Transcript AHRQ Slide Template 2004

Preventing Hospital-Acquired
Venous Thromboembolism
AHRQ Annual Meeting
September 20, 2011
Vicky Agramonte, RN, MSN
Project Manager
QIO Learning Network
Preventing H-A VTE Toolkit
 Focuses on the basics of
quality improvement
 Physician driven QI effort
 Though development of
VTE risk assessment and
order sets, preventable H-A
VTEs have dropped
 Developed based on the
research of Dr. Gregory
Maynard, in association
with the Society of Hospital
Medicine
VTE Toolkit
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Comprehensive guide that focuses on the basics of quality
improvement
Step-by-step instructions on the development and
implementation of an improved VTE prevention protocol
Hierarchy of Reliability
Provides sample VTE protocol
– 3–bucket risk assessment (low, moderate, and high risk)
– Sample order set
Measurement strategy for continuous improvement
Protocol = Risk assessment and corresponding order set of
pharmacological agents and/or mechanical prophylaxis
Toolkit Applicability
 VTE toolkit is usable in varying provider
settings
– Large hospital settings
– Smaller community hospitals
– Critical Access Hospitals
 Usable toolkit for providers that are:
– Have EHR
– Paper medical record
– Hybrid (both EHR and paper)
VTE Toolkit Contents
 Taking the Essential First Steps
 Laying Out the Evidence and Identify Best
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Practices
Analyzing Care Delivery
Tracking Performance with Metrics
Layering Interventions
Continuing to Improve
VTE Toolkit
Layer Interventions
 The VTE protocol serves as the main
intervention and focal point for the improvement
project
– Keep the protocol simple
– Do not interrupt workflow
– Design reliability into the process
– Pilot interventions on a small scale before attempting
wide scale implementation
– Monitor use of the protocol
Protocol = Risk assessment and corresponding order
set of pharmacological agents and/or mechanical
prophylaxis
Complex VTE Order Set
Simple VTE Order Set
Simple Order Set
Hierarchy of Reliability
Situational Awareness and
“Measure-vention”- Getting to 95%
 Identify patients on no anticoagulation
 Empower nurses to place mechanical
prophylaxis
 Contact MD if no anticoagulant in place and
no obvious contraindication
– Template note, text page, etc
 Back up these interventions
– Physicians can not “shoot the messenger”
Maynard G, Stein J. Designing and Implementing Effective VTE Prevention Protocols:
Lessons from Collaboratives. J Thromb Thrombolysis 2010 Feb:29(2):159-166.
Making the Right Thing to do…
 …the easy thing to do:
– The desired action is the default action (i.e., not doing
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–
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the desired action requires opting out)
The desired action is prompted by a reminder or a
decision aide.
The desired action is standardized into a process
The desired action is scheduled to occur at known
intervals
Responsibilities for desired action are redundant
If designed well, the VTE protocol will be an
intervention
VTE Levels of Risk
Levels of Risk
Low risk
• Mobile minor surgery patients
• Fully mobile medical patients
Moderate risk
• Most general, open gynecologic
or urologic surgery
• CHF
• COPD, pneumonia
• Medically Ill
High risk
• Hip or knee arthroplasty, HFS
• Major trauma, SCI
• Abdominal/pelvic cancer surgery
DVT Risk Without
Prophylaxis
<10 %
10-40%
40-80%
Adapted from Geerts WH, et al. Chest. 2008;133:381S-453S.
Suggested Options
• No specific
thromboprophylaxis
• Early and “aggressive”
ambulation
• LMWH, UFH tid > bid, or
fondaparinux
• LMWH, fondaparinux, VKA
(INR 2-3)
• Mechanical prophylaxis
may be used if risk of
bleeding is high; switch to
anticoagulants when risk
decreases
ACCP VTE Prophylaxis
Guidelines 8th Edition
1. Every hospital should develop formal strategy to prevent
VTE
2. Do not use aspirin alone for prophylaxis
3. Use mechanical prophylaxis primarily for patients at high
bleeding risk or as an adjunct to pharmacologic
prophylaxis
4. Give thromboprophylaxis for
– Major trauma
– Spinal cord injury
– Acute medical illness
– Most ICU patients
– Moderate and high risk surgery
Geerts WH, et al. Chest. 2008;133:381S-453S.
“Patients without risk factors for VTE are
called outpatients.” G. Maynard (2010)
VTE Prophylaxis
Effective, Safe, and Cost-Effective
 Pharmacologic prophylaxis substantially reduces
the risk for VTE
– Symptomatic and asymptomatic VTE reduced
 Bleeding complications are rare
 HIT is a serious complication of heparin therapy
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Cost-effectiveness of VTE prophylaxis well
documented
Barriers to Reducing VTE Risk
 Belief that VTE incidence has declined
 VTE not perceived as important
 Lack of familiarity with guidelines
 Underestimation of thrombotic risk
 Overestimation of bleeding risk
 Translation of complicated guidance into
simple orders
 Institutional / structural
Barriers to Reducing VTE Risk
 Implementation of protocol is flawed
 Order set not user friendly
 Process creates duplicate work for
physicians
 Protocol does not fit individual patient
 Competing order sets
VTE Impact Case Study
Year 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
Year 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
Year 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
Expert Recommendations
 VTE protocols embedded in order sets
 Simple risk stratification schema, based on
VTE-risk groups (2-3 levels of risk should do it)
 Institution-wide if possible (a few carve outs ok)
 Local modification is OK
– Details in gray areas not that important
 Use “measure-vention” to accelerate
improvement
Maynard G, Stein J. Designing and Implementing Effective VTE Prevention
Protocols: Lessons from Collaboratives. J Thromb Thrombolysis 2010
Feb:29(2):159-166.
Collaborative Efforts
 AHRQ / QIO (NY, IL, IA) - 40 sites
 AHRQ / QIO 2 and AHRQ / QIO 3 - 33 & 28 sites
 ASHP Advantage collaborative - 6 sites
 CHW with CIIS - 2 sites
 IHI Expedition for VTE Prevention - 50 sites
 SHM VTE Prevention Collaborative I - 25 sites
 SHM VTE Prevention Collaborative III - 30 sites
 SHM / VA Pilot Group - 6 sites PLUS
 SHM / Cerner Pilot Group - 6 sites
 Vancouver Hospital Medicine - 25 sites
QIO Learning Network
Activity
Resources
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Preventing HA VTE- a guide for
effective quality improvement
http://www.ahrq.gov/QUAL/vtgui
de/
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Society of Hospital Medicine
VTE Collaborative
http://www.hospitalmedicine.org
Reference
Maynard G, Stein, J. Preventing Hospital-Acquired Venous thromboembolism:
A Guide for Effective Quality Improvement. Prepared by the Society of
Hospital Medicine, AHRQ Publication No. 08-0075. Rockville, MD:
Agency for Healthcare Research and Quality. August 2008
http://www.ahrq.gov/qual/vtguide/.
Society of Hospital Medicine: http://www.hospitalmedicine.org
Maynard G, Stein J. Designing and Implementing Effective VTE Prevention
Protocols: Lessons from Collaboratives. J Thromb Thrombolysis 2010
Feb:29(2):159-166.
Geerts et al. Prevention of Venous Thromboembolism: American College of
Chest Physicians Evidence-Based Clinical Practice Guidelines (8th
Edition) Chest June 2008 133:381S453S; 10.1378/chest.08-0656
Contact Information
AHRQ QIO Learning Network Project Team
Vicky Agramonte, RN, MSN
Project Manager
IPRO
AHRQ QIO Learning
Network
518-426-3300 or 1-800-2330360
Ext.115
[email protected]
Sheryl Ruhland
Contract Coordinator
IPRO
AHRQ QIO Learning
Network
518-426-3300 or 1-800-2330360
Ext.114
[email protected]