1. Preventing VTE in Surgical Patients

2. Today’s Topics The common sense science of VTE prevention Brief history of VTE prevention techniques High yield methods of preventing VTEs in surgical patients A glance at the reporting requirements for VTE Understanding your needs: A series of polls

3. Why Are We Focusing In Surgery?

4. Common Sense Science: Venous Thromboembolism (VTE) When blood clots form in the vein and form a mass Two types: –Deep Vein Thrombosis (DVT): occurs in leg veins (clot that forms in the deep veins of the body) –Pulmonary Embolism – occurs when a clot detaches from the vessel and travels to the lungs and lodges within the pulmonary arteries DVT + PE = VTE

5. Common Sense Science Continued ~ 300,000-600,000 Americans develop VTE each year 60,000-100,000 die each year from VTE Annual cost of care is estimated at $1.5 billion About two-thirds of all VTE events are related to hospitalization 40% or more of hospital associated VTE is preventable through prophylaxis U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism: 2008. Office of the Surgeon General and the National Heart, Lung, and Blood Institute of the National Institutes of Health; 2008. Available at: http://accpstorage.org/chest08/bestOF/SurgeonGeneralsReport.pdf. Accessed July 31, 2009.

6. Venous Thromboembolism: A Brief History Rudolf Carl Virchow 1821-1902

7. Virchow’s Triad Stasis of blood flow (blood slows down) Injury to the vein State of the body (Hypercoagulability)

8. VTE Main Risk Factors Increasing age (risk rises steadily from age 40) Prolonged/restricted mobility Cancer and cancer therapy Cardiac problems Systemic lupus erythematous Infection Microalbuminuria associated with ESRD Stroke Nephrotic syndrome Trauma Inflammatory bowel syndrome Atherscelerosis History of DVT or PE Inherited or acquired predisposition to clotting Obesity Pregnancy and postpartum period Oral contraceptive or hormone replacement with estrogen Varicose veins

9. The Greatest Risks for VTE The trauma of surgery itself Prolonged/restricted mobility Length of the surgical procedure

10. The Most Important Question to Ask “Is this patient going to be in bed for a long time?”

11. Surgical Patients at Risk for VTE Risk LevelPatient Population Highest Undergoing hip or knee surgery With multiple risk factors With major trauma High Older than 60 years Patents ages 40-60 years with additional risk factors Moderate Additional risk factors undergoing minor surgery 40-60 years with no additional risk factors Low Younger than 40 years with no additional risk factors undergoing minor surgery

12. Prophylaxis Options Pharmacological Options Low-dose unfractionated heparin (LDUH) Low molecular weight heparin (LMWH) or Factor Xa Antagonist Warfarin Oral Factor Xa Inhibitor (Rivaroxaban) Non- Pharmacological/Mechanical Options Intermittent pneumatic compression (IPC) Graduated compression stockings (GCS) Venous foot pump (VFP)

14. Preventing VTE Is Complicated (Slide 1 of 3) Hight, Henrietta. Venous Thromboembolism & Prophylaxis in the Surgical Patient. FMQI. http://www.hsag.com/App_Resources/Documents/FMQAI_SCIP_VTE_LearningModule.pdf. 27 June 2013

15. Preventing VTE Is Complicated (Slide 2 of 3) Hight, Henrietta. Venous Thromboembolism & Prophylaxis in the Surgical Patient. FMQI. http://www.hsag.com/App_Resources/Documents/FMQAI_SCIP_VTE_LearningModule.pdf. 27 June 2013

16. Preventing VTE Is Complicated (Slide 3 of 3) Hight, Henrietta. Venous Thromboembolism & Prophylaxis in the Surgical Patient. FMQI. http://www.hsag.com/App_Resources/Documents/FMQAI_SCIP_VTE_LearningModule.pdf. 27 June 2013

17. Sample Order Set Sample order sets are available at: http://www.fmqai.com/library/at tachment- library/VTERiskAssessmentToo ls.pdf

18. Work within a Specialty

19. Surgical Care Improvement Project (SCIP) Measures VTE Measure 1: Surgery patients with recommended venous thromboembolism (VTE) prophylaxis ordered anytime from hospital arrival to 24 hours after Anesthesia End Time. VTE Measure 1: Surgery patients with recommended venous thromboembolism (VTE) prophylaxis ordered anytime from hospital arrival to 24 hours after Anesthesia End Time. VTE Measure 2: Surgery patients who received appropriate venous thromboembolism (VTE) prophylaxis within 24 hours prior to Anesthesia Start Time to 24 hours after Anesthesia End Time. VTE Measure 2: Surgery patients who received appropriate venous thromboembolism (VTE) prophylaxis within 24 hours prior to Anesthesia Start Time to 24 hours after Anesthesia End Time. Centers for Medicare & Medicaid Services (CMS). The Joint Commission. Specifications Manual for National Hospital Inpatient Quality Measures. Version 3.1a. Revised November 6, 2009; 135-177 [SCIP-VTE 1-1 – SCIP-VTE 2-23]. QualityNet Web site. Available at: http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier4&cid=1228749003528. Accessed March 8, 2010.

20. Joint Commission Measures The number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission VTE-1 Venous Thromboembolism Prophylaxis The number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after the initial admission (or transfer) to the Intensive Care Unit (ICU) or surgery end date for surgeries that start the day of or the day after ICU admission (or transfer). VTE-2 Intensive Care Unit VTE The number of patients diagnosed with confirmed VTE who received an overlap of parenteral (intravenous [IV] or subcutaneous [subcu]) anticoagulation and warfarin therapy, VTE-3 VTE Patients with Anticoagulation Overlap Therapy The number of patients diagnosed with confirmed VTE who received intravenous (IV) UFH therapy dosages AND had their platelet counts monitored using defined parameters such as a nomogram or protocol. VTE-4 VTE Patients Receiving Unfractionated Heparin with Dosages/Platelet Count Monitored by Protocol or Nomogram The number of patients diagnosed with confirmed VTE that are discharged to home, home care, court/law enforcement or home on hospice care on warfarin with written discharge instructions that address all four criteria: compliance issues, dietary advice, follow-up monitoring, and information about the potential for adverse drug reactions/interactions. VTE-5 Venous Thromboembolism Warfarin Therapy Discharge Instructions The number of patients diagnosed with confirmed VTE during hospitalization (not present at admission) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnostic testing order date. VTE-6 Hospital Acquired Potentially- Preventable Venous Thromboembolism

21. Poll 1: Realistically, how often do you think that patients receiving surgery in your facility receive treatment that fulfills some of the guidelines that we talked about? Never Sometimes Most of the time Always

22. Poll 2: Additional resources from the SCHA to help us further refine our VTE prophylaxis efforts would be helpful? Yes No

23. Poll 3: What do you see as the biggest barrier to more consistent use of VTE guidelines? (Open-ended question)

24. Take Home Messages Preventing VTE is complicated and requires interventions across the entire system of care Creating guidelines/order sets by specialty is helpful The hospital association would like to learn more about your experiences with VTE please send an email to Lorri Gibbons at lgibbons@scha.org with: –any successes that you have had –if you have any suggestions for future topics to help further your work in this area

25. ? ? Questions

26. Office Hours: Wednesday 2:00-3:00

27. Resources Website: www.safesurgery2015.org Email: safesurgery2015@hsph.harvard.edu