Preventing Hospital-Acquired Preventing Hospital-Acquired Venous ThromboembolismVenous Thromboembolism

AHRQ Annual MeetingAHRQ Annual MeetingSeptember 20, 2011 September 20, 2011

Vicky Agramonte, RNVicky Agramonte, RN, , MSNMSN

Project ManagerProject Manager

QIO Learning Network QIO Learning Network

Preventing H-A VTE Toolkit Preventing H-A VTE Toolkit

Focuses on the basics of Focuses on the basics of quality improvement quality improvement

Physician driven QI effort Physician driven QI effort Though development of Though development of

VTE risk assessment and VTE risk assessment and order sets, preventable H-A order sets, preventable H-A VTEs have dropped VTEs have dropped

Developed based on the Developed based on the research of Dr. Gregory research of Dr. Gregory Maynard, in association Maynard, in association with the Society of Hospital with the Society of Hospital Medicine Medicine

VTE ToolkitVTE Toolkit

Comprehensive guide that focuses on the basics of quality Comprehensive guide that focuses on the basics of quality improvementimprovement

Step-by-step instructions on the development and implementation of an Step-by-step instructions on the development and implementation of an improved VTE prevention protocolimproved VTE prevention protocol

Hierarchy of Reliability Hierarchy of Reliability Provides sample VTE protocol Provides sample VTE protocol

– 3–bucket risk assessment (low, moderate, and high risk)3–bucket risk assessment (low, moderate, and high risk)– Sample order setSample order set

Measurement strategy for continuous improvementMeasurement strategy for continuous improvement

Protocol = Risk assessment and corresponding order set of Protocol = Risk assessment and corresponding order set of pharmacological agents and/or mechanical prophylaxispharmacological agents and/or mechanical prophylaxis

Toolkit ApplicabilityToolkit Applicability

VTE toolkit is usable in varying provider VTE toolkit is usable in varying provider settingssettings– Large hospital settingsLarge hospital settings

– Smaller community hospitalsSmaller community hospitals

– Critical Access HospitalsCritical Access Hospitals

Usable toolkit for providers that are: Usable toolkit for providers that are: – Have EHR Have EHR

– Paper medical recordPaper medical record

– Hybrid (both EHR and paper) Hybrid (both EHR and paper)

VTE Toolkit Contents VTE Toolkit Contents

Taking the Essential First Steps Taking the Essential First Steps Laying Out the Evidence and Identify Best Laying Out the Evidence and Identify Best

Practices Practices Analyzing Care DeliveryAnalyzing Care Delivery Tracking Performance with Metrics Tracking Performance with Metrics Layering Interventions Layering Interventions Continuing to Improve Continuing to Improve

VTE Toolkit VTE Toolkit Layer Interventions Layer Interventions

The VTE protocol serves as the main intervention and The VTE protocol serves as the main intervention and focal point for the improvement projectfocal point for the improvement project– Keep the protocol simpleKeep the protocol simple

– Do not interrupt workflowDo not interrupt workflow

– Design reliability into the processDesign reliability into the process

– Pilot interventions on a small scale before attempting wide Pilot interventions on a small scale before attempting wide scale implementationscale implementation

– Monitor use of the protocolMonitor use of the protocol

Protocol = Risk assessment and corresponding order set of Protocol = Risk assessment and corresponding order set of pharmacological agents and/or mechanical prophylaxispharmacological agents and/or mechanical prophylaxis

Complex VTE Order Set Complex VTE Order Set

Simple VTE Order Set Simple VTE Order Set

Simple Order SetSimple Order Set

Hierarchy of Reliability Hierarchy of Reliability

Situational Awareness and Situational Awareness and ““Measure-ventionMeasure-vention””- Getting to 95%- Getting to 95%

Identify patients on no anticoagulationIdentify patients on no anticoagulation Empower nurses to place mechanical prophylaxisEmpower nurses to place mechanical prophylaxis Contact MD if no anticoagulant in place and no Contact MD if no anticoagulant in place and no

obvious contraindicationobvious contraindication– Template note, text page, etcTemplate note, text page, etc

Back up these interventionsBack up these interventions– Physicians can not Physicians can not ““shoot the messengershoot the messenger””

Maynard G, Stein J. Designing and Implementing Effective VTE Prevention Protocols: Lessons Maynard G, Stein J. Designing and Implementing Effective VTE Prevention Protocols: Lessons from Collaboratives. from Collaboratives. J Thromb ThrombolysisJ Thromb Thrombolysis 2010 Feb:29(2):159-166. 2010 Feb:29(2):159-166.

Making the Right Thing to do…Making the Right Thing to do…

……the easy thing to do: the easy thing to do: – The desired action is the default action (i.e., not doing The desired action is the default action (i.e., not doing

the desired action requires opting out)the desired action requires opting out)

– The desired action is prompted by a reminder or a The desired action is prompted by a reminder or a decision aide.decision aide.

– The desired action is standardized into a processThe desired action is standardized into a process

– The desired action is scheduled to occur at known The desired action is scheduled to occur at known intervalsintervals

– Responsibilities for desired action are redundantResponsibilities for desired action are redundant

– If designed well, the VTE protocol will be an If designed well, the VTE protocol will be an interventionintervention

Levels of RiskDVT Risk Without

ProphylaxisSuggested Options

Low risk• Mobile minor surgery patients• Fully mobile medical patients

<10 %

• No specific thromboprophylaxis

• Early and “aggressive” ambulation

Moderate risk• Most general, open gynecologic

or urologic surgery• CHF• COPD, pneumonia• Medically Ill

10-40%• LMWH, UFH tid > bid, or

fondaparinux

High risk• Hip or knee arthroplasty, HFS• Major trauma, SCI• Abdominal/pelvic cancer surgery 40-80%

• LMWH, fondaparinux, VKA (INR 2-3)

• Mechanical prophylaxis may be used if risk of bleeding is high; switch to anticoagulants when risk decreases

VTE Levels of RiskVTE Levels of Risk

Adapted from Geerts WH, et al. Chest. 2008;133:381S-453S.

ACCP VTE Prophylaxis ACCP VTE Prophylaxis Guidelines 8Guidelines 8thth Edition Edition

1.1. Every hospital should develop formal strategy to prevent Every hospital should develop formal strategy to prevent VTEVTE

2.2. Do not use aspirin alone for prophylaxisDo not use aspirin alone for prophylaxis

3.3. Use mechanical prophylaxis primarily for patients at high Use mechanical prophylaxis primarily for patients at high bleeding risk or as an adjunct to pharmacologic bleeding risk or as an adjunct to pharmacologic prophylaxisprophylaxis

4.4. Give thromboprophylaxis forGive thromboprophylaxis for

– Major traumaMajor trauma

– Spinal cord injurySpinal cord injury

– Acute medical illnessAcute medical illness

– Most ICU patientsMost ICU patients

– Moderate and high risk surgeryModerate and high risk surgery

Geerts WH, et al. Chest. 2008;133:381S-453S.

““Patients without risk factors for VTE are Patients without risk factors for VTE are called outpatients.called outpatients.”” G. Maynard (2010)G. Maynard (2010)

VTE ProphylaxisVTE ProphylaxisEffective, Safe, and Cost-EffectiveEffective, Safe, and Cost-Effective

Pharmacologic prophylaxis substantially reduces Pharmacologic prophylaxis substantially reduces the risk for VTEthe risk for VTE– Symptomatic and asymptomatic VTE reducedSymptomatic and asymptomatic VTE reduced

Bleeding complications are rare Bleeding complications are rare HIT is a serious complication of heparin therapyHIT is a serious complication of heparin therapy Cost-effectiveness of VTE prophylaxis well Cost-effectiveness of VTE prophylaxis well

documenteddocumented

Barriers to Reducing VTE Risk Barriers to Reducing VTE Risk

Belief that VTE incidence has declined Belief that VTE incidence has declined VTE not perceived as important VTE not perceived as important Lack of familiarity with guidelinesLack of familiarity with guidelines Underestimation of thrombotic riskUnderestimation of thrombotic risk Overestimation of bleeding riskOverestimation of bleeding risk Translation of complicated guidance into Translation of complicated guidance into

simple orderssimple orders Institutional / structuralInstitutional / structural

Barriers to Reducing VTE Risk Barriers to Reducing VTE Risk

Implementation of protocol is flawedImplementation of protocol is flawed Order set not user friendlyOrder set not user friendly Process creates duplicate work for Process creates duplicate work for

physiciansphysicians Protocol does not fit individual patientProtocol does not fit individual patient Competing order setsCompeting order sets

VTE Impact Case Study VTE Impact Case Study Year 1 ProviderYear 1 Provider

Madison Memorial Hospital (MMH) in Rexburg, Idaho developed and implemented a standardized VTE protocol for all hospital admissions based on the recommendations presented in the toolkit. VTE incidence of hospital-associated VTE per 1000 patient days has decreased from a rate of 1.30 to 0.18, an 86% relative improvement, between baseline (4/09-2/10) and remeasurement periods (3/10-11/10). According to team leaders, there also has been significant qualitative impact to their hospital culture and quality performance as a result of the changes made to the VTE protocol: they have implemented the first standardized best practice protocol.

VTE Impact Case Study VTE Impact Case Study Year 2 ProviderYear 2 Provider

A New Mexico hospital entered the project without a VTE protocol in place. As a result of participating in the project, the facility developed a protocol consistent with the toolkit to include a three-level risk-stratified assessment linked to treatment options. The hospital aggressively pursued improvement of its VTE protocol by developing, approving, and implementing a new VTE protocol hospital-wide in less than one month after attending the initial learning session. As a result, compliance with physician use of the protocol is 100 percent, with prevalence of appropriate VTE prophylaxis increasing from 33 to 75 percent between March and July 2011. The facility is now implementing “measure-vention”—concurrent review and interventions of patients in real time--to continue to foster improvement in the prevalence of appropriate VTE prophylaxis.

VTE Impact Case Study VTE Impact Case Study Year 2 ProviderYear 2 Provider

When Memorial Health Care Systems in Seward, Nebraska began the collaborative, Hank Newburn, MD, Family Practice Physician explains, “When we joined the VTE Collaboration in February 2011 Memorial Health Care Systems did not have a risk assessment tool, or protocols for interventions in place. We completed the risk assessment tool which models Dr. Gregory Maynard’s recommendations. Since the inception of the project, we have realized a 5% increase in VTE prophylaxis due to heightening the awareness. I anticipate a significant percentage increase after implementation due to the availability of a consistent risk assessment process, and protocols for interventions. This project has provided great direction for the development of our VTE tools, which will aid us in providing best practice for VTE prophylaxis consistently, promoting increased safety for our patients.”

Key Points Key Points Expert RecommendationsExpert Recommendations

VTE protocols embedded in order setsVTE protocols embedded in order sets Simple risk stratification schema, based on Simple risk stratification schema, based on

VTE-risk groups (2-3 levels of risk should do it)VTE-risk groups (2-3 levels of risk should do it) Institution-wide if possible (a few carve outs ok)Institution-wide if possible (a few carve outs ok) Local modification is OKLocal modification is OK

– Details in gray areas not that importantDetails in gray areas not that important

Use Use ““measure-ventionmeasure-vention”” to accelerate improvement to accelerate improvement

Maynard G, Stein J. Designing and Implementing Effective VTE Prevention Maynard G, Stein J. Designing and Implementing Effective VTE Prevention Protocols: Lessons from Collaboratives. Protocols: Lessons from Collaboratives. J Thromb ThrombolysisJ Thromb Thrombolysis 2010 2010 Feb:29(2):159-166. Feb:29(2):159-166.

Collaborative EffortsCollaborative Efforts

AHRQ / QIO (NY, IL, IA) - 40 sitesAHRQ / QIO (NY, IL, IA) - 40 sites AHRQ / QIO 2 and AHRQ / QIO 3 - 33 & 28 sitesAHRQ / QIO 2 and AHRQ / QIO 3 - 33 & 28 sites ASHP Advantage collaborative - 6 sitesASHP Advantage collaborative - 6 sites CHW with CIIS - 2 sitesCHW with CIIS - 2 sites IHI Expedition for VTE Prevention - 50 sitesIHI Expedition for VTE Prevention - 50 sites SHM VTE Prevention Collaborative I - 25 sitesSHM VTE Prevention Collaborative I - 25 sites SHM VTE Prevention Collaborative III - 30 sitesSHM VTE Prevention Collaborative III - 30 sites SHM / VA Pilot Group - 6 sites PLUSSHM / VA Pilot Group - 6 sites PLUS SHM / Cerner Pilot Group - 6 sitesSHM / Cerner Pilot Group - 6 sites Vancouver Hospital Medicine - 25 sitesVancouver Hospital Medicine - 25 sites

QIO Learning Network QIO Learning Network Activity Activity

ResourcesResources

Preventing HA VTE- a guide for Preventing HA VTE- a guide for effective quality improvement effective quality improvement http://www.ahrq.gov/QUAL/vtguide/

Society of Hospital Medicine Society of Hospital Medicine VTE Collaborative VTE Collaborative http://www.hospitalmedicine.org

Reference Reference

Maynard G, Stein, J. Preventing Hospital-Acquired Venous thromboembolism: Maynard G, Stein, J. Preventing Hospital-Acquired Venous thromboembolism: A Guide for Effective Quality Improvement. Prepared by the Society of A Guide for Effective Quality Improvement. Prepared by the Society of Hospital Medicine, AHRQ Publication No. 08-0075. Rockville, MD: Agency Hospital Medicine, AHRQ Publication No. 08-0075. Rockville, MD: Agency for Healthcare Research and Quality. August 2008 for Healthcare Research and Quality. August 2008 http://www.ahrq.gov/qual/vtguide/..

Society of Hospital Medicine: Society of Hospital Medicine: http://www.hospitalmedicine.org

Maynard G, Stein J. Designing and Implementing Effective VTE Prevention Maynard G, Stein J. Designing and Implementing Effective VTE Prevention Protocols: Lessons from Collaboratives. Protocols: Lessons from Collaboratives. J Thromb ThrombolysisJ Thromb Thrombolysis 2010 2010 Feb:29(2):159-166. Feb:29(2):159-166.

Geerts et al. Prevention of Venous Thromboembolism: American College of Geerts et al. Prevention of Venous Thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Edition) Chest June 2008 133:381S453S; 10.1378/chest.08-0656Chest June 2008 133:381S453S; 10.1378/chest.08-0656

Contact InformationContact Information

AHRQ QIO Learning Network Project Team AHRQ QIO Learning Network Project Team

Vicky Agramonte, RN, MSN Vicky Agramonte, RN, MSN Project ManagerProject Manager

IPRO IPRO AHRQ QIO Learning AHRQ QIO Learning

NetworkNetwork518-426-3300 or 1-800-233-518-426-3300 or 1-800-233-

03600360Ext.115Ext.115

vagramonte@ipro.org

Sheryl RuhlandSheryl RuhlandContract Coordinator Contract Coordinator

IPRO IPRO AHRQ QIO Learning AHRQ QIO Learning

NetworkNetwork518-426-3300 or 1-800-233-518-426-3300 or 1-800-233-

03600360Ext.114Ext.114

sruhland@ipro.org