VTE PREVENTION UPDATE, WA (May 2010)

Dr Helen van Gessel Office of Safety and Quality Luke Slawomirski Performance Activity & Quality Division

Delivering a Healthy WA

Safety and Quality Investment for Reform (SQuIRe) Program

• Since 2006/07 $8M each year across WA Health

• 8 quasi-collaboratives addressing priority clinical practice improvement areas

– IHI “bundles”, process improvement focus– Central OSQ department “scaffolding” – Not voluntary– Area Health Services (x4) determine resource

allocation and implementation

www.safetyandquality.health.wa.gov.au/squire/index.cfm

SQuIRe VTE prevention • AIM

– prevent VTE by performing risk assessment and correct prophylaxis (based on VTE Working Gp evidence summary – NB no formal state policy)

• PROCESSES TO MEASURE AND IMPROVE

– % patients risk assessment– % patients at risk receiving correct prophylaxis

• Aligned with QUM indicator defn and sampling method

• Suggested initial focus surgical patients

Mid 2009 progress

State-wide Venous Thromboembolism Prevention

0%

20%

40%

60%

80%

100%

Nov-06

Jan-07M

ar-07M

ay-07Jul-07S

ep-07N

ov-07Jan-08M

ar-08M

ay-08Jul-08S

ep-08N

ov-08Jan-09M

ar-09M

ay-09

Month / Year

Co

mp

lian

ce

Risk Assessment Prevention

Estimated coverage 20% inpatients ;

All hospitals have “VTE team”;

Moves to sustainable process monitoring;

Range of achievement

2010 aim – generate a “sense of urgency”

• Visit by NHS experts February 2010

• Created WA VTE Prevention Network - 3 meetings, evolving interprofessional community of practice

– “bring outside in” (Kotter)– Share ideas, experiences, learnings– Generate stories and new ideas – Generate data and talk about it in a meaningful way

Ideas progressing / testing

• NIMC risk assessment and mechanical prophylaxis prescription incorporation

• “signal” event investigation

• State VTE prevention policy

• State risk assessment tool

• Craft group – specific prophylaxis guidelines ?via Clinical Networks / professional

• Investigating value of coded data

• Talking to RFDS for country patient transfer diagnoses

Estimating Iatrogenic VTE Burden WA

• UK 12 000 000 adult admissions; 311 000 inpatient VTE in untreated pts; 124 400 deaths/yr in untreated pts (UK Parliamentary Report)

• WA 400 000 adult admissions; 10 366 inpatient VTE in untreated pts; 4 146 deaths/yr in untreated pts

• Est. 25 VTE untreated pts / 1000 separations

Iatrogenic VTE Incidence - Literature

• Gallagher et al (2009): 2.57 cases / 1000 CWS http://qshc.bmj.com/content/18/5/408.full

• Leibson et al (2008): 2.59 / 1000 ‘encounters’

http://journals.lww.com/lww-medicalcare/Abstract/2008/02000/Identifying_In_Hospital_Venous_Thromboembolism.5.aspx

VTE Incidence Data WARequest to Epidemiology Branch for 3 years’ VTE morbidity

and mortality data

• ICD-10-AM codes (based Access Economics study 2008)

• COF (c-prefix) not used (WA: since July 2008)

• Aims:

– Gauge extent of incidence and burden – ‘URGENCY’– Validate VTE coding sensitivity & specificity (case note

r/v, radiology, RFDS)

– Calculate extended LOS and additional cost of VTE

Codes (preliminary list)

WA DoH Request Access Economics Study 2008I26 pulmonary Embolism

I26.0 pulmonary Embolism with mention of acute cor pulmonale

I26.8 iatrogenic pulmonary embolism

I26.9 pulmonary Embolism without mention of acute cor pulmonale

I63.1 cerebral infarction due to embolism of pre-cerebral arteries

I63.4 cerebral infarction due to embolism of cerebral arteries

I74 arterial embolism and thrombosis

I80.2 deep vein thrombosis not otherwise specified

I80.3 embolism or thrombosis of lower extremity

I82.2 embolism and thrombosis of vena cava

I82.3 embolism and thrombosis of renal vein

I82.8 embolism and thrombosis of other specified veins

I82.9 embolism and thrombosis of unspecified vein

I26 pulmonary Embolism

I26.0 pulmonary Embolism with mention of acute cor pulmonale

I26.8 iatrogenic pulmonary embolism

I26.9 pulmonary Embolism without mention of acute cor pulmonale

I63.1 cerebral infarction due to embolism of pre-cerebral arteries

I63.4 cerebral infarction due to embolism of cerebral arteries

I74 arterial embolism and thrombosis

I82 other venous embolism and thrombosis

I82.2 embolism and thrombosis of vena cava

I82.3 embolism and thrombosis of renal vein

I82.8 embolism and thrombosis of other specified veins

I82.9 embolism and thrombosis of unspecified vein

Preliminary Administrative Data Extract

• WA Area Health Service; July 2009 – March 2010

• Total separations ~ 147,000

• ICD-10-AM codes from prev. slide

• COF* 1 & 2 = 832 cases (5.6 per 1000 separations)

• Est. 50% healthcare associated = 416 (2.8 / 1000 seps)

• COF 1 only = 107 cases

* see next 2 slides for definitions

Condition onset Flag (COF)

http://meteor.aihw.gov.au/content/index.phtml/itemId/354816

COF 1

• Condition with onset during the episode of admitted patient care

• a condition which arises during the episode of admitted patient care and would not have been present on admission

• Includes:

– Conditions resulting from misadventure during medical or surgical care during the episode of admitted patient care.

– Abnormal reactions to, or later complication of, surgical or medical care arising during the episode of admitted patient care.

– Conditions arising during the episode of admitted patient care not related to surgical or medical care (for example, pneumonia).

COF 2

• Condition not noted as arising during the episode of admitted patient care

• a condition present on admission such as the presenting problem, a comorbidity, chronic disease or disease status. 

• a previously existing condition not diagnosed until the episode of admitted patient care.

• Includes:

– In the case of neonates, the conditions present at birth.– A previously existing condition that is exacerbated during the episode of

admitted patient care.– Conditions that are suspected at the time of admission and

subsequently confirmed during the episode of admitted patient care.– Conditions that were not diagnosed at the time of admission but clearly

did not develop after admission (for example malignant neoplasm).– Conditions where the onset relative to the beginning of the episode of

admitted patient care is unclear or unknown.

% of administrastive data sample (n=832) coded for DVT, PE and Cerebral Infarct (CI) using COF 1 and 2

PE45%

DVT39%

CI16%

PE

DVT

CI

COF 1 & 2 dataset (n=832)

Follow-up work to assess utility of admin data sources

• Larger data set pending

• Case note review validation

– Sample of code – positive and code-negative records

Total No. of Hospital Aquired VTE between July 2009 to March 2010 by Speicalty

05

101520253035404550

Cancer/ Neurosc Critical Care Med Specs Rehab andOrthopaedics

Surgical

Specialty

Tota

l no.

of V

TE a

cqui

red

Source of Data: The patient administration system

COF 1 dataset (n=107)

COF 1 dataset (n=107)Total No. of Hospital Aquired Venous Thromboembolism [VTE] between July 2009 to

March 2010 by Specialty

Critical Care7%

Med Specs21%

Rehab and Orthopaedics20%

Surgical43%

Cancer/ Neurosc9%

Source of Data: The patient administration system