vte standardized risk assessment and appropriate … classes/vte power... · national consensus...

VTE

Standardized Risk Assessment and Appropriate Prophylaxis

Goal: Reduce the number of potentially preventable hospital acquired VTEs through the implementation and use of a standardized VTE risk assessment/order form. To improve physician compliance and knowledge.

Objectives: Upon completion of this education, the learner will:

• Understand the prevalence and impact of hospital acquired VTEs• Understand the importance of reducing hospital acquired VTEs• Understand the need for a standardized process to assess VTE risk and implement appropriate prophylaxis orders

• Understand the CFV process for assessing VTE risk and ordering prophylaxis.

• Understand the VTE Risk Assessment/Orders Form and how and when to complete it.

VTE According to Service (N=384)

0 25 50 75 100 125 150 175

Other

Thoracic surgery

Orthopaedic surgery

Medical oncology

General surgery

Medical

Number of VTE events

Total VTEPEDVT

44

16

10

9

8

14

Goldhaber SZ et al. Chest 2000;118:1680-4.

Total VTE (%)Patients

Presenter

Presentation Notes

The medical patient is also at high risk. Medical patients probably account for more than half of all hospital-acquired VTE events. In the DVT Free registry study, half the inpatients who suffered from VTE were non-surgical and had no surgical procedures in the preceding 3 months.

VTE: A Major Source of Mortality and Morbidity

• 200,000 VTE deaths per year (half primary)– More than HIV, MVAs, Breast Cancer combined

• 80,000 preventable deaths in hospital• 10% of hospital deaths, most common cause of

preventable hospital death• Huge costs and morbidity• Recurrence of DVT, post-thrombotic syndrome

and chronic PE / PAH are long term sequelae

Presenter

Presentation Notes

1 in 10 of the > 2 million Americans developing DVT goes on to die from pulmonary embolism (PE). These 200,000 patient deaths represent more annual deaths than those from breast cancer, AIDS, and traffic accidents combined. Many of these VTE deaths contribute to hospital mortality. Pulmonary embolism is the most common preventable cause of death in the hospital; an estimated 10% of inpatient deaths are secondary to PE. Not only do patients with VTE suffer a 30% cumulative risk for recurrence, they are also at risk for the potentially disabling post-thrombotic syndrome.

Mo

rtali

ty (

%)

Days From Diagnosis

17.5%

77 1414 3030 6060 9090

0

5

10

15

20

25

ICOPER: CUMULATIVE MORTALITY AFTER DIAGNOSIS

Lancet. 1999;353:1386-1389.

Presenter

Presentation Notes

Patients who survive the initial diagnosis of PE face a mortality rate of 17.5% at 90 days. Ref 10,11

ECONOMIC BURDEN OF VTEPEDVTMIStroke

$12,148

$7001

$12,680

$11,514

Inpatient Costs

MI = Myocardial Infarction

AHRQ – Statistics from the HCUP-3 nationwide inpatient sample for 1994: DRG.

Available at http://www.ahrq.gov/data.hcup/94drgs.htm. Accessed April 7, 2004.

0 $2500 $5000 $7500 $10,000 $12,500 15,000

2007: $10,000 / DVT $20,000 / PE

Presenter

Presentation Notes

The incremental length of stay and costs of treating the unprevented VTE event are substantial. AHRQ HCUP estimates of incremental inpatient cost in 1994 was over $7,000 per DVT and over $12,000 per PE, equating to $10,000 per DVT and $20,000 per PE in 2007 dollars.

Good News! Effective, safe, and cost-effective VTE

prophylaxis is available!• Pharmacologic Prophylaxis reduces DVT and PE

by 50-65%• Symptomatic and Asymptomatic VTE reduced. • Bleeding risk due to prophylaxis is rare. • HIT

– 2.37% with UFH (occasionally very serious)– .06% with LMWH

•

Cost effectiveness of VTE prophylaxis has been repeatedly demonstrated.

Geerts et al. Chest. 2004 Sep;126(3 Suppl):338S-400S.Shojania KG et al. Making health care safer… .www.ahrq.gov/clinic/ptsafety/. Martel – Blood 2005;106:2710

Presenter

Presentation Notes

Pharmacologic prophylaxis reduces the incidence of asymptomatic and symptomatic DVT and PE by 50-65%. Prevention of DVT also prevents PE and fatalities from PE. The chief concern of prophylaxis is bleeding, but bleeding risk secondary to pharmacologic prophylaxis is a rare event, based on abundant data from meta-analyses and placebo controlled randomized controlled trials. Overwhelming evidence reveals that pharmacologic VTE prophylaxis not only prevents adverse patient outcomes, it is also cost effective.

National Position Statements• Leapfrog1:PE is “the most common preventable cause of hospital death in the United States”

• Agency for Healthcare Research and Quality (AHRQ)2:Thromboprophylaxis is the number 1 patient safety practice

• American Public Health Association (APHA)3:“The disconnect between evidence and execution as itrelates to DVT prevention amounts to a public health crisis.”

1. The Leapfrog Group Hospital Quality and Safety Survey. Available at: www.leapfrog.medstat.com/pdf/Final/doc

2. Shojania KG, et al. Making Healthcare Safer: A Critical Analysis of Patient Safety Practices. AHRQ, 2001. Available at: www.ahrq.gov/clinic/ptsafety/

3. White Paper. Deep-vein thrombosis: Advancing awareness to protect patient lives. 2003. Available at: www.alpha.org/ppp/DVT_White_Paper.pdf

A lot of things can go wrong….. Education alone won’t get it done

• Risk assessments for VTE and bleeding not standardized• Risk assessment fails to occur• Definitions of appropriate prophylaxis variable• Conflicting order sets and protocols• Contributing risks (lines, sedation, restraints)• Prophylaxis fails to shift with changes in patient status• Platelet monitoring does not occur • When to stop prophy uncertain, not standardized.• Medication changes, weight, age, renal function, recent

or impending procedures can alter optimal approach. • Transitions across providers and locations leads to

inconsistent approach.

National Recommendations• American College of Chest Physicians (ACCP)1:“We recommend that every hospital develop a formal strategy that addresses the prevention of thromboembolic complications.”

• National Quality Forum (NQF)2:“Evaluate each patient upon admission, and periodically thereafter, for the risk of DVT/PE. Utilize clinically appropriate methods to prevent DVT/VTE.” (Safe Practice 17)

• Joint Commission on Accreditation of HealthcareOrganizations (JCAHO)3:“Contraindications to DVT prophylaxis must be documented”

1. Geerts WH, et al. Chest 2004;126:338S2. National Consensus Standards for the Prevention and Care of Deep Vein

Thrombosis, 2004. Available at: www.qualityforum.org3. Available at: www.jcaho.org/pms/core+measures/2adicu3dvt.pdf

Seventh ACCP Consensus

“All institutions should have a program in place that allows for the evaluation of a patient’s risk of developing VTE. If patients are found to be at risk of VTE, appropriate prophylaxis should be implemented (Grade 1A).”

Geerts WH, et al. Chest 2004;126:338S-400S.

Strategies to Improve Thromboprophylaxis Success• Excellent quality guidelines• National body endorsement• Hospital accreditation (JCAHO)• Pay for performance (CMS)• Local written policy (care pathway) for

the hospital / program / patient care unit• Multidisciplinary team• Goals and Measures• Standardized risk assessment and order sets

Presenter

Presentation Notes

SHM has provided a roadmap for all of the essential elements needed to optimize prevention of VTE. Choose an Important Process Necessary Substrate: Institutional Support, a Physician Leader, and a Multidisciplinary Empowered Team Timeline with Specific Goals Metrics that are Reliable, Practical Map out Process, Integrate High Reliability Design Standardized Order Sets Algorithms / Protocols Build Algorithm into Order Set Whenever Possible Education: Certification / Mandatory Education for some things

% Adequate VTE Prophylaxis (Audit Sample Size Range: 56 - 198 per month)

53% 52% 55% 58%

73%65%

71%

51% 55% 51%57%

66% 68%59%

72%

80%90%

69%

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100%

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Patients w/ Preventable HA VTE

0

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Dramatic Improvement is Possible

Presenter

Presentation Notes

Data from UCSD showing a marked decrease in preventable VTE accompanying improved VTE prophylaxis rates.

Summary• VTE is a very important source of hospital acquired

cost, mortality, and morbidity.• Effective, safe, and cost-effective medications are

available, but underutilized in our institution.• Increasing scrutiny from multiple agencies • Institutional prioritization and support needed. • A roadmap enhancing our chances of success is

available.

Our Policy• Standardized Risk Assessment/Order Form• Form is completed for every adult patient on admission, transfer

to or from ICU, and post-op • Physician completes risk assessment at top of form and then

orders recommended prophylaxis as listed on form• If contraindications exist-document these on back on form as

listed.• All required documentation is then complete and in one

location. • Permanent part of record• Incomplete forms will be assigned as a medical records

deficiency. • Trends in deficiency assignments and or failure to complete will

be reported at CPIC

Venous Thromboembolism (VTE) Risk Assessment/Orders

How to complete the risk assessment form.

• Faculty Disclosure: Cape Fear Valley Health System adheres to the Essential Areas and Policies of the North Carolina Medical Society (NCMS) and the Accreditation Council on Continuing Medical Education (ACCME) regarding industry support of continuing medical education. Disclosure of faculty/planning committee members and commercial relationships will be made known at the activity. Speakers are also expected to openly disclose inclusion of discussion of any off-label, experimental, or investigational use of drugs or devices in their presentations.

• CME Accreditation: Cape Fear Valley Health System designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

• Coordination: The CME activity is coordinated through Physician Education of Cape Fear Valley Health System. Dr. Eugene Wright is the Medical Advisor for this symposium. For CME information, call the Office of Physician Education at (910) 615-7038. For questions or comments on the content please contact Marcia Smith, RN, Clinial Educator at (910)-615-7062

• Transcripts: Please direct all CME inquiries and questions to the Office of Physician Education (910) 615-7038.

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