Transcript Anticoagulation Management Service Safety Projects

Optimizing Venous Thromboembolism
Prophylaxis using Physician Order Entry:
Johns Hopkins Hospital Experience
Michael B. Streiff, MD
Associate Professor of Medicine
Division of Hematology
Medical Director,
Johns Hopkins Anticoagulation Management Service
Venous thromboembolism (VTE)
Prevention- Why should we care?
• Venous thromboembolism is
common
– 900,000 DVT/PE annually
• VTE is deadly
– 10% of hospital deaths due to
PE
– Only 1/3 suspected antemortem
• VTE causes long-term
morbidity
– Recurrent VTE occurs in 40%
by 10 years
– Post-thrombotic syndrome
affects 30% by 5 years
• VTE is preventable
– Effective prophylaxis reduces
DVT incidence by 60%
• Worchester VTE
study- 1897 patients
with VTE from 12
hospitals
• Seventy-four percent
were outpatients
• Sixty percent recently
hospitalized
• Only 43% received
DVT prophylaxis
(Spencer FA et al. Arch Intern Med 2007)
Prophylaxis (%)
VTE Prevention- We are failing our
patients!
100
90
80
70
60
50
40
30
20
10
0
50
29
33
29
50
28
US 91 Canada US 02 UK 03 World
01
07
World
08
Anderson Arch Intern Med 1991 Rahim et al. Thromb Res 2003. Tapson et al. Blood 2004, Rashid J Royal
Soc Med 2005; Spencer et al. Arch Intern Med 2007; Tapson et al. Chest 2007; Cohen AT Lancet 2008
Joint Commission Standards for
VTE Management
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Prevention
Documentation of Venous Thromboembolism Risk Assessment/Prophylaxis within 24
Hours of Hospital Admission
Documentation of Venous Thromboembolism Risk Assessment/Prophylaxis within 24
Hours of Transfer to ICU
Treatment
Documentation of Inferior Vena Cava Filter Indication
Venous Thromboembolism Patients with Overlap of Parenteral and Warfarin
Anticoagulation Therapy
Venous Thromboembolism Patients Receiving Unfractionated Heparin with Platelet
Count Monitoring
Venous Thromboembolism Patients Receiving Unfractionated Heparin Management
by Nomogram/Protocol
Venous Thromboembolism Discharge Instructions
Outcome
Incidence of Potentially Preventable Hospital-Acquired Venous Thromboembolism
ACCP Guideline Adherence (%)
Hopkins Surgical Services:
DVT Prophylaxis Baseline Adherence 2005
50
45
40
35
30
25
20
15
10
5
0
50
50
30
21
27
20
17
12
Cardiac
GI
Gyn/Onc
Halsted
Orthopedics
PMR
Transplant
Vascular
Data courtesy of Deb Hobson RN Center for Innovations in Quality Patient Care
Physical Medicine & Rehabilitation VTE
Prophylaxis Performance
ACCP Adherence (%)
100
90
80
70
60
50
40
30
20
10
0
N=914 93
88
98
99.2 99.2 99.2 100
97 97.4
87.2
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Pre
MarJan-Feb Apr
2005
2005
Qrt 2
2005
Qrt 3
2005
Qrt 4
2005
Qrt 1
2006
Qrt 2
2006
Qrt 3
2006
Qrt 4
2006
Qrt 1
2007
Qrt 2
2007
Data courtesy of S Mayer MD PM&R & Deb Hobson RN Center for Innovations in Quality Patient Care
ACCP Compliance (%)
General Surgery Overall Compliance with
Recommended VTE Prevention
100.0
100
80
67.9
60
40
69.9
68.8
High
Very High
72/103
95/138
47.4
26.1
20
0
Aggregate
2005
Aggregate
11/2006
Low
Mod
42/161
178/262
2/2
9/19
N= 297 cases reviewed 11/2006 (35 cases contraindicated for pharmacologic prophylaxis)
Data courtesy of Deb Hobson RN Center for Innovations in Quality Patient Care
Johns Hopkins VTE Prevention
Collaborative – Version 1.0 Results
• Evidence-based Paper VTE Prophylaxis Tool
– Success
• Improved VTE Prophylaxis compliance from 25% to 50-100%
• Decreased VTE incidence on some floors
– Shortcomings
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Complex
Forms not always available
Labor intensive data collection
Out of usual work flow stream on CPOE units
Result = Sub-optimal VTE prevention
Solution = Electronic Risk Stratification/Order Entry
Impact of the POE VTE Order set on Compliance
on the Orthopedic Spine Service
Risk stratification 24 hrs
Risk Stratification
Prophylaxis 24 hrs
Prophylaxis
100
90
Admissions (%)
80
70
60
50
40
30
20
10
0
Paper Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08
N= 15
40
35
42
37
21
42
40
37
Impact of the POE VTE Order set on Compliance
on the Medicine Service
Risk stratification
Risk Stratification 24 hrs
Prophylaxis
Prophylaxis 24 hrs.
100
90
80
70
60
50
40
30
20
10
0
Paper
Jan-08
N=20
N=1059
Feb-08
N=1039
Mar-08
N=1097
Annual Incidence of VTE at JHH
2004
2005
2006
2007
VTE (% of discharges)
6
5
4
3
2
1
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Conclusions
• We have developed a POE VTE prophylaxis
order set that facilitates rapid VTE risk
stratification and evidence-based VTE
prophylaxis ordering
• Benefits of the order set include…
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Increased VTE risk stratification
Increased risk-appropriate VTE prophylaxis
Enhanced VTE performance monitoring/reporting
Targeted provider education of VTE risk factors and
prophylaxis modalities
– More effective strategy to improve VTE prevention
than electronic alerts
Future Plans
• Study the impact of the order set on VTE
and bleeding event rates
• Study the impact of the order set on
provider VTE management knowledge
base
Acknowledgments
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Paula Biscup-Horn PharmD, BCPS
Deb Hobson, BSN
Elliot Haut, MD
Peggy Kraus, PharmD, CAPS
Chad Smith, FACHE
Katy Olive
JHMCIS
– Peter Greene MD
– Steve Mandell, Peggy Ardolino, Pat Zeller, Annette DurretteSmith, Irma Sutanto, Bonnie McCoy & JHMCIS Team
• The VTE Collaborative Teams
• The Center for Innovation in Quality Patient Care
• Renee Demski, MSW, MBA and the Johns Hopkins
Health System Quality Improvement Office
Questions ?