Presentation on theme: "Prevention of Venous Thromboembolism Surgical Care Improvement Project"— Presentation transcript:
1 Prevention of Venous Thromboembolism Surgical Care Improvement Project Dale W. Bratzler, DO, MPHPresident and CEOOklahoma Foundation for Medical QualityDale W. Bratzler, DO, MPHQIOSC Medical Director
2 Why is there a need to measure the quality of hospital care? The passive strategy of guideline publication and dissemination does not effectively change clinical practiceThe time lag between publication of evidence and incorporation into care at the bedside is very longVariations in care and delivery of care that is not consistent with evidence-based recommendations is well documentedBratzler DW. Development of national performance measures on the prevention and treatment of venous thromboembolism. J Thromb Thrombolysis (in press)
3 Prevention of Venous Thromboembolism (VTE) – an example The American College of Chest Physicians published their first consensus conference on antithrombotic therapy in 1986In 2008 published their 8th edition of the evidence-based guidelineDespite all of these published editions…..VTE - the most common preventable cause of hospital death- 2/3 of all cases occur in recently hospitalized patients- up to 3/4 of all cases of PE death are a result of hospitalization
4 Prevention of Venous Thromboembolism – an example Multiple studies that have included hospital medical record audits show consistent underuse of VTE prophylaxisUp to 2/3 of patients with hospital-acquired VTE did not receive prophylaxisAudits of patients receiving treatment for confirmed VTE show non-compliance with guideline-recommended treatmentBratzler DW. Development of national performance measures on the prevention and treatment of venous thromboembolism. J Thromb Thrombolysis (in press)
5 “The best estimates indicate that 350,000 to 600,000 Americans each year suffer from DVT and PE, and that at least 100,000 deaths may be directly or indirectly related to these diseases. This is far too many, since many of these deaths can be avoided. Because the disease disproportionately affects older Americans, we can expect more suffering and more deaths in the future as our population ages–unless we do something about it.”
6 Risk Factors for DVT or PE Nested Case-Control Study (n=625 case-control pairs) SurgeryTraumaInpatientMalignancy with chemotherapyMalignancy without chemotherapyCentral venous catheter or pacemakerNeurologic diseaseSuperficial vein thrombosisVaricose veins/age 45 yrVaricose veins/age 60 yrVaricose veins/age 70 yrCHF, VTE incidental on autopsyCHF, antemortem VTE/causal for deathLiver disease51015202550Odds ratio
7 Risk Factors for VTE Surgery Trauma Immobility, paresis Malignancy Most hospitalized patients have at least one additional risk factor for VTESurgeryTraumaImmobility, paresisMalignancyCancer therapyhormonal therapy, chemotherapy or radiotherapyPrevious VTEIncreasing agePregnancy and post-partum periodEstrogen-containing oral contraception or HRT or SERMAcute medical illnessHeart failureRespiratory failureInflammatory bowel diseaseNephrotic syndromeMyeloproliferative disordersObesitySmokingVaricose veinsCentral venous catheterizationInherited or acquired thrombophiliaTravelSo how do we begin assessing patients for the risk of VTE?This leads me to risk factors. It is rather apparent, that we need to be assessing patients for risk factors in order to ensure that we provide effective prophylaxis and improve our quality of patient care.The risk factors for VTE are fairly well-known and documented.As your can see from this slide, I have highlighted the need to especially consider the risks of developing VTE in patients with a prior history of VTE, suffer from heart failure, or respiratory failure. We have already established the significance of risk factors in this presentation.Geerts W et al. Chest. 2004;126:338S-400S.
8 VTE FactsAlmost half of the outpatients with VTE had been recently hospitalizedLess than half of the recently hospitalized patients had received VTE prophylaxis during their hospitalizationsAbout half had a length of stay (LOS) of < 4 daysDays After Discharge0-2930-5960-9070605040Outpatients With VTE, %302010MedicalHospitalizationOnlyHospitalizationwith SurgeryGoldhaber S. Arch Intern Med. 2007;167:Spencer FA et al. Arch Intern Med. 2007;167(14):
9 Categories of Risk for Venous Thromboembolism in Patients Low risk:Minor surgery in mobile patientsModerate risk:Most medically ill, general, open gyn or urologic surgery patientsHigh risk:Cancer surgery, hip or knee arthroplasty, hip fracture surgery, major trauma or spinal cord injuryGeerts W et al. Chest. 2008;133:381S-453S.
12 5,000 IU SC 2 hours preoperatively and 8 hours thereafter for 7 days. Prophylaxis Against Fatal Post-Operative PE With LDUH: A Multicenter, Prospective, Randomized TrialStudy population: 4,121 patients age > 40 y undergoing a variety of elective major surgical proceduresP < 0.0050.90.7188.8.131.52.5Patients with PE (%)0.40.30.20.0970.1Control (N = 2,076)UFH* (N = 2,045)5,000 IU SC 2 hours preoperatively and 8 hours thereafter for 7 days.Kakkar VV et al. Lancet. 1975;2:45-51.
13 Mechanical Thromboprophylaxis For particularly high-risk surgery patients with multiple risk factors, pharmacologic method should be combined with mechanical method (GCS, IPC) (1C)Use mechanical methods for patients with high bleeding risk (1A), when bleeding risk decreases substitute or add pharmacological thromboprophylaxis (1C)Geerts WH et al. Chest. 2008;133(6 Suppl):381S-453S.
14 Problems with Mechanical Prophylaxis Non-compliance~ 50% of med-surg floors~80% in intensive care unitsMost common reasons for non-compliance~80% of the time, not on the patient~20% of the time, on the patient but not turned on
15 VTE Prophylaxis Grade 1 Recommendations Surgery*Recommended ProphylaxisGeneral surgeryLow-dose unfractionated heparin (LDUH)Low molecular weight heparin (LMWH)Fondaparinux (effective 10/01/07)LDUH or LMWH combined with IPC or GCSGeneral surgery with a reason for not administering pharmacologic prophylaxis documentedGraduated Compression stockings (GCS)Intermittent pneumatic compression (IPC)Gynecologic surgeryFactor Xa inhibitorIntermittent pneumatic compression devices (IPC)LDUH, LMWH, or factor Xa inhibitor combined with IPC or GCS*Limited to those patients who have an anesthesia duration of at least 60 minutes, and a hospital stay of at least three calendar days (two nights in the hospital).*Open surgical procedure > 30 minutes requiring in-hospital stay > 24 hours postoperative.
16 VTE Prophylaxis Grade 1 Recommendations SurgeryRecommended ProphylaxisUrologic surgeryLow-dose unfractionated heparin (LDUH) 5000 units bid or tidLow molecular weight heparin (LMWH)Factor Xa inhibitor (fondaparinux)Intermittent pneumatic compression devices (IPC)Graduated compression stockings (GCS)LDUH, LMWH, or factor Xa inhibitor combined with IPC or GCSElective total hip replacementAdjusted-dose warfarin (INR target 2.5, range )Elective total knee replacementVenous foot pumps (VFP)
17 VTE Prophylaxis Grade 1 Recommendations SurgeryRecommended ProphylaxisHip fracture surgeryLow molecular weight heparin (LMWH)Factor Xa inhibitorAdjusted-dose warfarin (INR target 2.5, range )Low-dose unfractionated heparin (LDUH)Hip fracture surgery (HFS) or elective total hip replacement with a reason for not administering pharmacologic prophylaxis documentedGraduated Compression stockings (GCS) (HFS only)Intermittent pneumatic compression (IPC)Venous foot pumps (VFP)Intracranial neurosurgeryIPC with or without GCSPostoperative Low molecular weight heparin (LMWH)LDUH or LMWH combined with IPC or GCS*Open surgical procedure > 30 minutes requiring in-hospital stay > 24 hours postoperative.
18 Performance Measurement Does Not Happen without Controversy
19 Hip or Knee Arthroplasty Summary American Academy of Orthopedic Surgeons (AAOS) Clinical Guideline on Prevention of Symptomatic Pulmonary Embolism in Patients Undergoing Total Hip or Knee ArthroplastyStandard risk PE, Standard risk Bleeding*aspirinLMWHsynthetic pentasaccharideswarfarinLevel III, Grade B recommendationStandard risk PE, Elevated risk BleedingnoneLevel III, Grade C recommendationElevated risk PE, Standard risk BleedingElevated risk PE, Elevated risk BleedingSCIP VTE 1 Performance MeasureHip or Knee ArthroplastyNo Bleeding Risk DocumentedDocumented Bleeding RiskHip or knee arthroplasty:Knee arthroplasty only:intermittent pneumatic compression devicesvenous foot pumpMechanical Prophylaxis[any other modality (including aspirin or warfarin) can be added]
20 What else does the AAOS guideline say? They do NOT recommend the use of aspirin aloneThey recommend the use of mechanical prophylaxis started in the operating room or immediately postoperatively in all patients – continued to dischargeThey recommend pharmacologic prophylaxis with LMWH, factor Xa inhibitor, or warfarin in high risk patientsprevious history of cancer, thromboembolism, hypercoagulable states such as polycythemia, spinal cord injury patients, multi-trauma patients, and genetic predisposition
21 VTE Prophylaxis Other issues Timing of prophylaxis Neuraxial anesthesiaRenal insufficiencyDuration of prophylaxis
23 Venous Thromboembolism Statement of Organization Policy “Every healthcare facility shall have a written policy appropriate for its scope, that is evidence-based and that drives continuous quality improvement related to VTE risk assessment, prophylaxis, diagnosis, and treatment.”23
24 Measure specifications available at: www.qualitynet.org
25 Electronic Submission of Performance Measures In the recently published final IPPS rule for fiscal year 2010, CMS has announced that through an interagency agreement with the Office of the National Coordinator for Healthcare Information Technology, they are developing interoperable standards for electronic medical record submission of the newly-endorsed VTE measures. Vendors of electronic medical record systems would be able to code their systems with the new specifications by the end of 2009.Centers for Medicare & Medicaid Services. Medicare Program; Changes to the Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and Fiscal Year 2010 Rates; and Changes to the Long-Term Care Hospital Prospective Payment System and Rate Years 2010 and 2009 Rates. Available at: Accessed 10 August 2009.
27 Strategies to Improve VTE Prophylaxis Hospital policy of risk assessment or routine prophylaxis for all admitted patientsMost will have risk factors for VTE and should receive prophylaxisPreprinted protocols for surgical patients
28 Electronic Alerts to Prevent VTE among Hospitalized Patients Hospital computer system identified patient VTE risk factorsRCT: no physician alert vs physician alertControl Alertgroup group PNo , ,255Any prophylaxis % % <0.001VTE at 90 days % * 4.9 %Major bleeding % % NS* NNT = 30Kucher – NEJM 2005;352:969
29 Improving Compliance with Treatment Protocols Use of standardized protocols, nomograms, algorithms, or preprinted ordersAddress overlap (either 5 days in hospital or discharge on overlap)When used, UFH should be managed by nomogram/protocol, and the protocol should ensure routine platelet count monitoring
30 Essential Elements for Improvement Institutional supportA multidisciplinary team or steering committeeReliable data collection and performance trackingSpecific goals or aimsA proven QI frameworkProtocolsEssential elements to reach breakthrough levels of improvement in care include:Institutional support and prioritization for the initiative, expressed in terms of a meaningful investment in time, equipment, personnel, and informatics, and a sharing of institutional improvement experience and resources to support any project needsA multidisciplinary team or steering committee focused on reaching VTE prophylaxis targets and reporting to key medical staff committeesReliable data collection and performance trackingSpecific goals, or aims, which are ambitious, time-defined, and measurableA proven QI framework to coordinate steps towards breakthrough improvementProtocols that standardize VTE risk assessment and prophylaxisInstitutional infrastructure, policies, practices, or educational programs promoting the use of the protocol. The protocol that standardizes VTE risk assessment is so fundamental that is must not merely exist. It must be embedded in patient care. High reliability design should be used to enhance effective implementation.SHM Resource Room. Accessed September 2009.
31 Maynard GA, et al. J Hosp Med 2009 Sep 14. [Epub ahead of print] RiskAssessmentProphylaxisLowAmbulatory patient without VTE risk factors; observation patient with expected LOS 2 days; same day surgery or minor surgeryEarly ambulationModerateAll other patients (not in low-risk or high-risk category); most medical/surgical patients; respiratory insufficiency, heart failure, acute infectious, or inflammatory diseaseUFH 5000 units SC q 8 hours; OR LMWH q day; OR UFH 5000 units SC q 12 hours (if weight < 50 kg or age > 75 years); AND suggest adding IPCHighLower extremity arthroplasty; hip, pelvic, or severe lower extremity fractures; acute SCI with paresis; multiple major trauma; abdominal or pelvic surgery for cancerLMWH (UFH if ESRD); OR fondaparinux 2.5 mg SC daily; OR warfarin, INR 2-3; AND IPC (unless not feasible)Maynard GA, et al. J Hosp Med 2009 Sep 14. [Epub ahead of print]
32 Maynard GA, et al. J Hosp Med 2009 Sep 14. [Epub ahead of print]
33 Maynard GA, et al. J Hosp Med 2009 Sep 14. [Epub ahead of print]
34 Maynard GA, et al. J Hosp Med 2009 Sep 14. [Epub ahead of print]
35 Attention to Transitions of Care Ensure adequate training of the patientEducation on medications, diet, follow up appointments, lab monitoring, dietary precautions, and adverse reactions or drug-drug interactionsEducation for familyReferral to anticoagulation clinicHospital abstractors must find explicit documentation of this training/education in the chart
36 Does public reporting accelerate quality improvement?
37 Changes in National Performance Baseline to Q1, 2009 //*National sample of 19,497 Medicare patients undergoing surgery in US hospitals during the first quarter of (Bratzler, unpublished data
38 Hospital-acquired Conditions Background of the “Never Events” Deficit Reduction Act (DRA) of 2005 requires the Secretary of HHS to identify conditions that are:High cost or high volume (or both); andResult in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis; andCould reasonably have been prevented through the application of evidence-based guidelines.
40 Conclusions VTE remains a substantial health problem in the US VTE prophylaxis remains underutilizedNational performance measures will address both prophylaxis and treatment of VTE across broad hospital populations