTE prophylaxis (Figure

6.1), unfractionated heparin (UFH) 5000 units subcutaneously (SQ) thrice daily (TID) is

recommended, while for medical patients without any major VTE risk factors and no

contraindications to pharmacologic prophylaxis, UFH 5000 units SQ twice daily (BID) is

recommended. Mechanical prophylaxis (sequential compression devices ± graduated

compression stockings) is recommended for patients with any contraindication to

pharmacological VTE prophylaxis. Patients receiving therapeutic dose anticoagulation

are not required to have any additional prophylaxis ordered. Due to the increased risk of

developing VTE associated with hospitalization, we recommended some form of

prophylaxis, either pharmacological or mechanical, for all medically ill patients in the

absence of therapeutic dose anticoagulation.103

56

Figure 6.1 Flow chart describing the major components of the “smart order set”:

the major risk factors for VTE, the contraindications, and decision-making

algorithm

*Major Risk Factors Age older than 60 years Cancer (active or on chemotherapy) Previous VTE Acute Cerebrovascular event with

paresis (within last 3 months) Thrombophilia Decompensated New York Heart

Association (NYHA) Class III/IV congestive heart failure

Respiratory failure (ventilator-dependent)

Clinically-significant infection/sepsis Pregnancy/post-partum state

‡Contraindications High risk of bleeding Active bleeding Systemic anticoagulation INR ≥ 1.5 or aPTT ratio ≥ 1.3 Platelet count < 50,000/µL

57

Study Design, Outcomes, Measures, and Data Collection

Study Design

We hypothesized that implementation of a VTE prophylaxis “smart order set”

would increase orders for risk-appropriate VTE prophylaxis and decrease VTE events

without compromising safety (as measured by prophylaxis-associated bleeding). To test

this hypothesis, we designed a retrospective cohort study of all patients admitted to the

Internal Medicine service at the Johns Hopkins Hospital during November 2007 (the

month immediately prior to the smart order set activation) and April 2010 (the last month

prior to initiation of data collection). The only exclusion criterion was a hospitalization of

24 hours or less. Study approval was obtained from the Johns Hopkins Institutional

Review Board.

Outcomes and Measures

The primary efficacy endpoints were: (1) the proportion of patients ordered risk-

appropriate VTE prophylaxis, (2) the proportion of patients with symptomatic VTE

during hospitalization and up to 90 days post discharge, and (3) the proportion of patients

with preventable harm from VTE. Preventable harm was defined as VTE in the absence

of risk-appropriate prophylaxis.104 The primary safety end- points included: (1) the

proportion of patients with major bleeding events during hospitalization and (2) in-

hospital all-cause mortality. We also evaluated the number of patients prescribed: (1) any

form of VTE prophylaxis, (2) any pharmacologic VTE prophylaxis, and (3) mechanical

VTE prophylaxis.

58

Data Collection

The Johns Hopkins Electronic Patient Record (EPR) and CPOE system were

manually reviewed for all the patients in both cohorts for the index hospitalization and for

90 days post discharge. Follow-up was limited to electronic documentation and

radiologic studies in our electronic system. The following data elements were retrieved

by hand review of the electronic medical record for all patients admitted to the Internal

Medicine service: age, gender, race, VTE risk factors, and contraindications to

pharmacologic prophylaxis present at the time of admission, ordered VTE prophylaxis or

therapeutic anticoagulation, major bleeding episodes during the hospitalization, and

objectively documented episodes of symptomatic VTE during the index hospitalization

and up to 90 days post discharge. The definitions we used for these items are provided in

Table 6.1.105-107 We also recorded all deaths during the index hospitalization and the 90-

day post-discharge follow-up period.

VTE risk was categorized as high or moderate using a risk stratification model

from the order set based upon the presence of VTE risk factors. Prophylaxis was defined

as risk-appropriate if the ordered prophylaxis matched the recommendations generated by

the VTE prophylaxis smart order set. (Figure 6.1) Patients receiving therapeutic

anticoagulation at the time of admission were considered to have risk-appropriate

prophylaxis since no added prophylaxis was warranted.

59

Table 6.1 Definitions Used for Data Collection

Statistical analyses

We compared patient demographics, risk factors and contraindications for

pharmacologic VTE prophylaxis for patients in the pre- and post-implementation groups

using two-sided chi square for categorical variables and unpaired t-tests for continuous

variables. Proportions of patients ordered risk-appropriate VTE prophylaxis and the types

of VTE prophylaxis ordered were compared with two-sided chi square test. Pro- portions

of patients developing VTE, preventable harm from VTE, bleeding events, or in-hospital

mortality were compared using a two-sided Fisher’s exact test (due to small numbers of

events) between the pre- and post-implementation cohorts. A P-value <0.05 was

considered to be statistically significant. A stratified, multivariable sensitivity analysis

was performed by reanalyzing the data four times to account for the imbalance in the

distribution of VTE risk factors between the pre- and post- implementation groups. First,

after removal of patients with each of three key risk factors (cancer, sepsis, and/or

mechanical ventilation) individually. Then, we compared the cohorts after removal of

60

patients with any of these factors. All statistical analyses were performed using STATA

version 11.0 (StataCorp, College Station, TX).

Results

Baseline demographic and clinical characteristics

A total of 1,000 and 942 patients in the pre- and post- implementation periods,

respectively, were hospitalized for >24 hr and constituted the study cohort. There were no

statistically significant differences in the age, race, sex, or the median duration of

hospitalization (median length of stay 3 days) between the two groups. (Table 6.2)

Table 6.2 Demographics and Baseline Characteristics

61

More patients in pre-intervention group had at least 1 major VTE risk factor

compared with the post-intervention group (63.9% versus 57.1%, p <0.0025). (Table 6.2)

Active cancer, significant infection/sepsis and acute respiratory failure requiring

mechanical ventilation were all more prevalent in the pre-implementation group and

accounted for most of the noted differences in the combined prevalence of VTE risk

factors between the two groups (Table II). No statistically significant differences were

identified between the two groups in the number of patients with any contraindication to

pharmacologic VTE prophylaxis on admission (21.2% vs. 23.9%, P = 0.173). (Table 6.2)

Prescription of VTE Prophylaxis

The proportion of patients prescribed risk-appropriate VTE prophylaxis increased

from 65.6% to 90.1% between the pre-implementation and post-implementation cohort (P

< 0.0001). (Table 6.3) In addition, the proportion of patients prescribed any form of VTE

prophylaxis (76.4% vs. 95.6%, P < 0.0001), any form of pharmacologic VTE prophylaxis

(70.7% vs. 75.6%, P = 0.0176), and mechanical VTE prophylaxis alone (5.7% vs. 20.1%,

P < 0.0001) were higher in the post-implementation cohort. The proportion of patients

not receiving any form of VTE prophylaxis decreased from 23.6% to 4.4% (P < 0.0001).

Thrice daily UFH was more commonly prescribed in the pre-implementation cohort,

whereas twice daily UFH was more common in the post-intervention cohort. Therapeutic

anticoagulation was more common in the pre-implementation cohort (12.0% vs. 8.7%, P

= 0.0213). (Table 6.3)

62

Table 6.3 VTE Prophylaxis Before and After Implementation

of the “Smart Order Set”

Symptomatic VTE and Bleeding Events

Thirty-day follow up was available for 797 patients (79.7%) in the pre-

intervention group and 707 patients (75.1%) in the post-intervention group (P = 0.0167).

Ninety-day follow up was obtained in 733 patients (73.3%) in the pre-intervention group

and 622 patients (66.0%) in the post-implementation group (P = 0.0295). A total of 32

patients (1.6%) developed symptomatic VTE. Ten patients (31.3%) suffered VTE during

the index hospitalization, and 22 patients (68.8%) developed VTE after hospital

discharge, but within 90 days of discharge. Among post discharge VTE, 11 patients

developed VTE within the first 30 days post discharge (34% of all events, 50% of post-

discharge events), and 11 additional patients developed VTE between Day 31 and Day 90

post discharge (Table IV). The proportion of patients developing VTE (in hospital 1 90-

day post discharge) decreased significantly between the pre-implementation and post-

implementation periods (2.5% vs. 0.7%, P = 0.0022). This reduction was entirely

attributable to a decrease in events occurring post discharge (2.7% vs. 0.3%, adjusted for

the 90-day follow-up rates, P = 0.0003). The percentage of patients suffering VTE in

hospital was similar pre- and post-order set implementation (0.5%. vs. 0.5%, P = 1.0).

63

Six of the 32 VTE (18.8%) occurred in patients at moderate VTE risk (those

without major VTE risk factors) including five episodes in the pre- and one episode in the

post-implementation group. There was a non-significant decline in the frequency of VTE

in moderate risk patients from 5/361 (1.4%) in the pre-implementation group to 1/404

(0.3%) in the post-implementation cohort (P = 0.1057). Twenty-six VTE occurred in

patients with high VTE risk (those with at least 1 major VTE risk factor) (81.2% of all

events). The prevalence of VTE in high risk patients declined significantly from 20/639

(3.1%) in the pre-implementation cohort to 6/538 (1.1%) in the post-implementation

cohort (P = 0.0267).

Given the higher prevalence of some VTE risk factors (sepsis/significant

infection, cancer, and mechanical ventilation) in the pre-implementation group, we

conducted a sensitivity analysis to account for these differences. After removing all

patients with any of the three VTE risk factors (sepsis/significant infection, cancer, and

mechanical ventilation), a stratified, multivariable sensitivity analysis maintained the

significant reduction in VTE episodes after implementation (2.5% vs. 0.5%, P = 0.0019).

Despite the increased use of prophylaxis, there was no increase in major bleeding

episodes (0.3% vs. 0.1%, P = 0.625). All-cause in-hospital mortality was similar between

groups (1.3% vs. 2.0%, P = 0.285). (Table 6.4)

Most patients with symptomatic VTE had isolated lower extremity DVT (17/32,

53.1%). Eight patients (25%) developed symptomatic PE (±DVT), of which three were

fatal. The reduction in symptomatic VTE post-order set implementation was due to a

significant decrease in symptomatic lower extremity DVT (1.4% vs. 0.3%, P = 0.013).

64

The rates of symptomatic PE (±DVT) (0.5% vs. 0.3%, P = 0.7270) and fatal PE (0.5% vs.

0.3%, P = 1.0) were not significantly different between the two groups. (Table 6.4)

Table 6.4 Clinical Outcomes

In the pre-implementation cohort, 11 patients (1.1%) developed symptomatic

VTE who were not prescribed risk-appropriate VTE prophylaxis. In the post-

implementation cohort, all 7 patients who developed symptomatic VTE were prescribed

risk-appropriate VTE prophylaxis. Therefore, preventable harm, defined as a patient

developing VTE in the absence of risk-appropriate VTE prophylaxis, was completely

eliminated in the post-implementation cohort (1.1–0%, P = 0.001).

Discussion

We have developed a mandatory CPOE-based VTE prophylaxis “smart order set”

that guides providers to assess risk factors for VTE and bleeding and facilitates

prescription of risk-appropriate VTE prophylaxis. The benefits of this order set on patient

65

care included: (1) A significant increase in prescription of any form of VTE prophylaxis,

(2) A significant increase in risk-appropriate VTE prophylaxis, (3) A significant

reduction in symptomatic VTE, (4) The elimination of preventable harm from VTE, and

(5) No increase in major bleeding or all-cause mortality. Our study demonstrates that

mandatory computerized CDS “smart order sets” can promote improvements in quality

medical practice and lead to improved clinical outcomes.

Numerous strategies have been employed to improve prescription of VTE

prophylaxis. Educational campaigns on the importance of VTE prophylaxis have had

mixed success.54, 108 In contrast, computerized CDS systems have had much more

consistent impact on VTE prevention practices. In 2000, Durieux et al. 80 used a

computerized CDS system that employed instant messaging to providers that increased

VTE prophylaxis compliance from 82.8% to 94.9% on the orthopedic surgery service.

Kucher et al.51 developed an electronic alert to physicians that was shown in a

randomized trial to result into more mechanical (10% vs. 1.5%, P < 0.0001) and

pharmacologic prophylaxis (23.6% vs. 13.0%, P < 0.001), and fewer episodes of

symptomatic VTE (4.9% vs. 8.2%) in the “alert” patients. Maynard et al devised a three-

tiered VTE prophylaxis risk assessment tool that demonstrated an increase in the

prescription of adequate VTE prophylaxis from 58% to 93% and the number of hospital-

acquired VTE declined by 39%.101 Similarly, we found a significant reduction in

preventable harm from VTE among adult trauma patients at the Johns Hopkins Hospital

over three years after implementation of the trauma-specific VTE “smart order set”

compared with one year prior to implementation (1.0% vs. 0.17%, P = 0.04).53

66

Our CDS “smart order sets” share similarities with these previously published

successful interventions to improve VTE prophylaxis but also adds substantive new

innovations. Unlike “electronic alerts,” our order sets are proactive rather than reactive

and efficiently incorporate VTE prevention into provider work flow. The order sets allow

providers to rapidly assess their patients for VTE risk factors and contraindications to

pharmacologic prophylaxis and provide risk-appropriate recommendations for VTE

prophylaxis. The order sets also provide a convenient platform to introduce newly

identified VTE or bleeding risk factors as well as new pharmacologic or mechanical

approaches to VTE prevention allowing for rapid translation of new research findings

into clinical practice. Finally, the order set saves all patient/provider data in a database to

facilitate reporting of VTE prophylaxis performance on a provider, patient, clinical

division, service, physical location, department, and hospital level.

While some organizations, including the American College of Physicians, suggest

that some medically ill patients are at sufficiently low risk to not warrant use VTE

prophylaxis, our data indicate that even lower risk patients develop VTE. Six of the 32

VTE (18.8%) occurred in the moderate risk patient population (those without major VTE

risk factors). Similar findings have been noted in “low-risk” surgical patients.34 These

data highlight the potential harm experienced by patients as a result of withholding

prophylaxis and emphasize the need for evidence-based well-validated risk stratification

tools.

The main limitations of our study include its retrospective nature and the

possibility of incomplete follow-up after hospital discharge (though the difference in the

number of patients lost to follow up between the groups is small). In addition, some VTE

67

risk factors were more prevalent in the pre-implementation cohort. Nonetheless, a

sensitivity analysis demonstrated that the reduction in symptomatic VTE remains valid.

Another limitation of our study is that it evaluated the prescription of VTE prophylaxis

but not its actual administration, which may also have an effect on efficacy of

prophylaxis.109, 110 Our study also had a limited number of cancer and stroke patients,

and. therefore the results may not be generalizable to these patient populations.

The goal of any intervention to improve VTE prophylaxis should be to eliminate

preventable episodes of VTE 52, 53, not all VTE as the latter is an unachievable goal.20 Our

“smart order sets” completely eliminated preventable harm from VTE. We believe our

“smart order sets” will be a valuable CDS tool to achieve universal risk-appropriate VTE

prophylaxis, and can lead to significant reduction in occurrence of preventable VTE in

hospitalized medical patients (including post-discharge events), without compromising

patients’ safety.

Conclusions and Future Directions

In conclusion, we have developed a VTE prophylaxis “smart order set” that

increased the prescription of risk-appropriate prophylaxis and reduced the number of

symptomatic VTE episodes without increasing the frequency of VTE prophylaxis-

associated major bleeding. Our order sets integrate risk factor assessment into the

standard work flow and facilitate the prescription of risk-appropriate VTE prophylaxis. In

the future, we plan to develop the next generation of smart order sets that incorporate an

alert function to prompt risk factor reassessment and a real-time provider report card for

VTE prophylaxis performance.

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CHAPTER 7

Linking Processes and Outcomes: A Key Strategy to Prevent and Report Harm From Venous Thromboembolism in Surgical Patients34

(reprinted with permission from JAMA-Surgery)

Introduction

Venous thromboembolism (VTE) prophylaxis for surgical patients cannot be

overemphasized. The Joint Commission, the American College of Surgeons, the

American College of Chest Physicians, the Agency for Healthcare Research and Quality,

and others advocate risk-appropriate prophylaxis for all surgical patients. Despite strong

evidence supporting its efficacy, VTE prophylaxis is frequently underutilized, with

reported rates of 32% to 59%.15, 111 Although VTE has been labeled a “never event” by

some organizations, it is clear that many hospital-acquired events are not preventable.20, 28

A newly suggested definition of preventable harm linking the process of VTE

prophylaxis to outcomes28 has been adopted as a Clinical Quality Measure by the

Centers for Medicare and Medicaid Services in their “meaningful use” incentive

program. We sought to link process and outcome data from disparate sources in order to

determine the proportions of surgical patients prescribed risk-appropriate VTE

prophylaxis who developed potentially preventable VTE.

Methods

We analyzed surgical inpatient data from the American College of Surgeons

National Surgical Quality Improvement Program (NSQIP) at The Johns Hopkins Hospital

from July 2010 to September 2011. These outcome data were linked to VTE prophylaxis

prescription data from our mandatory computerized clinical decision support (CCDS)

tool.52, 53

69

The outcomes of interest were VTE, deep vein thrombosis (DVT), and/or

pulmonary embolism (PE) within 30 days after an operation and potentially preventable

VTE (defined as VTE in a patient not prescribed risk appropriate prophylaxis).28 The

percentage of patients with vs without risk-appropriate prophylaxis prescribed, stratified

by level of risk, were compared using a 2-sided Fisher exact test in STATA version 12

(StataCorp). The Johns Hopkins Medicine institutional review board approved our study.

Results

We were able to link VTE prophylaxis prescription data for 1628 of the 1734

surgical patients (94%) in our NSQIP data set. Of these, 1412 (87%) were prescribed

risk-appropriate prophylaxis, and 45 (2.8%) developed VTE, with 24 patients (1.5%)

developing DVT only, 13 patients (0.8%) having PE only, and 8 patients (0.5%)

developing both DVT and PE. The percentages of patients with VTE did not differ by

risk stratum: moderate risk (2.2%), high risk (2.4%), and very high risk (3.4%),

respectively (P = .49). The proportion of patients prescribed risk-appropriate prophylaxis

differed by risk level (very high risk [92%], high risk [80%], and moderate risk [86%],

respectively; P < .001). When comparing patients with vs without VTE, there was no

difference in the percentage prescribed risk-appropriate prophylaxis in any strata. (Table

7.1) The vast majority of patients with VTE, DVT, and/or PE were prescribed best-

practice prophylaxis (91%, 97%, and 86%, respectively). Only 4 patients (0.2% of all

patients and 8.9% of patients with VTE) developed potentially preventable VTE (3 with

PE 1 with DVT). (Figure 7.1)

70

Table 7.1 Proportion of Surgical Patients With vs. Without VTE Who Were

Prescribed Risk-Appropriate VTE Prophylaxis Stratified by Risk Status

71

Figure 7.1 The percentage of patients with postoperative venous thromboembolism

(VTE), deep vein thrombosis (DVT), and pulmonary embolism (PE) who were

prescribed risk-appropriate VTE prophylaxis compared with those who were not.

The vast majority of VTE events occurred in patients prescribed risk-appropriate

prophylaxis.

Comments

Using our mandatory CCDS tool, providers prescribed risk-appropriate VTE

prophylaxis for 87% of surgical patients, far exceeding published rates. Nevertheless,

VTE occurred in 2.8% of patients. In fact, 91% of cases occurred in patients prescribed

72

risk-appropriate prophylaxis; only 4 cases were potentially preventable. Similar VTE

rates were noted in all risk strata, which indicates that prophylaxis remains important

even for moderate-risk patients.

By linking this clinically relevant postsurgical complication to a process measure,

we identify patients with VTE events that are truly potentially preventable. Although we

would have liked to study prophylaxis-associated bleeding, this variable is not well

defined or captured in the NSQIP. However, there is general consensus that the benefit of

prophylaxis outweighs the harm for surgical patients. Our data underscore that, although

the elimination of all hospital-acquired VTE is not realistic, the elimination of potentially

preventable VTE (consistent with the nationally adopted “meaningful use” definition) is

attainable and should be the appropriate measurement tool for VTE prevention

programs.46

Our approach combines the best of both worlds: the NSQIP reports well-defined,

well-validated 30-day VTE events, while our CCDS tool optimizes prophylaxis and

provides a standardized report of patient-specific, risk-appropriate prophylaxis

prescription. By linking these 2 rich data sources, we were able to efficiently identify

potentially preventable VTE. Unfortunately, we cannot compare rates of potentially

preventable VTE between hospitals because the NSQIP does not currently capture

prophylaxis data. If our CCDS tool was implemented at all 400 NSQIP participating

hospitals, we could improve VTE prevention, facilitate valid reporting of potentially

preventable harm, and improve the quality of care for surgical patients.

73

CONCLUSIONS

The work of this dissertation has already begun to help influence national policy.

The Centers for Medicare and Medicaid Services (CMS) has included multiple VTE

related elements in its financial incentives programs for the “meaningful use” of certified

electronic health record (EHR) technology to improve patient care. There are six VTE-

specific clinical quality measures (CQMs) that all eligible hospitals must complete. VTE-

6 is defined as “the number of patients diagnosed with confirmed VTE during

hospitalization (not present at admission) who did not receive VTE prophylaxis between

hospital admission and the day before the VTE diagnostic testing order date.”112 This

definition, written after publication of our paper, followed our suggestion that

“performance measures could link a process of care with adverse outcomes when

defining incidences of preventable harm.”28 We posed the question “what percentage of

patients who develop a DVT (outcome) received appropriate risk assessment and

prophylaxis (process)?”28 CMS decided to require that all participating hospitals across

the country answer our query.

In the period of less than three years since its publication, “Surveillance Bias in

Outcomes Reporting” has been cited over thirty times including six citations in high

impact journals: JAMA (three citations),113-115 BMJ (twice),46, 52 and PLoS ONE

(once).116 This paper has heightened the awareness of a well-known, yet

underappreciated, form of bias that may impact the external validity and generalizability

of comparative effectiveness research studies. A broad array of health services

researchers have realized the importance of surveillance bias and are citing this paper as

the definitive, current reference on the subject. It has garnered interest among researchers

74

on both and national and international level publishing on cancer epidemiology,117-120

cardiovascular disease,121, 122 health care-associated infections,123-127 and complications

after major trauma.128-130

Our previous work had focused on surveillance bias in DVT reporting after

trauma specifically. Recently, we replicated and expanded the concept and studied it on a

“broad, nationally representative sample of operations and hospitals”. In 2013, Bilimoria

et. al. examined the relationship between hospital-level VTE event and VTE diagnostic

imaging rates using Medicare data.115 This study included 954,526 Medicare patients 65

years of age or older at 2,786 hospitals who underwent one of 11 common, major

operations: Colon Surgery, Rectal Surgery, Total Knee Surgery, Craniotomy, Pancreas

Surgery, Esophagus Surgery, Lung Resection, Gastric Bypass, Abdominal Aortic

Aneurysm Surgery, Coronary Artery Bypass Graft Surgery, or Cystectomy. The study

found that “increased hospital VTE event rates were associated with increasing hospital

VTE imaging use rates.” The authors concluded that “surveillance bias limits the

usefulness of the VTE quality measure for hospitals working to improve quality and

patients seeking to identify a high-quality hospital.”115

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FUTURE DIRECTIONS

1) Expansion of VTE risk stratification and computerized clinical decision support

across the Johns Hopkins Health System and beyond

The scope of our clinical decision support tools have been on a single hospital

(Johns Hopkins Hospital) level. The impact we have had already should not be

underestimated. Approximately 50,000 patients are admitted each year and are risk

stratified using our advanced computerized clinical decision support tool. However, we

have further progress ahead. Our team’s next major step is ongoing work within the

Armstrong Institute for Quality and Patient Safety to harmonize VTE prevention across

the entire Johns Hopkins Health System (JHHS) including all six hospitals (Johns

Hopkins Hospital, Johns Hopkins Bayview, Johns Hopkins Suburban, Howard County

General, Sibley, and All Children's). Our guiding principle is to ensure that “every patient

will receive a specialty-specific standardized VTE/bleeding risk assessment based on

individual risk factors and recommended prophylaxis, regardless of the JHHS hospital

they choose.”

We have already convened clinical and administrative leadership and gotten

support from the highest levels across the hospitals in a first step toward standardization.

We plan to move forward with consensus building to agree on a standardized process and

clinical algorithms for risk assessment and prophylaxis. Only then will we be able to

create an integrated, uniform process into available information technology platforms to

ensure consistency and foster compliance at all six JHHS hospitals. Our eventual long-

term goal is and an automated, standardized process which will reliably capture important

performance measures. We aim for 96% compliance for best-practice VTE prophylaxis, a

76

target set by The Johns Hopkins Medicine Board of Trustees.131 Phase one will focus on

three clinical service lines (Internal Medicine, General Surgery, Orthopedics) based on

patient volume and high risk of VTE. Phase two will complete with the rest of the patient

services (e.g. Trauma, Neurology, Obstetrics/Gynecology, Oncology, Neurosurgery,

Pediatrics, Psychiatry).

Simultaneous to the clinical and administrative hurdles that we are beginning to

deal with, the transfer into a new electronic health record has been a daunting task. We

implemented our computerized clinical decision support tool as an add-on medical logic

module (MLM) onto the provider order entry system at Johns Hopkins Hospital on the

Allscripts Sunrise Clinical Portal™. However, since its first initial rollout in 2007, Johns

Hopkins Medicine has decided to transition the entire computing infrastructure to a new

software vendor, Epic. Epic is the dominant leader in healthcare information technology

software with a huge market share. Two JHHS hospitals (Howard County General and

Sibley) have already gone live on Epic for inpatient orders and documentation, with a

third (Johns Hopkins Suburban) set to go live in July 2014. In anticipation of this change,

we have been working closely with the Epic design team to create a product with similar

functionality into their existing system. A rudimentary version, with many known flaws,

was initially installed and we have been working to upgrade the product incrementally to

eventually meet our relentlessly high standards. Future iterations will need to incorporate

the lessons learned in our initial information technology build to ensure the tool is

reliably used on every hospitalized patient.52 We plan to build, validate, and publish the

benefits of using this tool in the Epic platform. Then, we will be poised to expand this

77

tool nationally. We already have been in discussions with Epic to partner with us to help

encourage its spread in this manner.

2) Promulgate linkage of process and outcomes measures for VTE reporting to state

and national scales

Within the state of Maryland, there is a “pay-for-performance” program which

imposes a financial penalty for hospitalized patients developing any of the specifically

defined Maryland Hospital Acquired Conditions (MHACs).132 The Maryland Health

Services Cost Review Commission (HSCRC) has selected two VTE events (both DVT

and PE), currently using only event rates, and has not yet considered the issue of

surveillance bias. In addition, they have not adopted the CMS accepted definition of

potentially preventable harm from VTE. They examine only administrative discharge

data and do not link to any VTE prevention process measure data. We are currently

working to change these unfair and misleading Maryland policies by supplying the state

with data showing that the majority of VTE events for which we are financially penalized

are not preventable by current best practice methods. Our single hospital’s preliminary

data show that approximately two thirds of all events for which financial penalties were

assigned were not preventable. In one third of the VTE events, patients had been ordered

and administered every dose of best practice VTE pharmacological prophylaxis. In

another third of events, patients had catheter associated DVT which is well known to be

not amenable to prevention.133 We are pushing the state to link poor outcomes with

substandard prophylaxis to more closely align with national standards.

In addition to working on expanding our definition to the state of Maryland, we

are working with two large national surgical quality collaboratives run by the American

78

College of Surgeons (ACS). The ACS is a scientific and educational association of

surgeons founded in 1913 to improve the quality of care for the surgical patient by setting

high standards for surgical education and practice. They have an ongoing series of local

presentations titled the "Inspiring Quality Tour: Lessons Learned." In August 2011, I was

asked to speak on the topic of VTE prevention and quality reporting at the Maryland

session alongside keynote speaker, Senator Ben Cardin (Democrat-MD).134We have a

research protocol in collaboration with the Trauma Quality Improvement Program (ACS-

TQIP) which includes over 200 level 1 and level 2 trauma centers across the country.

This group already provides risk-adjusted mortality benchmarking reports to participating

centers. One of their first complications reports will include both overall VTE rates and

“potentially preventable harm” from VTE based on our definition by linking process and

outcomes measures, both of which are already being measured.

We are in the planning phase of a large-scale, national knowledge translation

project to expand the reach of our validated computerized clinical decision support tool

for VTE risk stratification of surgical patients. We will partner with Epic to build our

front-end computerized tool into their electronic health record. From the Epic system, we

will be able to extract process measure data including risk assessment, prescription, and

administration of prophylaxis medications. We will partner with The American College

of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) who will

provide the largest, most reliable surgical outcomes data source in the world. This

collaborative of over 500 surgical hospitals included actively collected 30-day post

surgical outcomes for hundreds of thousands of surgical patients every year. Although

79

this may seem difficult to do, we have shown the feasibility of this endeavor on a single

hospital scale in the final chapter of this dissertation.34

3) Missed doses of prophylaxis medications- A new frontier in defining preventable

harm from VTE

The majority of quality improvement research and interventions in VTE

prevention have focused on the prescription of appropriate prophylaxis medications for

patients at risk. However, this shortsighted and limited approach is based on the flawed

assumption that ordering adequate VTE prophylaxis ensures its administration. Adequate

prescription and administration are related, but clearly distinct, critical links in the chain

to provide optimal, defect-free preventive care for VTE. The significance of medication

non-administration, or missed doses, remains relatively underappreciated in the inpatient

realm in general, and for VTE prophylaxis in particular.

Fanikos et. al. published a small series of 250 patients in whom VTE prophylaxis

was prescribed and noted that 10% of all prescribed doses were not administered.135

Using our electronic health record at The Johns Hopkins Hospital, we published a study

of 103,160 ordered VTE prophylaxis doses and found that 12% of prescribed doses of

VTE prophylaxis medication were not administered. Only 59% of patients received every

ordered medication dose. Most importantly, VTE prophylaxis medication non-

administration was not randomly distributed. Missed doses were clustered by floor (with

missed doses ranging from 5% to 28% of doses) and by patients (with 80% of the missed

doses occurring in 20% of the patients).136

Our study found that “patient or family member refusal was the most commonly

documented reason for non-administration of ordered doses, accounting for 59% of all

80

non-administrations.”136 This specific finding prompted us to embark on another angle of

research – a patient centered care approach to VTE prevention. Using these data and

some qualitative research on the impact of nursing behaviors on VTE dose

administration, we applied for and were granted a 3-year contract from The Patient

Centered Outcomes Research Institute (PCORI) to study interventions to improve

medication administration. Our project, titled “Preventing Venous Thromboembolism:

Empowering Patients and Enabling Patient-Centered Care via Health Information

Technology,” will enable patients to make well-informed decisions, empower them to

take an active role in their care, and engage patients in meaningful, patient-centered

communication.137

We plan to expand our scope and are beginning to study non-administration

within the Epic software platform at all JHHS hospitals. Due to variation in patient

populations and culture of care, we hypothesize that non-administration of prescribed

medications will vary significantly both within hospitals and between hospital settings.

We will evaluate the prevalence of VTE prophylaxis non-administration across

heterogeneous hospital environments (comparing community and academic hospitals)

leveraging the clinical informatics opportunity afforded by a single electronic health

record.

To provide truly defect-free care, medications must be administered, not just

prescribed. If VTE process measures are going to studied and publicly reporting, we must

measure best-practice, optimal, perfect prophylaxis and not give full credit for sub-

optimal work. There are many possible points of failure when attempting to provide

perfect VTE prophylaxis. Physicians can skip prophylaxis altogether, or prescribe

81

suboptimal or incorrect medications, dosages or frequencies. Medications can be not

administered for a variety of reasons based on system, nurse, and patient factors. We plan

to continue our work and are pushing to define preventable VTE as events occurring in

patients who have ANY defect in care, either at the medication prescription or

administration level. We may never completely eradicate all VTE events, but we can

eliminate preventable VTE, with a renewed focus on defect-free VTE prevention.

82

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Lehmann CU, Pinto BL, Ross PA, Streiff MB. Patterns of non-administration of

ordered doses of venous thromboembolism prophylaxis: Implications for novel

intervention strategies. PLoS One 2013 Jun 14;8(6):e66311.

137. Preventing Venous Thromboembolism: Empowering Patients and Enabling Patient-

Centered Care via Health Information Technology [Internet] [cited 2014 April 9].

Available from: http://www.pcori.org/pfaawards/preventing-venous-

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thromboembolism-empowering-patients-and-enabling-patient-centered-care-via-

health-information-technology/.

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Brief Biography Elliott Richard Haut was born on August 15, 1970 in Cleveland, Ohio to parents

Michael and Rosalie. At the age of nine, he moved to the Philadelphia area when his

father took a job as a hematologist/oncologist at Pennsylvania Hospital. After college at

Brown University, he graduated from medical school at The University of Pennsylvania.

Dr. Haut completed all his clinical training in Philadelphia including an internship and

residency in General Surgery at Pennsylvania Hospital and a fellowship in Traumatology

and Surgical Critical Care at The Hospital of the University of Pennsylvania.

In 2004, Dr. Haut joined the faculty at The Johns Hopkins University School of

Medicine where he is now Associate Professor of Surgery, Anesthesiology / Critical Care

Medicine (ACCM), and Emergency Medicine in the Division of Acute Care Surgery,

Department of Surgery. He is certified in General Surgery and Surgical Critical Care by

the American Board of Surgery and is a Fellow of the American College of Surgeons

(FACS). Dr. Haut directs the Trauma / Acute Care Surgery Fellowship at The Johns

Hopkins Hospital where his clinical practice covers all aspects of trauma and acute care

surgery, as well as surgical critical care.

Dr. Haut’s research focuses on the diagnosis, prevention, and public reporting of

deep vein thrombosis (DVT) and pulmonary embolism (PE). He has received research

funding from AHRQ and PCORI. Dr. Haut has authored over 120 peer-reviewed articles

as well as dozens of invited editorials, books, and chapters in the field.

Dr. Haut is married to Jayne S. Gerson and has two amazing children, Arenal and

Fletcher.

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ELLIOTT RICHARD HAUT, MD, FACS Curriculum Vitae The Johns Hopkins University School of Medicine April 9, 2014 DEMOGRAPHIC INFORMATION Current Appointments

2009-present Associate Professor of Surgery, Johns Hopkins Medicine 2009-present Associate Professor of Anesthesiology & Critical Care Medicine,

Johns Hopkins Medicine 2011-present Associate Professor of Emergency Medicine, Johns Hopkins Medicine 2007-present Fellowship Director, Trauma / Acute Care Surgery Fellowship, Johns

Hopkins Hospital 2012-present Core Faculty, Armstrong Institute for Patient Safety and Quality, JHM 2012-present Core Faculty, Center for Surgical Trials and Outcomes Research

(CSTOR), Johns Hopkins Medicine 2009-present PhD candidate, Graduate Training Program in Clinical Investigation

(GTPCI), The Johns Hopkins Bloomberg School of Public Health Personal Data

Elliott R. Haut, MD, FACS Division of Acute Care Surgery Department of Surgery Sheikh Zayed 6107C 1800 Orleans St. Baltimore, MD 21287 Phone: 410-502-3122 Fax: 410-502-3569 Email: ehaut1@jhmi.edu Website: https://www.meddium.com/ehaut1.mp

Education and Training Undergraduate

1992 BS, Chemistry, Brown University, Providence, RI

Doctoral / Graduate 1996 MD, The University of Pennsylvania School of Medicine, Phila, PA

Postdoctoral

1996-1997 Internship, Surgery, Pennsylvania Hospital, Philadelphia, PA 1997-1999 Residency, Surgery, Pennsylvania Hospital, Philadelphia, PA 1999-2000 Research Fellowship, Harrison Department of Surgical Research

The University of Pennsylvania School of Medicine, Philadelphia, PA 2000-2002 Residency, Surgery, Pennsylvania Hospital, Philadelphia, PA 2002-2004 Fellowship, Traumatology and Surgical Critical Care,

Hospital of the University of Pennsylvania, Philadelphia, PA 2009-present PhD candidate, Graduate Training Program in Clinical Investigation

(GTPCI), The Johns Hopkins Bloomberg School of Public Health

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Professional Experience 2003-2004 Clinical Instructor, Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA 2004-2009 Assistant Professor, Surgery, Johns Hopkins Medicine, Baltimore, MD 2006-2009 Assistant Professor, Anesthesia & Critical Care Medicine, JHM 2006-present Associate Director, Adult Tracheostomy and Airway Service, JHH 2007-present Fellowship Director, Trauma / Acute Care Surgery Fellowship, JHH RESEARCH ACTIVITIES Peer Reviewed Original Science Publications

1. Naranja RJ Jr, Reilly PJ, Kuhlman JR, Haut ER, Torg JS. Long-term evaluation of the Elmslie-Trillat-Maquet Procedure for Patellofemoral Dysfunction. American Journal of Sports Medicine. 1996;24(6): 779-84.

2. Haut ER, Abbas A, Schuricht A. Pancreatic Cancer: the role of the Primary Care Physician. Consultant. 1999;39(12): 3329-3335.

3. Scherpereel A, Rome JJ, Wiewrodt R, Watkins SC, Harshaw DW, Alder S, Christofidou-Solomidou M, Haut ER, Murciano JC, Nakada M, Albelda SM, Muzykantov VR. Platelet- endothelial cell adhesion molecule-1-directed immunotargeting to cardiopulmonary vasculature. Journal of Pharmacology and Experimental Therapeutics (JPET). 2002; 300(3): 777-86.

4. Schuricht A, Haut ER, Wetzler M. Surgical Options in the Treatment of Sports Hernia. Operative Techniques in Sports Medicine. 2002; 10(4): 224-227.

5. Reilly PM, Schwab CW, Haut ER, Gracias VH, Dabrowski GP, Gupta R, Pryor JP, Kauder DR. Training In Trauma Surgery: Quantitative And Qualitative Aspects Of A New Paradigm For Fellowship. Annals of Surgery. 2003; 238(4):596-604.

6. Haut ER, Nance ML, Keller MS, Groner JI, Ford HR, Kuhn A, Tuchfarber B, Garcia V, Schwab CW, Stafford PW. Management of Penetrating Colon Injury in the Pediatric Patient. Diseases of the Colon and Rectum. 2004; 47:1526-1532.

7. Haut ER, Sicoutris CP, Meredith DM, Sonnad SS, Reilly PM, Schwab CW, Hanson CW, Gracias VH. Improved Nurse Job Satisfaction and Job Retention with the Transition from a “Mandatory Consultation” Model to a “Semi-Closed” Surgical Intensive Care Unit: A 1-Year Prospective Evaluation. Critical Care Medicine. 2006; 34(2):387-95.

8. Sing RF, Camp SM, Henford BT, Rutherford EJ, Dix S, Reilly PM, Holmes JH, Haut E, Hayanga A. Timing of Pulmonary Emboli after Trauma: Implications for Retrievable Vena Cava Filters. Journal of Trauma. 2006;60(4):732-4.

9. Williams CG, Haut ER, Ouyang H Riall TS, Makary M, Efron DT, Cornwell 3rd EE, Video-Assisted Thoracic Surgery (VATS) Removal of Foreign Bodies after Penetrating Chest Trauma. Journal of the American College of Surgeons (JACS). 2006;202(5):848-52. (Corresponding Author)

10. Early AS, Gracias VH, Haut ER, Sicoutris CP, Wiebe DJ, Reilly PM, Schwab CW. Anemia Management Program (AMP) Reduces Transfusion Volumes, Incidence of Ventilator Associated Pneumonia, and Cost In Trauma Patients. Journal of Trauma. 2006;61(1):1-7.

11. Brooke B, Efron DT, Chang DC, Haut ER, Cornwell 3rd EE. Patterns and Outcomes Among Penetrating Trauma Recidivists: It Only Gets Worse. Journal of Trauma. 2006;61(1):16-20.

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12. Haut ER, Chang DC, Efron D, Cornwell 3rd EE. Injured Patients Have Lower Mortality When Treated By "Full-Time" Trauma Surgeons Vs. Surgeons Who Cover Trauma "Part-Time". Journal of Trauma. 2006;61(2):272-279.

13. Efron DT, Haider A, Chang DC, Haut ER, Brooke B, Cornwell 3rd EE. The Alarming Surge in Non-Survivable Urban Trauma and the Case for Violence Prevention. Archives of Surgery. 2006;141(8):800-3.

14. Shoher A, Chang DC, Efron DT, Cornwell 3rd EE, Haut ER. Multiple Simultaneous Trauma Patients: Are They Worse Off? Journal of Trauma. 2006;61(3):611-5.

15. Karmy-Jones R, Jurkovich GJ, Velmahos GC, Burdick T, Spaniolas K, Todd SR, McNally M, Jacoby RC, Link D, Janczyk RJ, Ivascu FA, McCann M, Obeid F, Hoff WS, McQuay N Jr, Tieu BH, Schreiber MA, Nirula R, Brasel K, Dunn JA, Gambrell D, Huckfeldt R, Harper J, Schaffer KB, Tominaga GT, Vinces FY, Sperling D, Hoyt D, Coimbra R, Rosengart MR, Forsythe R, Cothren C, Moore EE, Haut ER, Hayanga AJ, Hird L, White C, Grossman J, Nagy K, Livaudais W, Wood R, Zengerink I, Kortbeek JB. Practice Patterns and Outcomes of Retrievable Vena Cava Filters in Trauma Patients: An AAST Multicenter Study. Journal of Trauma. 2007;62(1):17-25.

16. Haider AH, Efron DT, Haut ER, DiRusso M, Sullivan T, Cornwell 3rd EE. Black Children experience worse Clinical and Functional Outcomes after Traumatic Brain Injury: an analysis of the National Pediatric Trauma Registry. Journal of Trauma. 2007;62(5):1259-63.

17. Haut ER, Kamal MK, Reilly PM, Stavropoulos SW. Successful Percutaneous Retrieval of a Swan-Ganz Catheter Entrapped in an Inferior Vena Caval (IVC) Filter. Journal of Trauma. 2007;62(6): 1507-1510.

18. Weiss ES, Hayanga AJ, Efron DT, Noll K, Cornwell 3rd EE, Haut ER. Laterality of Deep Venous Thrombosis Among Trauma Patients: Are We Screening Our Patients Adequately? Journal of Surgical Research. 2007;141(1):68-71.

19. Haider AH, Efron D, Haut ER, Chang D, Paidas C, Cornwell 3rd EE. Mortality in Adolescent Girls vs Boys Following Traumatic Shock: An Analysis of the National Pediatric Trauma Registry. Archives of Surgery. 2007;142(9):875-80.

20. Haut ER, Noll K, Efron DT, Berenholz SM, Haider A, Cornwell 3rd EE, Pronovost PJ. Can Increased Incidence of Deep Vein Thrombosis (DVT) Be Used as a Marker of Quality of Care in the Absence of Standardized Screening?: The Potential Effect of Surveillance Bias on Reported DVT Rates. Journal of Trauma. 2007;63(5):1132-1137.

21. Meneshian A, Brooke B, Cornwell 3rd EE, Haut ER. Retroperitoneal Gunshot Wound Hernia: An Unusual Cause Of Early Post-Operative Small Bowel Obstruction After Laparotomy for Trauma. Journal of Trauma. 2008;64:213-4.

22. Efron DT, Sorock G, Schneider E, Mackenzie E, Cornwell EE, Chang D, Haut ER, Jurkovich GJ. Preinjury Statin Use Is Associated With Improved In-Hospital Survival in Elderly Trauma Patients. Journal of Trauma. 2008;64:66-74.

23. Chang DC, Handly N, Abdullah F, Efron DT, Haut ER, Haider AH, Pronovost PJ, Cornwell 3rd EE. The occurrence of potential patient safety events among trauma patients: Are they random? Annals of Surgery. 2008;247:327–334.

24. Kardooni S, Haut ER, Pierce CA, Chang DC, Efron DT, Haider AH, Pronovost PJ, Cornwell 3rd EE. Hazards of Benchmarking Complication Rates With The National Trauma Data Bank: Numerators in Search of Denominators. Journal of Trauma. 2008;64(2):273-279. (Corresponding Author) (Cover figure)

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25. Pierce CA, Haut ER, Kardooni S, Chang DC, Efron DT, Haider AH, Pronovost PJ, Cornwell 3rd EE. Surveillance Bias and Deep Vein Thrombosis in the National Trauma Data Bank (NTDB): The More We Look, The More We Find. Journal of Trauma. 2008;64:932-937. (Corresponding Author)

26. Weiss ES, Hayanga AJ, Efron DT, Noll K, Cornwell 3rd EE, Haut ER. Laterality of Deep Vein Thrombosis in Trauma Patients. Phlebology Digest. 2008;21:12-4.

27. Gracias VH, Sicoutris CP, Stawicki SP, Meredith DM, Horan AD, Gupta R, Haut ER, Auerbach S, Sonnad S, Hanson CW 3rd, Schwab CW. Critical Care Nurse Practitioners Improve Compliance with Clinical Practice Guidelines in "Semi-closed" Surgical Intensive Care Unit. Journal of Nursing Care Quality. 2008;23(4):338-44.

28. Pham JC, Catlett CL, Berenholtz SM, Haut ER. Change in Use of Allogeneic Red Blood Cell Transfusions Among Surgical Patients Over Time. Journal of the American College of Surgeons (JACS). 2008;207(3):352-9.

29. Haider AH, Chang DC, Efron DT, Haut ER, Crandall M, Cornwell E. Race and Insurance Status as Risk Factors for Trauma Mortality. Archives of Surgery. 2008;143(10):945-9.

30. Mukherjee D, Lidor AO, Chu KM, Gearhart SL, Haut ER, Chang DC. Postoperative venous thromboembolism rates vary significantly after different types of major abdominal operations. Journal of Gastrointestinal Surgery. 2008;12(11):2015-22.

31. Tinti MS, Haut ER, Horan AD, Sonnad S, Reilly PM, Schwab CW, Gracias VH. Transition to a Semi-Closed Surgical Intensive Care Unit (SICU) Leads to Improved Resident Job Satisfaction: A Prospective, Longitudinal Analysis. Journal of Surgical Education. 2009;66(1):25-30.

32. Haut ER, Chang DC, Pierce CA, Colantuoni E, Efron DT, Haider AH, Cornwell 3rd EE, Pronovost PJ. Predictors of Post-Traumatic Deep Vein Thrombosis (DVT) - Hospital Practice vs. Patient Factors: An Analysis of the National Trauma Data Bank (NTDB). Journal of Trauma. 2009;66(4):994-9.

33. Streiff MB, Haut ER. The CMS Ruling on Venous Thromboembolism After Total Knee or Hip Arthroplasty: Weighing Risks and Benefits. Journal of the American Medical Association (JAMA). 2009;301(10):1063-1065.

34. Haider AH, Chang DC, Haut ER, Cornwell E, Efron DT. Mechanism of Injury Predicts Patient Mortality and Impairment After Blunt Trauma. Journal of Surgical Research. 2009;153(1):138-42.

35. Haider AH, Crompton JG, Oyetunji TA, Efron DT, Chang DC, Stevens KA, Cornwell, III EE, Haut ER. Females have fewer complications and lower mortality following trauma than similarly injured males. Surgery. 2009;146(2):308-315.

36. Haut ER, Chang DC, Hayanga AJ, Efron DT, Haider AH, Cornwell 3rd EE. System-Based and Surgeon-Based Influences on Trauma Mortality. Archives of Surgery. 2009;144 (8):759-764.

37. Oyetunji T, Crompton JG, Efron DT, Haut ER, Chang DC, Cornwell EE 3rd, Baker SP, Haider AH. Simplifying physiologic injury severity measurement for predicting trauma outcomes. Journal of Surgical Research. 2010;159(2):627-32.

38. Crompton JG, Oyetunji TA, Stevens KA, Efron DT, Haut ER, Haider AH. Motorcycle helmets save lives, but not limbs: A National Trauma Data Bank analysis of functional outcomes after motorcycle crashes. Journal of Surgical Research. 2010;158(1):1-5.

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39. Haut ER, Kalish BT, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE 3rd, Chang DC. Spine Immobilization in Penetrating Trauma: More Harm Than Good? Journal of Trauma. 2010;68(1): 115–121.

40. Barreiro CJ, Haut ER. Image of the month--quiz case. Foreign body (ingested chicken bone). Archives of Surgery. 2010;145(4):395-6.

41. Cotton BA, Dossett LA, Haut ER, Shafi S, Nunez TC, Au BK, Zaydfudim V, Johnston M, Arbogast P, Young PP. Multicenter Validation of a Simplified Score to Predict Massive Transfusion in Trauma. Journal of Trauma. 2010;69:S33–S39.

42. Maybury RS, Bolorunduro OB, Villegas C, Haut ER, Stevens K, Cornwell EE 3rd, Efron DT, Haider AH. Pedestrians struck by motor vehicles further worsen race- and insurance-based disparities in trauma outcomes: the case for inner-city pedestrian injury prevention programs. Surgery. 2010;148(2):202-8.

43. Crompton JG, Pollack KM, Oyetunji T, Chang DC, Efron DT, Haut ER, Cornwell EE 3rd, Haider AH. Racial disparities in motorcycle-related mortality: an analysis of the National Trauma Data Bank. American Journal of Surgery. 2010;200(2):191-196.

44. Pandian V, Vaswani, RS, Mirski MA, Haut E, Gupta S, Bhatti NI. Safety of Percutaneous Dilatational Tracheostomy in Coagulopathic Patients. Ear Nose & Throat Journal. 2010;89(8):387-395.

45. Haider AH, Crompton JG, Efron D, Haut E, Chang D, Cornwell E. Evidence of Hormonal basis for improved survival among females with trauma associated shock: An analysis of the National Trauma Data Bank. Journal of Trauma. 2010;69(3):537-540.

46. John PR, Shiozawa A, Haut ER, Haider AH, Efron DT, Cornwell III EE, Chang DC. An Assessment of the Impact of Pregnancy on Trauma Mortality. Surgery. 2011;149(1):94-98.

47. Muellner SK, Haut ER, Streiff MB, Holcomb JB, Cotton BA. ABO blood group as a potential risk factor for venous thromboembolism in acutely injured patients. Thrombosis and Haemostasis. 2011;105(1):5-13.

48. Oyetunji TA, Imudia D Ehanire ID, Crompton JG, Stevens KA, Efron DT, Haut ER, Chang DC, Cornwell III EE, Crandall ML, Haider AH. Multiple Imputation in trauma disparity research. Journal of Surgical Research. 2011;165(1):e37-41.

49. Haut ER, Schenider EB, Patel A, Streiff MB, Haider AH, Stevens KA, Chang DC, Neal ML, Hoeft C, Nathens AB, Cornwell EE 3rd, Pronovost PJ, Efron DT. Duplex Ultrasound Screening For Deep Vein Thrombosis In Asymptomatic Trauma Patients: A Survey of Individual Trauma Surgeon Opinions and Current Trauma Center Practices. Journal of Trauma. 2011;70(1):27-34.

50. Haut ER, Kalish BT, Cotton BA, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE 3rd, Chang DC. Pre-Hospital Intravenous Fluid Administration is Associated with Higher Mortality in Trauma Patients: A National Trauma Data Bank Analysis. Annals of Surgery. 2011; 253(2):371-377.

51. Mowery NT, Gunter OL, Collier BR, Diaz Jr JJ, Haut E, Hildreth A, Holevar M, Mayberry J, Streib E. Practice Management Guidelines for Management of Hemothorax and Occult Pneumothorax. Journal of Trauma. 2011;70(2):510-518.

52. Crompton JG, Bone C, Oyetunji T, Pollack KM, Bolorunduro O, Villegas C, Stevens K, Cornwell EE 3rd, Efron DT, Haut ER, Haider AH. Motorcycle Helmets Associated with Lower Risk of Cervical Spine Injury: Debunking the Myth. Journal of the American College of Surgeons. 2011;212(3):295-300.

53. Oyetunji TA, Haider AH, Downing SR, Bolorunduro OB, Efron DT, Haut ER, Chang DC, Cornwell III EE, Abdullah F, Siram SM. Treatment Outcomes Of

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Injured Children At Adult Level 1 Trauma Centers: Are There Benefits From Added Specialized Care? American Journal of Surgery. 2011;201(4):445-449.

54. Schneider EB, Haider AH, Lidor AO, Efron JE, Villegas CV, Stevens KA, Hirani SA, Haut ER, Efron DT. Global Surgical Package Reimbursement and the Acute Care Surgeon: a Threat to Optimal Care. Journal of Trauma. 2011;70(3):583-589.

55. Vettukatil A, Haider AH, Oyetunji TA, Chang DC, Haut ER, Stevens KA, Cornwell E 3rd, Efron DT. Do Trauma Safety Net Hospitals deliver truly safe trauma care? A multilevel analysis of the National Trauma Data Bank. Journal of Trauma. 2011;70(4):978-984.

56. Boelig M, Streiff MB, Hobson DB, Kraus PS, Pronovost PJ, Haut ER. Are Sequential Compression Devices Commonly Associated with In-Hospital Falls? A Myth-Busters Review Using the Patient Safety Net Database. The Journal of Patient Safety. 2011;7:77-79.

57. Oyetunji TA, Chang DC, Crompton JG, Greene WR, Efron DT, Haut ER, Cornwell III EE, Haider AH: Re-defining Hypotension in the Elderly: Normotension is not Reassuring. Archives of Surgery. 2011;146(7):865-869.

58. Haut ER, Pronovost PJ. Surveillance Bias in Outcomes Reporting. Journal of the American Medical Association (JAMA). 2011; 305(23):2462-3.

59. Bolorunduro OB, Villegas C, Oyetunji TA, Haut ER, Stevens KA, Chang DC, Cornwell III EE, Efron DT, Haider, AH. Validating the Injury Severity Score (ISS) In Different Populations: ISS Predicts Mortality Better Among Hispanics and Females. Journal of Surgical Research. 2011;166(1):40-4.

60. Haider AH, Crompton JG, Oyetunji T, Risucci D, Dirusso S, Basdag H, Villegas CV, Syed ZU, Haut ER, Efron DT. Mechanism of injury predicts case fatality and functional outcomes in pediatric trauma patients: the case for its use in trauma outcomes studies. Journal of Pediatric Surgery. 2011;46(8):1557-63.

61. Haider AH, Sexton J, Sriram N, Cooper LA, Efron DT, Swoboda S, Villegas CV, Haut ER, Bonds M, Pronovost PJ, Lipsett PA, Freischlag JA, Cornwell III EE. Association of Unconscious Race and Social Class Bias With Vignette-Based Clinical Assessments by Medical Students. Journal of the American Medical Association (JAMA). 2011;306(9):942-951.

62. Englum BR, Villegas C, Bolorunduro O, Haut ER, Cornwell III EE, Efron DT, Haider AH. Racial, Ethnic, and Insurance Status Disparities in Use of Posthospitalization Care after Trauma. Journal of the American College of Surgeons. 2011;213(6):699-708.

63. Haider AH, Villegas C, Saleem T, Efton DT, Stevens KA, Haut ER, Oyetunji TA, Cornwell EE 3rd, Bowman S, Haack S, Baker SP, Schneider EB. Should the ICD-9 Trauma Mortality Prediction Model (ICD9-TMPM) Become the New Paradigm for Benchmarking Trauma Outcomes? Journal of Trauma and Acute Care Surgery. 2012;72(6):1695-701.

64. Kisat M, Zafar SN, Latif A, Villegas CV, Efron DT, Stevens KA, Haut ER, Schneider EB, Zafar H, Haider AH. Predictors of Positive Head CT Scan and Neurosurgical Procedures After Minor Head Trauma. Journal of Surgical Research. 2012;173(1):31-7.

65. Pham JC, Haut ER, Catlett CL, Berenholtz SM. Association of Allogeneic Red-Blood Cell Transfusion with Surgeon Case-Volume. Journal of Surgical Research. 2012;173(1):135-144.

66. Zafar NS, Rushing A, Haut ER, Kisat MT, Villegas CV, Chi A, Stevens K, Efron DT, Zafar H, Haider AH. Outcome of selective non-operative management

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of penetrating abdominal injuries from the North American National Trauma Database. British Journal of Surgery. 2012; 99 (SUPPL. 1):155-164.

67. Haider AH, Ong'uti S, Efron DT, Oyetunji TA, Crandall ML, Scott VK, Haut ER, Schneider EB, Powe NR, Cooper LA, Cornwell EE 3rd. Association Between Hospitals Caring for a Disproportionately High Percentage of Minority Trauma Patients and Increased Mortality: A Nationwide Analysis of 434 Hospitals. Archive of Surgery. 2012;147(1):63-70.

68. Galvagno SM, Haut ER, Zafar SN, Millin MG, Efron DT, Koenig GJ, Baker SP, Bowman SM, Pronovost PJ, Haider AH. Association between helicopter vs. ground emergency medical services and survival for adults with major trauma. Journal of the American Medical Association (JAMA). 2012;307(15):1602-1610.

69. Pandian V, Gilstrap DL, Mirski MA, Haut ER, Haider AH, Efron DT, Bowman NM, Yarmus LB, Bhatti NI, Stevens KA, Vaswani R, Feller-Kopman D. Predictors of Short-Term Mortality in Patients Undergoing Percutaneous Dilatational Tracheostomy. Journal of Critical Care. 2012;27(4):420:e9-15.

70. Haider AH, Saleem T, Leow JJ, Villegas CV, Kisat M, Schneider EB, Haut ER, Stevens KA, Cornwell III EE, MacKenzie EJ, Efron DT. Influence of the National Trauma Data Bank on the Study of Trauma Outcomes: Is it Time to Set Research Best Practices to Further Enhance Its Impact? Journal of the American College of Surgeons. 2012;214(5):756-68.

71. Mirski MA, Pandian V, Bhatti N, Haut E, Feller-Kopman D, Morad A, Haider A, Schiavi A, Efron D, Ulatowski J. Safety, efficiency, and cost-effectiveness of a multidisciplinary percutaneous tracheostomy program. Critical Care Medicine. 2012;40(6):1827-34.

72. Streiff MB, Carolan HT, Hobson DB, Kraus PS, Holzmueller CG, Demski R, Lau BD, Biscup-Horn P, Pronovost PJ, Haut ER. Lessons from the Johns Hopkins Multi-Disciplinary Venous Thromboembolism (VTE) Prevention Collaborative. British Medical Journal (BMJ). 2012;344:e3935.

73. Crompton JG, Oyetunji T, Pollack KM, Stevens K, Cornwell EE 3rd, Efron DT, Haut ER, Haider AH. Association between helmets and development of facial injury after a motorcycle crash: An analysis of 40,000 patients from the National Trauma Data Bank. Archives of Surgery. 2012;147(7):674-676.

74. Yarmus L, Pandian V, Gilbert C, Schiavi A, Haider A, Chi A, Morad A, Miller C, Efron D, Stevens K, Gangidi S, Vaswani R, Haut E, Mirski M, Bhatti N, Feller-Kopman D. Safety and Efficiency of Interventional Pulmonologists Performing Percutaneous Tracheostomy. Respiration. 2012;84(2):123-7.

75. Obirieze AC, Gaskin, DJ, Villegas CV, Bowman SM, Schneider EB, Oyetunji TA, Haut ER, Efron DT, Cornwell EE III, Haider AH. Regional variations in cost of trauma care in the United States: Who is paying more? Journal of Trauma and Acute Care Surgery. 2012;73(2):516–522.

76. Pandian V, Miller CR, Mirski MA, Schiavi AJ, Morad AH, Vaswani RS, Kalmar CL, Feller-Kopman DJ, Haut ER, Yarmus LB, Bhatti NI. Multidisciplinary Team Approach in the Management of Tracheostomy Patients. Otolaryngology– Head and Neck Surgery. 2012;147(4):684–691.

77. Weygandt PL, Losonczy LI, Schneider EB, Kisat MT, Licatino LK, Cornwell EE 3rd, Haut ER, Efron DT, Haider AH. Disparities in mortality after blunt injury: does insurance type matter? Journal of Surgical Research. 2012;177(2):288-94.

78. Schneider EB, Hirani SA, Hambridge HL, Haut ER, Carlini AR, Castillo RC, Efron DT, Haider AH. Beating the weekend trend: increased mortality in older

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adult TBI patients admitted on weekends. Journal of Surgical Research. 2012;177(2):295-300.

79. Haut ER, Lau BD, Kraenzlin FS, Hobson DB, Kraus PS, Carolan HT, Haider AH, Holzmueller CG, Efron DT, Pronovost PJ, Streiff MB. Improved Prophylaxis and Decreased Rates of Preventable Harm With the Use of a Mandatory Computerized Clinical Decision Support Tool for Prophylaxis for Venous Thromboembolism in Trauma. Arch Surg. 2012;147(10):901-7.

80. Kerwin AJ, Haut ER, Burns JB, Como JJ, Haider A, Stassen N, Dahm P. The Eastern Association of the Surgery of Trauma (EAST) Approach to Practice Management Guideline Development using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) Methodology. Journal of Trauma and Acute Care Surgery. 2012;73(5):S283-S287.

81. Clancy K, Velopulos C, Bilaniuk JW, Collier B, Crowley W, Kurek S, Lui F, Nayduch D, Sangosanya A, Tucker B, Haut ER. Screening for blunt cardiac injury: An Eastern Association for the Surgery of Trauma practice management guideline. Journal of Trauma and Acute Care Surgery. 2012;73(5):S301-S306.

82. Moore FO, Duane TM, Hu CKC, Fox AD, McQuay Jr N, Lieber ML, Como JJ, Haut ER, Kerwin AJ, Guillamondegui O, Burns JB. Presumptive antibiotic use in tube thoracostomy for traumatic hemopneumothorax: An Eastern Association for the Surgery of Trauma practice management guideline. Journal of Trauma and Acute Care Surgery. 2012;73(5):S341-S344.

83. Pappou EP, Velopulos C, Fishman EK, Haut ER. Image of the Month: Hernia containing omentum and the right gastroepiploic artery. Archives of Surgery. 2012;147(11):1065.

84. Monn MF, Haut ER, Lau BD, Streiff M, Wick EC, Efron JE, Gearhart SL. Is Venous Thromboembolism in Colorectal Surgery Patients Preventable or Inevitable? One Institution's Experience. 2013 Journal of the American College of Surgeons (JACS). 2013;216(3):395-401.

85. Haut ER, Lau BD. Chapter 28: Prevention of Venous Thromboembolism: Brief Update Review. In “Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices.” March 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/evidencebased-reports/ptsafetyuptp.html

86. Bolorunduro OB, Haider AH, Oyetunji TA, Khoury A, Cubangbang M, Haut ER, Greene WR, Chang DC, Cornwell III EE, Siram SM. Disparities in trauma care: are fewer diagnostic tests conducted for uninsured patients with pelvic fracture? American Journal of Surgery. 2013;205(4):365-70.

87. Aboagye JK, Lau BD, Schneider EB, Streiff MB, Haut ER. Linking Processes and Outcomes: A Key Strategy to Prevent and Report Harm from Venous Thromboembolism in Surgical Patients. JAMA-Surgery. 2013;148(3):299-300.

88. Kisat M, Villegas CV, Onguti S, Zafar SN, Latif A, Efron DT, Haut ER, Schneider EB, Lipsett PA, Zafar H, Haider AH. Predictors of sepsis in moderately severely injured patients: an analysis of the national trauma data bank. Surg Infect (Larchmt). 2013;14(1):62-8.

89. Galvagno S, Thomas S, Baker S, Stephens C, Floccare D, Pronovost P, Haut ER, Hirshon JM. Helicopter emergency medical services for adults with major trauma. Cochrane Database of Systematic Reviews. 2013;3:CD009228.

90. Singh S, Haut ER, Brotman DJ, Sharma R, Chelladurai Y, Shermock KM, Kebede S, Stevens KA, Prakasa KR, Shihab HM, Akande TO, Zeidan AM, Garcia LJ, Segal JB. Pharmacologic and Mechanical Prophylaxis of Venous

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Thromboembolism Among Special Populations. Comparative Effectiveness Review No. 116. (Prepared by the Johns Hopkins University Evidence-based Practice Center under Contract No. 290-2007-10061-I.) AHRQ Publication No. 13-EHC082-1. Rockville, MD: Agency for Healthcare Research and Quality. 2013. www.effectivehealthcare.ahrq.gov/reports/final.cfm. http://effectivehealthcare.ahrq.gov/ehc/products/341/1501/venous-thromboembolism-special-populations-report-130529.pdf

91. Kruer RM, Harris LH, Goodwin H, Kornbluth J, Thomas KP, Slater LA, Haut ER. Changing Trends in the Use of Seizure Prophylaxis Following Traumatic Brain Injury: A shift from Phenytoin to Levetiracetam. Journal of Critical Care. 2013;28(5):883:e9-13.

92. Brotman DJ, Shihab HM, Prakasa KR, Kebede S, Haut ER, Sharma R, Shermock K, Chelladurai Y, Singh S, Segal JB. Pharmacologic and mechanical strategies for preventing venous thromboembolism after bariatric surgery: a systematic review and meta-analysis. JAMA-Surgery. 2013;148(7):675-86.

93. Hashmi ZG, Dimick JB, Efron DT, Haut ER, Schneider EB, Zafar SN, Schwartz D, Cornwell EE 3rd, Haider AH. Reliability adjustment: A necessity for trauma center ranking and benchmarking. Journal of Trauma and Acute Care Surgery. 2013;75(1):166-72.

94. Kebede S, Prakasa KR, Shermock K, Shihab HM, Brotman DJ, Sharma R, Chelladurai Y, Haut ER, Singh S, Segal JB. A systematic review of venous thromboembolism strategies in patients with renal insufficiency, obesity, or on antiplatelet agents. Journal of Hospital Medicine. 2013;8(7):394-401.

95. Haider AH, Hashmi ZG, Zafar SN, Hui X, Schneider EB, Efron DT, Haut ER, Cooper LA, MacKenzie EJ, Cornwell EE 3rd. Minority Trauma Patients Tend to Cluster with Worse-than-expected Mortality: Can this phenomenon help explain racial disparities in trauma outcomes? Annals of Surgery. 2013;258(4):572-581.

96. Diaz JJ, Cullinane DC, Khwaja KA, Tyson GH, Ott M, Jerome R, Kerwin AJ, Collier BR, Pappas PA, Sangosanya AT, Como JJ, Bokhari F, Haut ER, Smith LM, Winston ES, Bilaniuk JW, Tally CL, Silverman R, Croce MA.Eastern Association for the Surgery of Trauma - The Open Abdomen Part III: A Review of "Abdominal Wall Reconstruction." The Journal of Trauma and Acute Care Surgery. 2013;75(3):376-386.

97. Zeidan AM, Streiff MB, Lau BD, Ahmed SR, Kraus PS, Hobson DB, Carolan H, Lambrianidi C, Horn PB, Shermock KM, Tinoco G, Siddiqui S, Haut ER. Impact of a Venous Thromboembolism (VTE) Prophylaxis “Smart Order Set”: Improved Compliance, Fewer Events. American Journal of Hematology. 2013;88(7):545-549.

98. Obirieze AC, Kisat M, Hicks CW, Oyetunji TA, Schneider EB, Gaskin DJ, Haut ER, Efron DT, Cornwell EE 3rd, Haider AH. State-by-state variation in emergency versus elective colon resections: Room for improvement. Journal of Trauma and Acute Care Surgery. 2013;74(5):1286-91.

99. Shermock KM, Lau BD, Haut ER, Hobson DB, Ganetsky VS, Kraus PS, Efird LE, Lehmann CU, Pinto BL, Ross PA, Streiff MB. Patterns of non-administration of ordered doses of venous thromboembolism prophylaxis: implications for novel intervention strategies. PLoS One. 2013;8(6):e66311.

100. Dhiman N, Chi A, Pawlik TM, Efron DT, Haut ER, Schneider EB, Hashmi ZG, Scott VK, Hui X, Ali MT, Haider AH. Increased Death and Complication after Appendectomy in Patients with Cerebral Palsy: Are Special Needs Patients at Risk for Disparities in Outcomes? Surgery. 2013;154(3):479-85.

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101. Hui X, Haider AH, Hashmi ZG, Rushing AP, Dhiman N, Scott VK, Selvarajah S, Haut ER, Efron DT, Schneider EB.. Increased Risk of Pneumonia Among Ventilated TBI Patients: Every Day Counts! Journal of Surgical Research. 2013;184(1):438-43.

102. Bilimoria KY, Chung J, Ju Mila, Haut ER, Bentrem DJ, Ko CY, Baker DW. Evaluation of Surveillance Bias and the Validity of the Venous Thromboembolism Quality Measure. Journal of the American Medical Association (JAMA). 2013;310(14):1482-9.

103. Garonzik-Wang JM, Brat G, Salazar JH, Dhanasopon A, Lin A, Akinkuotu A, O’Daly A, Elder B, Olino K, Burns W, Camp M, Lipsett PA, Freischlag JA, Haut ER. Missing Consent Forms in the Pre-Operative Area: A Single Center Assessment of the Scope of the Problem and its Downstream Effects. JAMA-Surgery. 2013;148(9):886-9.

104. Stroh DA, Ray-Mazumder N, Norman JA, Haider AH, Stevens KA, Chi A, Rushing AP, Efron DT, Haut ER. Influencing Medical Student Education via a Voluntary Shadowing Program for Trauma and Acute Care Surgery. JAMA-Surgery. 2013;148(10):968-70.

105. Van Arendonk KJ, Schneider EB, Haider AH, Colombani PM, Stewart FD, Haut ER. Venous Thromboembolism After Trauma: When Do Children Become Adults? JAMA-Surgery. 2013;148(12):1123-30.

106. Haider AH, Figura RH, Ladha K, Johnston M, Noll KM, Heptinstall SR, Haut ER, Efron DT. Can we decrease the number of trauma patients “Missing in Action”? A prospective pilot intervention to improve trauma patient compliance with outpatient follow-up at an urban level-1 trauma center. American Surgeon. 2014;80(1):96-8.

107. Feinman M, Haut ER. Upper Gastrointestinal Bleeding. Surgical Clinics of North America. 2014;94(1):43-53.

108. Feinman M, Haut ER. Lower Gastrointestinal Bleeding. Surgical Clinics of North America. 2014;94(1):55-63.

109. Schwartz DA, Hui X, Velopulos CG, Schneider EB, Selvarajah S, Lucas D, Haut ER, McQuay N, Pawlik TM, Efron DT, Haider AH. Does Relative Value Unit-Based Compensation Shortchange the Acute Care Surgeon. J Trauma Acute Care Surg. 2014;76(1):84-92; discussion 92-4.

110. Haut ER, Garcia LJ, Shihab HM, Brotman DJ, Stevens KA, Sharma R, Chelladurai Y, Akande TO, Shermock K, Kebede S, Segal JB, Singh S. The Effectiveness of Prophylactic Inferior Vena Cava (IVC) Filters in Trauma Patients: A Systematic Review and Meta-Analysis. JAMA-Surgery. 2014;149(2):194-202.

111. Haider AH, Hashmi ZG, Zafar SN, Castillo R, Haut ER, Schneider EB, Cornwell EE 3rd, Mackenzie EJ, Efron DT. Developing Best Practices to Study Trauma Outcomes in Large Data Bases: An Evidence Based Approach to Determine the Best Mortality Risk Adjustment Model. Journal of Trauma and Acute Care Surgery. 2014;76(4):1061-9.

112. Monn MF, Xuan H, Lau BD, Haut ER, Streiff M, Wick, Efron JE, Gearhart SL. Diseases of the Colon & Rectum: Infection and Venous Thromboembolism in Colorectal Surgery Patients: What is the relationship? Diseases of the Colon & Rectum. 2014;57(4):497-505.

113. Losonczy LI, Weygandt PL, Villegas CV, Hall EC, Schneider EB, Cooper LA, Cornwell EE 3rd, Haut ER, Efron DT, Haider AH. The Severity of Disparity: Increasing Injury Intensity Accentuates Disparate Outcomes

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Following Trauma. Journal of Health Care for the Poor and Underserved. 2014;25(1):308-20.

114. Lucas DJ, Ejaz A, Haut ER, Spolverato G, Haider AH, Pawlik TM. Interhospital Transfer and Adverse Outcomes after General Surgery: Implications for Pay for Performance. Journal of the American College of Surgeons. 2014;218(3):393-400.

115. Newman MJ, Kraus PS, Shermock KM, Lau BD, Haut ER, Hobson DB, Streiff MB. Non-Administration of Thromboprophylaxis in Hospitalized Patients With HIV: A Missed Opportunity for Prevention. Journal of Hospital Medicine. 2014;9(4):215-20.

116. Crompton JG, Oyetunji TA, Haut ER, Cornwell EE 3rd, Haider AH. Systematically Tabulated Outcomes Research Matrix (STORM): A methodology to generate research hypotheses. Surgery. 2014;155(3):541-4.

117. Lau BD, Haut ER. Practices to Prevent Venous Thromboembolism: A Brief Review. BMJ Quality & Safety. 2014;23:187-95.

118. JohnBull EA, Lau BD, Schneider EB, Streiff MB, Haut ER. Hospital-Reported Perioperative Venous Thromboembolism Prophylaxis is not Associated with Outcome Rates in Publicly Reported Data. JAMA-Surgery. [Epub ahead of print]

119. Elder S, Hobson DB, Rand CS, Streiff MB, Haut ER, Efird LE, Kraus PS, Lehmann CU, Shermock KM. Hidden Barriers to Delivery of Pharmacological Venous Thromboembolism Prophylaxis: The Role of Nursing Beliefs and Practices. Journal of Patient Safety. [Epub ahead of print]

120. Haider AH, Young H, Kisat M, Villegas CV, Scott VK, Ladha K, Haut ER, Cornwell EE 3rd, MacKenzie EJ, Efron DT. Association between intentional injury and long term survival after trauma. Annals of Surgery. [Epub ahead of print]

121. Ejaz A, Spolverato Gaya, Kim Y, Lucas DM, Lau B, Weiss M, Johnston FM, Kheng M, Hirose K, Wolfgang CL, Haut E, Pawlik T. Defining Incidence and Risk Factors of Venous Thromboembolism after Hepatectomy. Journal of Gastrointestinal Surgery. [Epub ahead of print]

122. Pandian V, Miller CR, Schiavi AJ, Yarmus L, Contractor A, Haut ER, Feller-Kopman DJ, Mirski MA, Morad AH, Carey JP, Hillel AT, Maragos CS, Bhatti NI. Utilization of a Standardized Tracheostomy Capping and Decannulation Protocol to Improve Patient Safety. Laryngoscope. [Epub ahead of print]

123. Canner JK, Haider, AH, Selvarajah S, Hui X, Wang H, Efron DT, Haut ER, Velopulos CG, Schwartz DA, Chi A, Schneider EB. U.S. Emergency Department Visits for Fireworks Injuries, 2006-2010. Journal of Surgical Research. [Epub ahead of print]

124. Hicks CW, Hashmi ZG, Velopulos C, Efron DT, Schneider EB, Haut ER, Cornwell EE 3rd, Haider AH. Association between Race and Age in Survival after Trauma. JAMA-Surgery. (Accepted for Publication, In Press)

125. Lucas DJ, Haut ER, Hechenbleikner EM, Wick EC, Pawlik TM. AvoidingImmortal Time Bias in the ACS NSQIP Readmission Measure. JAMA-Surgery 2014. (Accepted for Publication, In Press)

126. Grimm JC, Berger JC, Lipsett PA, Haut ER. A Case of Profound Pneumatosis Intestinalis in a Patient with Recent Polytrauma. The Journal of Trauma and Acute Care Surgery. (Accepted for Publication, In Press)

127. Ferrada P, Velopulos CG, Sultan S, Haut ER, Johnson E, Praba-Egge A, Enniss T, Dorion H, Martin ND, Bosarge P, Rushing A, Duane TM. Timing and Type of Surgical Treatment of Clostridium difficile–Associated Disease (CDAD): a

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Practice Management Guideline from the Eastern Association for the Surgery of Trauma (EAST). Journal of Trauma and Acute Care Surgery. 2014. (Accepted for Publication, In Press)

Extramural Sponsorship Current Grant 7/1/2013-6/30/2016 “Preventing Venous Thromboembolism: Empowering Patients and

Enabling Patient-Centered Care via Health Information Technology” (PCORI) The Patient-Centered Outcomes Research Institute CE-12-11-4489 http://www.pcori.org/pfaawards/preventing-venous-thromboembolism-empowering-patients-and-enabling-patient-centered-care-via-health-information-technology/ PI: Elliott R. Haut Total Direct Cost: $1,499,194 25% Support

Previous Grants 1/1/2008-12/31/2008 “Screening Variability Makes DVT Rate an Unreliable Quality Measure

of Trauma Care” Johns Hopkins Department of Surgery Research Pilot Project Grant PI: Elliott R. Haut

Total Support: $20,000 7/1/2009-6/30/2013 “Does Screening Variability Make DVT an Unreliable Quality Measure of

Trauma Care?” AHRQ (Agency for Healthcare Research and Quality) Mentored Clinical Scientist Development Award K08 1K08HS017952-01 http://www.ahrq.gov/funding/training grants/grants/active/kawards/Kawdsumhaut.html PI: Elliott R. Haut Total Support: $783,950 75% Support

2011 ACS/EAST Health Policy and Leadership Scholarship to attend “Executive Leadership Program in Health Policy & Management at Brandeis University” American College of Surgeons / Eastern Association for the Surgery of Trauma

Total Support: $8,000 2011-2014 The Hopkins Sommer Scholars Program

The Johns Hopkins Bloomberg School of Public Health

Research Program Building / Leadership 2006-present Co-Director, Deep Vein Thrombosis (DVT) Collaborative, JHM

This committee continues to advance patient safety by preventing deep vein thrombosis through a multi-faceted approach across the entire Johns Hopkins Institutions. The group has successfully implemented mandatory patient risk stratification for all admitted patients via the

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computerized physician order entry (POE) system in an effort to ensure all patients are given appropriate prophylaxis. This group sponsors yearly education endeavors each March for DVT Awareness Month, including 2009’s highlight, a speech by the US Surgeon General.

EDUCATIONAL ACTIVITIES Educational Publications Invited Editorials

1. Haut ER. Head CT in Trauma Patients with Seizure Disorder: Is Routine Use Justified? Invited Critique. Archives of Surgery. 2005;140; 864.

2. Haut ER. Reduced Mortality at a Community Hospital Trauma Center: The Impact of Changing Trauma Level Designation From II to I. Invited Critique. Archives of Surgery. 2008;143(1):27-8.

3. Haut ER. Venous Thromboembolism: Are Regulatory Requirements Reasonable? Critical Connections (Society of Critical Care Medicine news magazine). 2008. (COVER article)

4. Haut ER. Trauma & Coagulopathy: A New Paradigm to Consider. Invited Critique. Archives of Surgery. 2008;143(8): 802.

5. Haut ER. Evaluation of posttraumatic venous sinus occlusion with CT venography - Invited Discussion. Journal of Trauma. 2009; 66(4):1006-7.

6. Haut ER. Invited Commentary: Preventing venous thromboembolism in surgical patients: current prophylaxis practices and quality improvement initiatives. The American Journal of Surgery. 2010;200(3):424-425.

7. Haut ER. Are surgeons ready to embrace a paradigm shift in surgical comparative effectiveness research? Invited Critique. Archives of Surgery. 2010;145(10):945-946.

8. Haut ER, Lau BD, Streiff MB. New oral anticoagulants for preventing venous thromboembolism. Are we at the point of diminishing returns? British Medical Journal (BMJ). 2012;344:e3820.

9. Kerwin AJ, Haut ER. Foreword for the 2012 Eastern Association for the Surgery of Trauma (EAST) Practice Management Guidelines Supplement. Journal of Trauma and Acute Care Surgery. 2012;73(5):S281-S282.

Letters, correspondence 1. Haider AH, Chang DC, Efron DT, Haut ER, Cornwell E. Authors response to

letter to the editor regarding: African American children experience worse Clinical and Functional Outcomes after Traumatic Brain Injury: An Analysis of the National Pediatric Trauma Registry. Journal of Trauma. 2008;65(2):497-498.

2. Rosenberg JJ, Haut ER. Letter to the Editor- "Surveillance Bias and Postoperative Complication Rates." Archives of Surgery. 2012;147(2):199-200.

3. Haut ER, Pronovost PJ, Schneider EB. Limitations of Administrative Databases. JAMA. 2012;307(24):2589.

4. Streiff MB, Lau BD, Carolan HT, Hobson DB, Kraus PS, Haut ER. “Re: Heparin prophylaxis has no benefit in medical patients.” http://www.bmj.com/content/345/bmj.e4940/rr/601840.

5. Haut ER, Kalish BT, Cotton BA, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE 3rd, Chang DC. Authors response to letter to the editor from Niven, Stelfox, Ball, and Kirkpatrick regarding: Pre-Hospital Intravenous Fluid Administration is Associated with Higher Mortality in Trauma Patients: A National Trauma Data Bank Analysis. Annals of Surgery. 2014;259(2):e17–e18.

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6. Haut ER, Kalish BT, Cotton BA, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE 3rd, Chang DC. Authors response to letter to the editor from Champion HR regarding: Pre-Hospital Intravenous Fluid Administration is Associated with Higher Mortality in Trauma Patients: A National Trauma Data Bank Analysis. Annals of Surgery. 2014;259(2):e20–e21.

7. Haut ER, Kalish BT, Cotton BA, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE 3rd, Chang DC. Authors response to letter to the editor from Rivkind AI, Glassberg E, Ganor O regarding: Pre-Hospital Intravenous Fluid Administration is Associated with Higher Mortality in Trauma Patients: A National Trauma Data Bank Analysis. Annals of Surgery. 2014;259(2):e20–e23.

8. Haut ER, Kalish BT, Cotton BA, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE 3rd, Chang DC. Authors response to letter to the editor from Paydar regarding: “ATLS Protocols of Initial Intravenous Fluid Administration for Trauma Patients; Needing a Revision?” Annals of Surgery. [Epub ahead of print]

Book Chapters 1. Haut ER. “How Much of Your Body Can You Lose and Still Live?” in Wendell

Jamieson’s “Father Knows Less or Can I Cook my Sister?” G.P. Putnam’s Sons, 2007.

2. Cornwell EE, Haut ER, Kuwiyama D. “Pancreatic Trauma” in “Shackleford’s Surgery of the Alimentary Tract”, 6th Edition. Yeo CJ, Dempsey DT, Klein AS, Pemberton JH, Peters JH. Saunders Elsevier, Philadelphia, 2007.

3. Haut ER. “Attempt to decrease phlebotomy” in Marcucci L, Martinez E, Haut ER, Slonim A, Suarez J. “Avoiding Common ICU Errors.” Lippincott Williams & Wilkins, Philadelphia, 2007.

4. Hayanga A, Haut ER. “Do not use Lovenox in patients with epidurals” in Marcucci L, Martinez E, Haut ER, Slonim A, Suarez J. “Avoiding Common ICU Errors.” Lippincott Williams & Wilkins, Philadelphia, 2007.

5. Hayanga A, Haut ER. “Rhabdomyolysis” in Marcucci L, Martinez E, Haut ER, Slonim A, Suarez J. “Avoiding Common ICU Errors.” Lippincott Williams & Wilkins, Philadelphia, 2007.

6. Matsen SL, Haut ER. “Use Bronchoscopic Guidance for Bedside Percutaneous Dilatational Tracheostomy" in Marcucci L, Martinez E, Haut ER, Slonim A, Suarez J. “Avoiding Common ICU Errors.” Lippincott Williams & Wilkins, Philadelphia, 2007.

7. Moncur L, Haut ER. “Consider the use of tris-hydroxymethyl aminomethane (THAM) to treat refractory or life-threatening metabolic acidosis” in Marcucci C, Cohen NA, Metro DG, Kirsch JR. “Avoiding Common Anesthesia Errors.” Lippincott Williams & Wilkins, Philadelphia, 2007.

8. Haut ER. “Blunt Cardiac Injury” in Cameron JL. “Current Surgical Therapy” 9th edition, Elsevier, Philadelphia, 2008, pp. 1063-1066.

9. Kennedy M, Haut ER. "Respiratory Compromise" in Pryor J, Todd B, Dryer M. “Clinician's Guide to Surgical Care”. McGraw-Hill Medical, New York, 2008, pp. 43-58.

10. Haut ER, Efron DT, Cornwell EE. “Liver” in Gracias VH, Reilly PM, McKenney MG, Velmahos G. “Emergency Surgery”. McGraw-Hill Medical, New York, 2008, pp. 99-108.

11. Haut ER, Gupta R. "Trauma Resuscitation" in Bledsoe G, Manyak M, Townes D. “Expedition and Wilderness Medicine”. Cambridge University Press, New York, 2009, pp. 529-543.

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12. Haut ER. “Evaluation and Acute Resuscitation of the Trauma Patient” in Evans SRT ed. “Surgical Pitfalls: Prevention and Management.” Saunders, Philadelphia. 2009, pp. 757-771.

13. Kemp CD, Haut ER. “Avoid Placing an Unnecessary Chest Tube” in Mattu A, Chanmugam A, Swadron S, Tibbles C, Woolridge D. “Avoiding Common Errors in the Emergency Department.” Lippincott Williams & Wilkins, Philadelphia, 2010. (Trauma Section Associate Editor)

14. Lum Y, Haut ER. “Know which trauma patients to screen for blunt cerebral vascular injury (BCVI) - even if they are neurologically normal” in Mattu A, Chanmugam A, Swadron S, Tibbles C, Woolridge D. “Avoiding Common Errors in the Emergency Department.” Lippincott Williams & Wilkins, Philadelphia, 2010. (Trauma Section Associate Editor)

15. Olino K, Haut ER. “Avoid Converting a Meta-Stable Airway to an Unstable Airway in Trauma Patients: But Also Know How to do a Surgical Cricothyroidotomy” in Mattu A, Chanmugam A, Swadron S, Tibbles C, Woolridge D. “Avoiding Common Errors in the Emergency Department.” Lippincott Williams & Wilkins, Philadelphia, 2010. (Trauma Section Associate Editor)

16. Serrano OK, Haut ER. “Don’t assume a normal heart rate and/or blood pressure ensures a patient is not in hypovolemic shock” in Mattu A, Chanmugam A, Swadron S, Tibbles C, Woolridge D. “Avoiding Common Errors in the Emergency Department.” Lippincott Williams & Wilkins, Philadelphia, 2010. (Trauma Section Associate Editor)

17. Pesce C, Haut ER. “Don’t ‘Pop the Clot’ - The Role Of Hypotensive Resuscitation in Trauma Care” in Mattu A, Chanmugam A, Swadron S, Tibbles C, Woolridge D. “Avoiding Common Errors in the Emergency Department.” Lippincott Williams & Wilkins, Philadelphia, 2010. (Trauma Section Associate Editor)

18. Emery K, Haut ER. “Understand the Basics of Gunshot Wound (GSW) Treatment” in Mattu A, Chanmugam A, Swadron S, Tibbles C, Woolridge D. “Avoiding Common Errors in the Emergency Department.” Lippincott Williams & Wilkins, Philadelphia, 2010. (Trauma Section Associate Editor)

19. Kieninger AN, Haut ER. “IV Access In Trauma: Carefully Decide Where to Place it and What Catheter to Use” in Mattu A, Chanmugam A, Swadron S, Tibbles C, Woolridge D. “Avoiding Common Errors in the Emergency Department.” Lippincott Williams & Wilkins, Philadelphia, 2010. (Trauma Section Associate Editor)

20. Garonzik-Wang J, Haut ER. “Use abdominal CT scan liberally based on mechanism or in unevaluable patients to rule out blunt abdominal trauma” in Mattu A, Chanmugam A, Swadron S, Tibbles C, Woolridge D. “Avoiding Common Errors in the Emergency Department.” Lippincott Williams & Wilkins, Philadelphia, 2010. (Trauma Section Associate Editor)

21. Berger J, Haut ER. “Know When Intubation Can Make a Trauma Patient Acutely Worse (As Opposed To Better)” in Mattu A, Chanmugam A, Swadron S, Tibbles C, Woolridge D. “Avoiding Common Errors in the Emergency Department.” Lippincott Williams & Wilkins, Philadelphia, 2010. (Trauma Section Associate Editor)

22. Stevens KA, Haut ER. “Airway Management in the Trauma Patient” in Cameron JL. “Current Surgical Therapy” 10th edition, Elsevier, Philadelphia. pp. 895-900.

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23. Streiff MB, Haut ER. “Coagulopathy of Trauma” in Cameron JL. “Current Surgical Therapy” 10th edition, Elsevier, Philadelphia. pp. 1014-1018.

24. Kieninger AN, Haut ER. “Penetrating Laryngotracheal Trauma” in Velmahos G, Degiannis E, Doll D. “Penetrating Trauma” Springer. pp. 215-220.

25. Haut ER, Cornwell EE. “Thromboembolic Disease” in Britt LD, Peitzman A, Barie P, Jurkovich G. “Acute Care Surgery.” Lippincott Williams & Wilkins. 2012. pp. 732-737.

26. Van Arendonk K, Haut ER. “Nutritional Support in the Critically Ill Patient” in “Clinical Scenarios in General Surgery: Decision Making and Operative Technique.” eds. Dimick J, Sonnenday C, Upchurch G. Lippincott Williams & Wilkins. 2012. pp. 594-599.

27. Rushing A, Cornwell EE, Haut ER. “Pancreatic Trauma” in “Shackleford’s Surgery of the Alimentary Tract”. Saunders Elsevier, Philadelphia. 2012. pp.1234-40.

28. Slater LA, Garcia LJ, Cartolano T, Velopulos CG, Farnejad F, Haut ER. “Trauma and Critical Care” in Neff MA “Passing the General Surgery Oral Board Exam”. 2nd edition, Springer, New York. 2013. pp. 113-131.

29. Velopulos CG, Haut ER. “Venous Thromboembolism: Prevention, Diagnosis and Treatment” in Cameron JL and Cameron AM. “Current Surgical Therapy” 11th edition, Elsevier, Philadelphia. 2014. pp. 958-963.

Books, Textbooks

1. Marcucci L, Martinez E, Haut ER, Slonim A, Suarez J, eds. “Avoiding Common ICU Errors”. Lippincott Williams & Wilkins, Philadelphia, 2007.

2. Nazarian SM, Meguid RA, Lipsett PA. “The Johns Hopkins ABSITE Review Manual” Lippincott Williams & Wilkins, Philadelphia, 2008. (Contributing editor)

3. Mattu A, Chanmugam A, Swadron S, Tibbles C, Woolridge D. “Avoiding Common Errors in the Emergency Department”. Lippincott Williams & Wilkins, Philadelphia, 2010. (Trauma Section Associate Editor)

4. Advanced Surgical Skills for Exposure in Trauma (ASSET) course syllabus, Contributor. American College of Surgeons Committee on Trauma (ACS-COT) Surgical Skills subcommittee.

5. Meguid RA, Van Arendonk K, Lipsett PA. “The Johns Hopkins ABSITE Review Manual” 2nd Edition. Lippincott Williams & Wilkins, Philadelphia, 2013. (Contributing editor)

Teaching Classroom Instruction 2001-2002 Laparoscopic Ventral Hernia Repair Course, Assistant Instructor, Pennsylvania

Hospital 2001-2002 Laparoscopic Ventral Hernia Repair Course, Assistant Instructor, Pennsylvania

Hospital 2004-2005 Quality Improvement, ACT II (Achieving Competence Today), Faculty,

Partnership for Quality Education, Johns Hopkins Medicine & The Robert Wood Johnson Foundation

2004-2009 Core Lecture Series for Medical Students on Surgery Clerkship, Lecturer, “Fluids and Electrolytes,” given each quarter, Johns Hopkins University School of Medicine

2004-present Core Lecture Series for Surgical Residents/Interns, Lecturer, 2-3 lectures per year 2006-present Surgical Resident/Intern Educational Labs, Lab Instructor, 3-4 labs per year

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2006-present Surgical Physician Assistant’s Residency Core Lecture Series, Lecturer, 1 lectures per year

2007-present Multi-Disciplinary Critical Care Fellow Lecture Series, Lecturer, 1-2 lectures per year

2004-present Trauma Nurse Orientation Seminars, Lecturer, “Shock and the Complications of Trauma,” yearly lecture to Surgery and Emergency Medicine Nursing Staff, JHH

Clinical Instruction 2004-present Inpatient Surgical Service, Attending Surgeon, Johns Hopkins Hospital 2004-present Surgical Intensive Care Units, Attending Physician, 8 weeks per year, JHH 2004-present In-House Trauma/Acute Care Surgery Attending, 4-6 calls per month, JHH

CME Instruction 2004-present Bi-weekly conference, “Clinical Problems in Trauma Series,” Lecturer, JHH

9/9/06 “Management of Extremity Trauma” 1/24/07 “Management of Abdominal Trauma” 2/7/07 “Management of Lightening strikes” 6/6/07 “Can Increased Incidence If DVT Be Used as a Marker of Quality of Care in the Absence of Standardized Screening?” 10/3/07 “Management of Abdominal Compartment Syndrome” 3/5/08 “Venous Thromboembolism (VTE) After Trauma” 11/5/08 “Should I Leave this Abdomen Open?” 6/3/09 “Will you Fall for the Trauma Pitfall?” 3/3/10 “DVT Prevention in Trauma” 5/18/11 “Improving Pre-Hospital Trauma Care via Health Services Research” 11/23/11 “Benchmarking the Quality of Trauma Care: What do DVT rates really tell us?” 3/6/13 “Creating and Using Trauma Practice Management Guidelines” 12/18/13 “Should I Leave this Abdomen Open? Damage control Surgery 101”

2005-present Advanced Trauma Operative Management (ATOM), Instructor, Baltimore, MD (3-4 courses / year)

2005 “The Johns Hopkins Perspective on Drugs and Alcohol in Trauma” Innovators Combating Substance Abuse Awards Program Symposium on Alcohol Screening, Intervention, and Confidentiality Requirements in Trauma Centers and Emergency Departments Department of Psychiatry and Behavioral Sciences, Johns Hopkins Medical Institutions

2007-present Advanced Trauma Life Support (ATLS), Instructor, Baltimore, MD (1-2 courses per year)

2007 “Should I Leave This Abdomen Open?” Trauma Care 2007: A Team Approach Maryland Committee on Trauma of the American College of Surgeons, Baltimore, MD

2007 “Abdominal Compartment Syndrome” 17th Annual Trauma Conference Peninsula Regional Medical Center, Ocean City, MD

2008 “Should I Leave This Abdomen Open?” Surgical Grand Rounds, Holy Cross Hospital, Silver Spring, Maryland

2008 “CT Scan after Abdominal Trauma: Routine vs. Selective?” Maryland Committee on Trauma of the American College of Surgeons, Baltimore, MD

2008 “Avoiding Common Errors in the Intensive Care Unit (ICU)”

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Providing Trauma Care - Washington County Trauma Conference, Hagerstown, MD

2011-present Advanced Surgical Skills for Exposure in Trauma (ASSET), Instructor, Baltimore, MD (1-2 courses per year)

Mentoring Trauma / Acute Care Surgery Fellows 2007-2008 Preeti Rebecca John, MD, MPH

Staff Surgeon - Critical Care/General Surgery, Baltimore VA Medical Center 2008-2009 Alicia Nicole Kieninger, MD

Immediate post-fellowship position Assistant Professor of Surgery, Washington University, St. Louis, MO Currently Trauma Director, St. Joseph Mercy Oakland, Pontiac MI

2009-2010 George Koenig Jr. DO Assistant Professor of Surgery, Thomas Jefferson University, Philadelphia, PA

2009-2010 Nicholas Jaszczak MD Trauma / Acute Care Surgeon, United States Army

2010-2011 Amy Page Rushing, MD Trauma / Acute Care Surgery Attending, York Hospital

2011-2012 Catherine Garrison Velopulos, MD, Fellow (Clinical) 2012-2013 Catherine Garrison Velopulos, MD, Fellow (Research)

Assistant Professor, Trauma / Acute Care Surgery, Johns Hopkins Medicine 2012-2013 Luis J. Garcia, MD

Assistant Professor, Trauma / Acute Care Surgery Attending, University of Iowa 2012-2013 Leigh Ann Slater, MD

Surgery Attending, Meritus Medical Center, Hagerstown, MD 2013-present Marcie Feinman, MD 2013-present William “Rob” Leeper, MD

Johns Hopkins Research Assistants and Junior Faculty 2012-13 Brandyn D. Lau, MPH, CPH

Senior Research Assistant Division of Acute Care Surgery, Department of Surgery, JHM

2013-present Brandyn D. Lau, MPH, CPH Instructor, Division of Acute Care Surgery, Department of Surgery, JHM

Johns Hopkins Bloomberg School of Public Health Students 2006-2007 Charles Pierce, DO, MPH MPH Student and Capstone Advisor

The Johns Hopkins Bloomberg School of Public Health MPH Thesis Title - “Surveillance Bias And Deep Vein Thrombosis In The National Trauma Data Bank: The More We Look, The More We Find” American Association for the Surgery of Trauma (AAST) Medical Student Scholarship First author published paper Surgical Resident at University of Arkansas

2007-2007 Shahrzad Kardooni, MD, MPH MPH Student Advisor

The Johns Hopkins Bloomberg School of Public Health

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American Association for the Surgery of Trauma (AAST) Medical Student Scholarship First author published paper Surgical Resident at Georgetown University

2010-2011 Rishav Shrestha, MD, MPH MPH Student and Capstone Advisor

The Johns Hopkins Bloomberg School of Public Health Thesis Title - “Did Patients with Post-Operative Venous Thromboembolism (VTE) receive best practice VTE prophylaxis? A descriptive study of the American College of Surgeons –National Surgical Quality Improvement Program (ACS-NSQIP) database”

2010-2011 Howard Carolan, MPH, MBA MPH, MBA Student and Capstone Advisor

The Johns Hopkins Bloomberg School of Public Health Public Health Informatics Practicum Advisor Thesis Title - “Quantifying the Impact of Electronic Decision Support for Prevention of Venous Thromboembolism” Second author (BMJ) paper

2011-2012 Jonathan Kumi Aboagye, MBChB, MPH

MPH Student and Capstone Advisor The Johns Hopkins Bloomberg School of Public Health MPH Thesis Title - “Is Risk Appropriate Prophylaxis Associated With Decreased Risk of Postsurgical Venous Thromboembolism (VTE)? A Study of the American College of Surgeons –National Surgical Quality Improvement Program (ACS-NSQIP) database from a Tertiary Health Center” First author (JAMA-Surgery) paper

2012-2013 Eric A. JohnBull, MPH

MPH Student and Capstone Advisor American College of Medical Quality, Student and Resident Quality Scholar

(2013) MPH Thesis Title – “Linking Process to Outcome: Hospital-Reported Venous Thromboembolism (VTE) Prophylaxis is Not Associated with VTE Rate in Publicly Reported Data” First author (JAMA-Surgery) paper

2012-2013 Nikhilesh Ray-Mazumder, MPH

MPH Student and Capstone Advisor MPH Thesis Title – “How Can EMS Save More Lives? A Study of Comparative Outcomes in Urban Gunshot Wound Patients” Presentation at American College of Surgeons Clinical Congress 2013- Surgical Forum Second author (JAMA-Surgery) paper

Johns Hopkins Surgical Residents (Research) 2004-2005 Avedis Meneshian, MD

“Retroperitoneal Gunshot Wound Hernia: An Unusual Cause Of Early Post-Operative Small Bowel Obstruction After Laparotomy for Trauma”

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First Author Paper 2006-2007 Angela Shoher, MD

“Multiple Simultaneous Trauma Patients: Are They Worse Off?” Eastern Association for the Surgery of Trauma (EAST) presentation 2006 2nd Prize, Maryland American College of Surgeons Committee on Trauma Resident Paper Competition and first author paper

2006-2007 Eric Weiss, MD, MPH

“Laterality of Deep Venous Thrombosis Among Trauma Patients: Are We Screening Our Patients Adequately?” Association of Academic Surgery (AAS) presentation 2007 and first author paper

2007-2008 Awori Hayanga, MD, MPH 1st Prize in Maryland and 1st Prize in Region 3 for American College of Surgeons Committee on Trauma Resident Paper Competition 2007-2008 and paper

2011-13 Jackie Garonzik- Wang, MD, PhD First Author (JAMA-Surgery) Paper

2011-13 Kyle Van Arendonk, MD, PhD

First Author (JAMA-Surgery) Paper Johns Hopkins University Medical Students 2009-2010 Matthew M. Boelig, MD

“Are Sequential Compression Devices (SCDs) Commonly Associated with In-Hospital Falls? A Myth-Busters Review Using the Patient Safety Net ® (PSN) Database” 1st author Journal of Patient Safety paper Currently Surgical Resident at The University of Pennsylvania

2011-2013 D. Alex Stroh, MD “Influencing Medical Student Education via a Voluntary Shadowing Program for Trauma and Acute Care Surgery First author (JAMA-Surgery) paper

Johns Hopkins University Undergraduate Students 2008-2009 Brian Kalish, BS

American Association for the Surgery of Trauma (AAST) Medical Student Scholarship 2nd author on two published papers

Currently Medical Student at Harvard Medical School Educational Program Building / Leadership 2007-present Trauma / Acute Care Surgery Fellowship Director, Johns Hopkins Hospital Dr. Haut is responsible for the education and training of post-residency surgical

fellows in the Trauma / Acute Care Surgery Fellowship at Johns Hopkins Hospital. Since taking over this role, he has increased the number of fellows (from 1 to 2) and expanded the fellowship from a trauma only fellowship to include the field of Acute Care Surgery, keeping pace with national trends.

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2008-present Multi-Disciplinary Emergency Airway Course, Johns Hopkins Hospital

Dr. Haut is the key representative from the Department of Surgery involved in the planning and development of a Multi-Disciplinary Emergency Airway Course which is now required all surgery, emergency medicine, anesthesiology & critical care medicine, and otolaryngology-head and neck surgery residents. The full-day course has didactic components and then hands on practice stations and high-fidelity simulated scenarios in the Johns Hopkins Simulation Center.

2013-present Assistant Program Director Armstrong Institute Resident Scholars (AIRS) Program in Patient Safety and Quality, JHM

CLINICAL ACTIVITIES Certification Medical, other state/government licensure 1998-present Pennsylvania #MD 068003-L 2004-present Maryland #D61858 2004-present Maryland Controlled substance: # M57533 2004-present Drug Enforcement Agency: # BH7853345 Board Certification 2003 (October) Diplomate, American Board of Surgery

(Certificate #48589), recertified 2012 (expires 7/1/2024) 2004 (October) Diplomate, American Board of Surgery, Surgical Critical Care

(Certificate #2121) (expires 7/1/2015) Other 1996 American College of Surgeons, Advanced Trauma Life Support (ATLS) 2002 Trauma Ultrasound Course (University of Pennsylvania) 2003-present American College of Surgeons, Advanced Trauma Life Support (ATLS),

Instructor 2004 Advanced Trauma Operative Management (ATOM) 2005-present Advanced Trauma Operative Management (ATOM), Instructor 2010 Advanced Surgical Skills for Exposure in Trauma (ASSET) 2011-present Advanced Surgical Skills for Exposure in Trauma (ASSET), Instructor Clinical (Service) Responsibilities: 2004-present Surgical Intensivist, attending approximately 8 weeks per year 2004-present Trauma/Acute Care Surgeon, (including 4-6 in-house overnight trauma calls) Clinical Program Building / Leadership 2005-present Director of Adult Trauma Performance Improvement, Johns Hopkins Hospital In March 2008 and again in June 2013, Dr. Haut was instrumental in helping

achieve Level I status recertification for the Adult Trauma Center at Johns Hopkins Hospital.

2006-present Associate Director, Percutaneous Tracheostomy Program, JHH The Percutaneous Tracheostomy Service comprises multidisciplinary staff from

the departments of Surgery, Otolaryngology-Head and Neck Surgery, Anesthesiology & Critical Care Medicine, and Pulmonary & Critical Care

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Medicine including physicians, nurse practitioners, nurses, speech pathologists and critical care technicians. This team collaboratively performs nearly 200 bedside percutaneous tracheostomy procedures each year for intubated patients in all adult intensive care units at Johns Hopkins Hospital. Dr. Haut has personally performed nearly 250 procedures and has trained dozens of surgical residents, emergency medicine residents, and critical care fellows.

2007-present Emergency Airway Management Committee, Johns Hopkins Hospital Dr. Haut is the primary surgical representative on the Airway Response Team

(ART) Initiative which is a multi-dimensional, multi-departmental program to improve emergency airway management in the Johns Hopkins Hospital. It includes three components: 1) Operational- to improve patient management, 2) Safety- to ensure novel safety programs based on quality assurance reporting and 3) Educational- to develop comprehensive didactic and simulation training for residents and faculty.

ORGANIZATIONAL ACTIVITIES Institutional Administrative Appointments 2001-2002 Critical Care Committee, Pennsylvania Hospital, Philadelphia, PA 2002-2004 Trauma Performance Improvement Committee,

The Hospital of the University of Pennsylvania, Philadelphia, PA 2003-2004 Surgical Critical Care Senior Administrative Fellow

Division of Traumatology and Surgical Critical Care, The University of Pennsylvania

2003-2004 Housestaff Committee, The Hospital of the University of Pennsylvania 2003-2004 Patient Safety Steering Committee, The Hospital of the University of

Pennsylvania 2004-present Trauma Performance Improvement Committee, JHH 2005-present Chair, Trauma Performance Improvement Committee, JHH 2005-present Assistant Program Director, General Surgery Residency, JHH 2006-present Associate Director, Tracheostomy Program, JHH 2006-present Tracheostomy Protocol and Orderset Committee, JHH 2006-present Co-Director, Deep Vein Thrombosis Collaborative, JHM 2007-present Promotions Committee, General Surgery Residency, JHH 2007-present Education Committee, General Surgery Residency, JHH 2007-present Emergency Airway Management Committee, JHH 2007-present Deep Vein Thrombosis Physician Order Entry Committee, JHH 2007-present Director, Trauma / Acute Care Surgery Fellowship, JHH 2007-present Co-Coordinator, Deep Vein Thrombosis Awareness Month Committee, JHH 2007-present Anticoagulation Task Force, JHH Anticoagulation Clinical Practice subcommittee Anticoagulation Metrics subcommittee 2009-present Peri-Operative Committee, JHH 2010-present Clinical Data and Documentation Committee, JHH 2010-2011 Search Committee, Executive Director Johns Hopkins Center for Talented Youth (CTY) 2011-present Physician’s Advisory Council, Johns Hopkins Lifeline Critical Care Transport

Service 2012-present Epic Decision Support Workgroup, JHH 2012-present Epic Research Task Force, JHH 2012-present Core Faculty, The Center for Surgical Trials and Outcomes Research, JHM

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2013-present Physician Advisory Board, J-CHiP, JHH 2013-present Assistant Director, Armstrong Institute Resident Scholars (AIRS) Program in

Patient Safety and Quality Editorial Activities Journal Supplement Editor 2012 Journal of Trauma and Acute Care Surgery EAST Practice Management Guidelines (PMG) Supplement Journal Reviewer 2003 Annals of Thoracic Surgery, Ad Hoc reviewer 2005, 2007, 2010, 2011 Archives of Surgery, Ad Hoc reviewer 2007 Diseases of the Colon and Rectum, Ad Hoc reviewer 2007 Clinical Intensive Care, Ad Hoc reviewer 2009, 2010, 2011, 2012, 2013 Journal of Trauma, Ad Hoc reviewer 2010, 2011 Journal of Clinical Anesthesia, Ad Hoc reviewer 2010, 2011, 2013, 2014 Annals of Surgery, Ad Hoc reviewer 2010 Critical Care Research and Practice, Ad Hoc reviewer 2011, 2012, 2013 Surgery, Ad Hoc reviewer 2011, 2012 Journal of The American College of Surgeons, Ad Hoc reviewer 2011 Journal of Patient Safety, Ad Hoc reviewer 2011 Traffic Injury Prevention, Ad Hoc reviewer 2011 Journal of Thrombosis and Haemostasis, Ad Hoc reviewer 2012 Critical Care, Ad Hoc reviewer 2012 British Medical Journal (BMJ) Open, Ad Hoc reviewer 2012 Journal of Hospital Medicine, Ad Hoc reviewer 2013 JAMA-Surgery, Ad Hoc reviewer 2013 Journal of Orthopedic Trauma, Ad Hoc reviewer Professional Societies 1991 Sigma Xi Scientific Research Honor Society - Brown University Chapter 1996 Philadelphia County Medical Society 1996 American Medical Association (AMA) 2001 Society of Critical Care Medicine (SCCM) 2002 Society of Laparoendoscopic Surgeons (SLS) 2004 Eastern Association for the Surgery of Trauma (EAST) Program Committee Member 2006-2009 Practice Management Guideline Committee 2009-2012 Publications Committee Member 2009-2012

Task Force on Research Related Issues 2010-2013 Chair, Practice Management Guidelines Ad Hoc Committee 2012-2013 Chair, Guidelines Committee 2013-present Board of Directors 2012-present

2005 Association for Academic Surgery (AAS) Outcomes Committee 2012-2014 2006 Fellow of the American College of Surgeons (FACS) ACS Committee on Trauma-Maryland Chapter Member (2007-present) Contributor, COT Surgical Skills subcommittee- ASSET course syllabus

Advanced Surgical Skills for Exposure in Trauma (ASSET) Scholarship Review Committee for ACS/EAST Health Policy Scholar (2012, 2014)

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2006 The American Society for Parenteral and Enteral Nutrition (ASPEN) 2006 Association for Surgical Education (ASE) 2006 Baltimore Academy of Surgery 2007 American Association for the Surgery of Trauma (AAST) Acute Care Surgery Committee (2010-2013) 2010 The Society of University Surgeons (SUS) 2012 North American Thrombosis Forum (NATF) RECOGNITION Awards, Honors 2002 Society of Laparoendoscopic Surgeons (SLS) Outstanding Laparoendoscopic

Resident Award 2004 Society of Critical Care Medicine (SCCM) Research Citation Finalist “Intensivist Managed Surgical Intensive Care Unit: Prospective Evaluation of the

Impact on Nursing Job Satisfaction” 2004 Society of Critical Care Medicine (SCCM) Research Citation Finalist “Nurse Practitioners Improve Compliance with Clinical Practice Guidelines in

the Surgical Intensive Care Unit” 2004 The Philadelphia Academy of Surgery Resident Research Award “Decreased Laboratory Utilization in an "Intensivist Managed" Surgical

Intensive Care Unit” 2004 Quality and Safety Award for “Improving Intensive Care” The Hospital of the University of Pennsylvania 2004 American College of Chest Physicians (ACCP) Young Investigator Award “Anemia Management Program (AMP) Reduces Transfusion Rates and Costs in

a Surgical Intensive Care Unit: A Prospective Study” 2010 The DVTeamCare™ Hospital Award from The North American Thrombosis

Forum (NATF) for the VTE Collaborative at Johns Hopkins Hospital 2011 Hopkins Sommer Scholar

The Johns Hopkins Bloomberg School of Public Health 2011 Health Policy and Leadership Scholarship

American College of Surgeons (ACS)/ Eastern Association for the Surgery of Trauma (EAST)

Invited Talks and Panels-National 1/18/07 Poster Walk Rounds Moderator, Eastern Association for the Surgery of Trauma (EAST), Fort Myers, FL 6/10/08 “New Topical Hemostatic Agents: Are They Cost Effective?”

American College of Surgeons Point/Counterpoint XXVII, Baltimore, MD 6/10/08 “Countdown on 7 Hot Topics”

American College of Surgeons Point/Counterpoint XXVII, Baltimore, MD 9/26/08 “Evaluation of Posttraumatic Venous Sinus Occlusion with CT Venography” Invited Discussant, American Association for the Surgery of Trauma (AAST)

Meeting 11/19/08 "Should I Leave This Abdomen Open? Damage Control Surgery in Trauma?"

Surgical Grand Rounds, George Washington University, Washington, DC 1/15/09 Invited Discussant, “External benchmarking of trauma center performance:

implications of missing data” Eastern Association for the Surgery of Trauma (EAST), Orlando, FL 6/8/09 “Appendicitis: Should CT Scan Be an Integral Component of the Diagnostic

Workup?”

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American College of Surgeons Point/Counterpoint XXVIII-Trauma, Critical Care & Acute Care Surgery, National Harbor, MD

6/8/09 “Necrotizing Soft Tissue Infections: Is Hyperbaric Oxygen Ever an Essential Adjunct? American College of Surgeons Point/Counterpoint XXVIII-Trauma, Critical Care & Acute Care Surgery, National Harbor, MD

6/10/09 “Inferior Vena Cava (IVC) Filter Placement: A Call for More Aggressive Use” American College of Surgeons Point/Counterpoint XXVIII-Trauma, Critical Care & Acute Care Surgery, National Harbor, MD

4/9/10 “Mandatory Computer-Based Decision Support System” North American Thrombosis Forum Hospital DVT Prophylaxis Strategies, Boston, MA

5/25/10 “Seatbelt sign and the unevaluable abdomen: mandatory celiotomy” American College of Surgeons Point/Counterpoint XXIX, National Harbor, MD

5/26/10 “Delerium in the ICU: a preventable entity?” American College of Surgeons Point/Counterpoint XXIX, National Harbor, MD

4/6/11 “Prevention & Treatment of DVT: Can/Should We Do Better?” Virgina Commonwealth University 12th Annual Trauma Symposium, Richmond, VA 5/10/11 “Benchmarking the Quality of Trauma Care: What Do DVT Rates Really Tell

Us?” & “Improving Pre-Hospital Trauma Care via Health Services Research” 17th Annual Trends in Trauma Conference, St. Louis, MO 6/15/11 “Irreversible Fulminate Hepatic Failure: Is Intracranial Pressure Monitoring

Essential? American College of Surgeons Point/Counterpoint XXX, National Harbor, MD

8/30/11 Panelist, American College of Surgeons Health Care Quality Forum With Keynote Speaker U.S. Senator Ben Cardin, Baltimore, MD 10/25/11 “Challenges in Surgical Critical Care: Monitoring and Ventilation”

Session Moderator and Speaker American College of Surgeons Clinical Congress, San Francisco, CA

1/13/12 “Multicenter Trials and Large Database Research: How Do You Make Them Work?” Sunrise Session Moderator and Speaker Eastern Association for the Surgery of Trauma, Orlando, FL

1/18/12 “Do Deep Vein Thrombosis (DVT) Rates Really Tell Us Anything About Quality of Care? Macon Surgical Society, Macon, Georgia

1/19/12 “Prevention & Treatment of Deep Vein Thrombosis (DVT): Can/Should We Do Better?” Surgical Grand Rounds and Invited Professorship, Medical Center of Central Georgia, Macon, Georgia

5/4/12 “Papers that Changed How We Practice: Surgical Critical Care” “Milestones in Trauma - 25 Years of Care - University of Pennsylvania Trauma Fellowship Reunion & Gala Celebration”, Philadelphia, PA

6/11/12 “Gallstone pancreatitis: ERCP and sphincterotomy should precede cholestectomy (PRO)” American College of Surgeons Point/Counterpoint XXXI, National Harbor, MD

6/13/12 “Weaning protocols: Overrated? (PRO)” American College of Surgeons Point/Counterpoint XXXI, National Harbor, MD

7/24/12 “Prevention & Treatment of Deep Vein Thrombosis (DVT): Can/Should We Do Better?”

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Trauma Rounds & Invited Professor George Washington University, Washington, DC

9/30/12 “Infectious Disease” in Post Graduate Course 17: Surgical Critical Care Board Review American College of Surgeons Clinical Congress, Chicago, IL

10/3/12 “Experts on the Hot Seat: Challenging Trauma and Emergency Surgery Cases” Panelist, American College of Surgeons Clinical Congress, Chicago, IL

11/10/12 “Don’t Strive To Improve Your Score On A Worthless Test……. Change The Metric By Which You Are Judged” National Workshop on Quality for Medical Education sponsored by the American College of Medical Quality (NCMQ)

11/10/12 “Career and Role Modeling Panel,” Panel Member National Workshop on Quality for Medical Education sponsored by the American College of Medical Quality (NCMQ)

11/15/12 “How Can We Deal with Surveillance Bias in Health Services Research?” Surgical Outcomes Club (SOC) / Association for Academic Surgery (AAS) Webinar

1/15/13 “Large Database Analysis: Availability and Pitfalls” in the “Multicenter Trials and Large Database Research: How Do You Make Them Work?” Workshop Eastern Association for the Surgery of Trauma, Orlando, FL

1/17/13 “How to Create, Understand, and Use Practice Management Guidelines” Sunrise Session Moderator & Speaker Eastern Association for the Surgery of Trauma, Orlando, FL

1/17/13 Practice Management Guidelines Plenary Session Moderator & Speaker Eastern Association for the Surgery of Trauma, Orlando, FL

1/18/13 Poster Walk Rounds Moderator Eastern Association for the Surgery of Trauma, Orlando, FL

4/18/13 “Preventing Avoidable VTE: Every Patient, Every Time” https://events.vha.com/index.cfm?fuseaction=reg.info&event_id=6495

VHA-TV Educational Program, 2013 Partnership for Patients Education Series Irving, TX 6/3/13 “Adhesive small bowel obstruction: Is a 48-hour period (or greater) too long for

conservative management when there is no substantial improvement? (PRO)” American College of Surgeons Point/Counterpoint XXXII, National Harbor, MD

6/3/13 “Acute appendicitis presenting in the late evening: waiting until the next morning to operate is an option (CON)” “Mechanical bowel preparation: Overrated? (CON)” American College of Surgeons Point/Counterpoint XXXII, National Harbor, MD

9/16/13 “Eliminating VTE with Clinical Decision Support” Users Group Meeting (UGM) Presentation, EPIC, Verona, WI 10/4/13 “Measuring Outcomes in Patient-Centered Research”

Association for Academic Surgery (AAS), 24th Annual Fundamentals of Surgical Research Course, Washington, DC

10/9/13 “Implementation of a Standard Handoff Process Facilitates Transfer of Care of Cardiac Surgical Patients from Operating Room to ICU” Surgical Forum Discussant, American College of Surgeons Clinical Congress, Washington, DC

11/17/13 “Improving Care: Clinical Decision Support for Quality Improvement” American College of Surgeons Trauma Quality Improvement Program (TQIP)

Annual Meeting, Phoenix, AZ

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11/21/13 “Preventing Venous Thromboembolism: Empowering Patients and Enabling Patient-Centered Care via Health Information Technology” In “Surgeons who have earned PCORI grants" Surgical Outcomes Club (SOC) Didactic Session Webinar

1/14/14 “So You Want to Write a Practice Management Guideline?” Workshop Course Director Eastern Association for the Surgery of Trauma, Naples, FL 1/14/14 “Who Reviews Your Grants & Other Sources of Funding Beyond the NIH?” In “Grant Writing Workshop for Young Faculty and Early Stage Investigators”

Eastern Association for the Surgery of Trauma, Naples, FL 1/16/14 “Using Practice Management Guidelines to Standardize Care and Obtain

Trauma Center Verification” Eastern Association for the Surgery of Trauma” Sunrise Session Moderator, Naples, FL 1/16/14 “Organizing and Establishing a Research Program” In “No Suit, No Tie, No Problem: Fostering Relationships & Building Careers” Eastern Association for the Surgery of Trauma, Naples, FL 1/16/14 Practice Management Guidelines Plenary Session Moderator Eastern Association for the Surgery of Trauma, Naples, FL 2/2/14 “Other Funding Agencies for Outcomes/Health Services Research: AHRQ,

PCORI, Foundations” Association for Academic Surgery (AAS) / Society of University Surgeons

(SUS) Surgical Investigators’ Course: The Grant Writing Workshop San Diego, CA 2/3/14 Mock Study Section Moderator Association for Academic Surgery (AAS) / Society of University Surgeons

(SUS) Surgical Investigators’ Course: The Grant Writing Workshop San Diego, CA 2/6/14 Oral Session Moderator “Trauma/Critical Care” Academic Surgical Congress (ASC), San Diego, CA 2/6/14 “Using Evidence to Guide Decisions and Improve Outcomes: Changing Clinical

Practice” Surgical Outcomes Club (SOC)/ Association for Academic Surgery (AAS)

Outcomes Panel Discussion Academic Surgical Congress (ASC), San Diego, CA 3/28/14 “Practice Management Guideline Development in Trauma” American Burn Association 46th Annual Meeting, Boston, MA

Invited Talks, Panels-Local 11/8/02 “Training the Trauma Fellow: The Fellow-In-Exception Model” Pennsylvania

Committee on Trauma (PACOT), Harrisburg, PA 10/31/03 “Intensivist Managed Surgical Intensive Care Unit: Prospective Evaluation of the

Impact on Nursing Satisfaction” Pennsylvania Committee on Trauma (PACOT), Carlisle, PA

11/19/03 “Improving Care in the ICU: The Anemia Dilemma” Pennsylvania Hospital, Philadelphia, PA 11/19/04 Maryland State Resident Paper Competition Judge American College of Surgeons Committee on Trauma (ACS-COT) Baltimore, MD 11/21/06 “What Improves Trauma Patient Outcomes? The System vs. the Surgeon” Acute Neurosciences Conference, JHH 2/8/07 “Blood Transfusion in the Surgical ICU - Friend or Foe?”

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Surgery Grand Rounds, JHH 3/9/07 “What Improves Trauma Patient Outcomes? The System vs. the Surgeon” Emergency Medicine Grand Rounds, JHH 5/3/07 "Can Increased Incidence of Deep Vein Thrombosis Be Used as a Marker of

Quality of Care in the Absence of Standardized Screening?” Department of Surgery Research Seminar, JHH 9/6/07 "Emergency Airway Management: A Standardized Case-Based Approach”

Anesthesiology/ Critical Care Medicine and Surgery Grand Rounds, JHH 10/27/07 “Multimodality Diagnostic Radiology and the Care of Penetrating Torso

Injuries” 48th Annual Maryland Society of Radiologic Technologists Meeting Franklin Square Hospital, Baltimore, MD 2/20/08 “DVT after Trauma”, Pediatric Trauma Center Conference, JHH 3/28/08 “So You Want to Be a Trauma Surgeon” Hopkins Emergency Response Organization (HERO), Johns Hopkins University 10/18/08 “Clotting and Trauma” Stop the Clot – Interactive Forum on Blood Clots for Patients, Their Families,

Healthcare Providers, and the Public, Sponsored by the National Alliance for Thrombosis & Thrombophilia (NATT) and the Centers for Disease Control and Prevention (CDC)

Baltimore, MD 3/3/09 “A Computerized Approach to VTE Risk Assessment” and “DVT Prevention

Innovation at Johns Hopkins” A Panel Discussion 1st Annual Deep Vein Thrombosis (DVT) Symposium, JHH With US Surgeon General Rear Admiral Steven K. Galson, MD, MPH 3/4/10 “DVT in the Trauma Patient” Seminars in Trauma 2010: A Continuing Education Series, JHH 3/5/10 “A Journey to Prevent VTE at Hopkins: Past, Present, & Future” 2nd Annual Deep Vein Thrombosis (DVT) Symposium, JHH 4/1/10 “Airway” Session Moderator

Trauma Care 2010; ABC’s Innovation and Integration Maryland Committee on Trauma of the American College of Surgeons, Baltimore, MD

7/15/10 “Regional Anesthesia: is it compatible with Antithrombotic Therapy?” Anesthesiology & Critical Care Medicine Grand Rounds, JHH

12/2/10 “Improving Pre-Hospital Trauma Care via Health Services Research” Department of Surgery Research Seminar, JHH 2/5/11 “Improving Pre-Hospital Trauma Care via Health Services Research”

Injury Prevention and Trauma Response Seminar National Study Center for Trauma and EMS, Baltimore, MD

3/25/11 Moderator, 3rd Annual Deep Vein Thrombosis (DVT) Symposium, JHH 3/26/11 “Do Deep Vein Thrombosis (DVT) Rates After Trauma Really Tell Us Anything

About Quality of Trauma Care?” All Surgeons Day, American College of Surgeons DC Chapter, Washington, DC 4/2/11 “Improving Pre-Hospital Trauma Care via Health Services Research: Why we do

things we do?” EMS Care 2011Waves of Change, Ocean City, MD 4/8/11 “DART: A Two-Year Review, Difficult Airway Response Team: a

Multidisciplinary Approach” 7th Annual Maryland Patient Safety Conference, Baltimore, MD 10/11/11 “So You Want to Be a Trauma Surgeon”

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Hopkins Emergency Response Organization (HERO), Johns Hopkins University 11/5/11 “Anticoagulation Therapy in Trauma” in Critical Issues in Trauma

Suburban Hospital, Bethesda, MD 2/8/12 “What's It Like To Be A Surgeon?”

The Halsted Surgery Interest Group, Johns Hopkins University 3/9/12 “The Future Directions of VTE Prevention: JHM and Beyond” 4th Annual Deep

Vein Thrombosis (DVT) Symposium, JHH 6/1/12 “Don’t Strive To Improve Your Score On A Worthless Test…….Change The

Metric By Which You Are Judged” 3rd Annual Johns Hopkins Medicine Patient Safety Summit 3/22/13 “Surveillance Bias in Venous Thromboembolism (VTE) Outcomes Reporting”

5th Annual Venous Thromboembolism (VTE) Symposium, JHH 4/11/13 “Ethics and the Learning Healthcare System: Are Current Regulations Working

as the Line Between Practice and Research is Increasingly Blurred?” Speaker and Panelist, JHM

5/3/13 “Venous Thromboembolism (VTE) Prevention: Computerized Clinical Decision Support Improves Prescribing, but Missed Doses Continue” Maryland Society of Health-System Pharmacy (MSHP) Spring Seminar, Timonium, MD

9/30/13 “Tracheostomy and Cricothyroidotomy” Percutaneous Tracheostomy and Advanced Airway Cadaver Course, JHM

10/17/13 “Venous Thromboembolism- Changing Practice, Changing Policy, Changing Public Reporting” Grand Rounds, Novant Health Prince William Medical Center, Manassas, VA

10/18/13 “Venous Thromboembolism- Changing Practice, Changing Policy, Changing Public Reporting” Grand Rounds, Suburban Hospital, Bethesda, MD

10/30/13 “Venous Thromboembolism- Changing Practice, Changing Policy, Changing Public Reporting” Grand Rounds, Sibley Memorial Hospital, Washington, DC

11/14/13 “Venous Thromboembolism- Changing Practice, Changing Policy, Changing Public Reporting” Surgery Grand Rounds, JHH

1/9/14 “Venous Thromboembolism- Changing Practice, Changing Policy, Changing Public Reporting” Armstrong Institute Patient Safety Grand Rounds, JHM

3/5/14 “Preventable Harm from Venous Thromboembolism (VTE) – A New Metric for Quality of Care”

PhD Defense, Graduate Training Program in Clinical Investigation (GTPCI) The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 3/7/14 “Missed Doses: An Opportunity for Patient-Centered Improvement” 6th Annual Johns Hopkins Medicine VTE Symposium, JHM 3/27/14 “A Multi-Disciplinary Approach To Patient-Centered VTE Prophylaxis”

Combined Grand Rounds (Surgery, Nursing, Anesthesiology and Critical Care Medicine) JHM