1. 1 MCIC VTE Prophylaxis All Team Call Sean Berenholtz, MD MHS and VTE Subcommittee 5.23.2006

2. 2 MCIC VTE Subcommittee JHH Paula Biscup Lisa Rowen Renee Demski Michael Streiff David Hunt Deborah Hobson URMC Edward Bell Robert Panzer Diane Cockrell Ivelisse Vicente Alan Curle Karen Zinnecker Charles Francis NYP Audrey Compton Joseph Cooke David Diuguid Sue Kim YNHH Nabil Atweh Andrea Benin Veronica Chiang Ann Ertel Charles Watson Kathy Hearn Pamela Cullen Lori Ryder Mary Ellen Ksoturko Keith Ruskin Ena Williams Walter Cholewczynski

3. 3 Safety Measures How often do we harm patients? –Measures of harm (Surgical site infections (SSI)) How often do we do what we should? –Surgical Care Improvement Project (SCIP) process measures, –Venous thromboembolism (VTE) prophylaxis, How often do we learn from defects? –Learn from one per month (National Quality Forum never events, mislabeled specimens) How well do we improve culture? –Safety Attitude Questionnaire (SAQ), –Comprehensive Unit Safety Program (CUSP)

4. 4 Most common preventable cause of hospital death Hirsh DR et al. JAMA 1995;274:335-7 Bick RL Semin Thromb Hemost 1999;25:251-3 Annual Incidence in US

5. 5 Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004 Sep;126(3 Suppl):338S-400S

6. 6 Recommendations General surgery –surgical oncology, gynecology, urology, vascular, transplant, thoracic surgery Orthopedics Trauma Neurosurgery

7. 7 Overall Adherence for VTE Prophylaxis at JHHS: Baseline n = 7/8n = 71/219*n = 3/13n = 20/88n = 13/44 * Aggregate DOES NOT INCLUDE GU cases that were contraindicated for pharmacologic interventions n = 12/16n = 12/31n = 3/15n = 1/4

8. 8 SCIP Measures SCIP VTE 1: Surgery patients with recommended VTE prophylaxis ordered SCIP VTE 2: Surgery patients who received appropriate VTE prophylaxis within 24 hours prior to surgery to 24 hours after surgery SCIP VTE 3: Intra- or postoperative PE diagnosed during index hospitalization and within 30 days of surgery (OUTCOME) SCIP VTE 4: Intra- or postoperative DVT diagnosed during index hospitalization and within 30 days of surgery (OUTCOME)

9. 9 Assumptions Data collected in immediate periop period (preop holding area thru time of PACU/ICU admission Concurrent data collection preferred Risk stratification defined by local consensus Evidence of risk stratification includes a completed risk stratification tool, a physician, NP, or PA note documenting that the patient is at risk for VTE Exclusions: < 18 yo, hospital LOS < 24 hours

10. 10 Proposed MCIC VTE Measures General surgery (includes surg onc, urology, vascular and transplant surgery) Trauma Neurosurgery (intracranial, spinal cord injury, elective spine surgery) Bariatric surgery

11. 11 Proposed MCIC VTE Measures Documentation of Risk Stratification –% patients with evidence of risk stratification in chart Prophylaxis for VTE –% patients who have an order written to start prophylaxis during the time period within 24 hrs prior to incision through 24 hrs after surgery end time –% patients who have an order written to start prophylaxis at the recommended dosing during the time period within 24 hrs prior to incision time through 24 hrs after surgery end time

12. 12 Proposed MCIC VTE Measures Contraindications to VTE prophylaxis –% patients with any contraindication to pharmacologic prophylaxis –% patients with contraindication to pharmacologic prophylaxis due to a high risk of bleeding treated with mechanical prophylaxis (GCS or IPC or SCD) % patients included in review process GCS: graduated compression stockings; IPC: intermittent pneumatic compression devices; SCD: sequential compression devices

13. 13 Data Collection Plan Data collection tool developed Pilot testing: June 2006 –Concurrent data collection: convenience sample of 5-10 pts –Retrospective Review: 10 randomly selected patient-charts Implementation: July 2006 –Concurrent data collection: All patients seen by the clinical area improvement team –Retrospective Review: 10 randomly selected patient-charts per month per surgery type Maintenance: >= 90% performance –TBD

14. 14 Reports Single period reports Performance over time Comparison to collaborative Data remains anonymous

15. 15 Change is Local Educate staff –Partner with hematology, Guidelines, Fact sheet, powerpoint slides Reduce complexity –Standardized tool, computerized decision support Create redundancy –Multidisciplinary teams, add to existing checklists, briefings/debriefings Measure performance –Identify when this will occur during the periop period

16. 16 Team Check-up Tool Reviewed data with team Number of team meetings Met with executive Reviewed data with executive Barriers to progress

17. 17 Next Steps Finalize teams Gain consensus on evidence and risk stratification Pilot test data collection tool Conference call to review pilot phase –Burden, revise measures/tools, timeline Live the grid Conference calls for sharing