1. Guide Available for Deep Vein Thrombosis Developed from Partnerships in Implementing Patient Safety program toolkit Developed from Partnerships in Implementing Patient Safety program toolkit Based on quality improvement initiatives undertaken at the University of California, San Diego Medical Center and Emory University Hospitals Based on quality improvement initiatives undertaken at the University of California, San Diego Medical Center and Emory University Hospitals Assists quality improvement practitioners in preventing one of the most important problems facing hospitalized patients - DVT / PE (VTE) Assists quality improvement practitioners in preventing one of the most important problems facing hospitalized patients - DVT / PE (VTE)

2. Why build a toolkit for VTE Prevention? VTE is a common source of inpatient M&M VTE is a common source of inpatient M&M – Jumbo jet crash / day- > Breast CA, HIV, MVA combined – May be # 1 preventable source of hospital death Effective and safe methods of prevention exist Effective and safe methods of prevention exist – Large “implementation gap” - best practice ≠ current practice These methods are grossly underutilized These methods are grossly underutilized – Awareness, difficulty implementing, no validated risk assessment P4P, public reporting, and core measures P4P, public reporting, and core measures Geerts WH, et al. Chest. 2008;133:381S-453S. Cohen, Tapson, Bergmann, et al. ENDORSE study: Lancet 2008; 371: 387–94. Surgeon General’s Call to Action to Prevent DVT and PE 2008 DHHS

3. To Achieve Improvement Real institutional support / prioritization Real institutional support / prioritization Will to standardize Will to standardize Physician leadership Physician leadership Measurement of process / outcomes Measurement of process / outcomes Protocol, integrated into order sets Protocol, integrated into order sets Education Education Continued refinement / tweaking- PDSA Continued refinement / tweaking- PDSA SHM and AHRQ Guides on VTE Prevention

4. Hierarchy of Reliability No protocol* (“State of Nature”) Decision support exists but not linked to order writing, or prompts within orders but no decision support Protocol well-integrated (into orders at point-of-care) Protocol enhanced (by other QI / high reliability strategies) (by other QI / high reliability strategies) Oversights identified and addressed in real time Level 4 1 2 3 5 Predicted Prophylaxis rate 40% 50% 65-85% 90% 95+% * Protocol = standardized decision support, nested within an order set, i.e. what/when

5. The Essential First Intervention The Essential First Intervention 1) a standardized VTE risk assessment, linked to… 2) a menu of appropriate prophylaxis options, plus… 3) a list of contraindications to pharmacologic VTE prophylaxis Challenges: Make it easy to use (“automatic”) Make sure it captures almost all patients Trade-off between guidance and ease of use / efficiency 5 VTE Protocol

6. Low Medium High Ambulatory with no other risk factors. Same day or minor surgery CHF COPD / Pneumonia Most Medical Patients Most Gen Surg Patients Everybody Else Elective LE arthroplasty Hip/pelvic fx Acute SCI w/ paresis Multiple major trauma Abd / pelvic CA surgery Early ambulation UFH 5000 units q 8 h (5000 units q 12 h if > 75 or weight 75 or weight <50 kg)LMWH Enox 40 mg q day Enox 40 mg q day Other LMWH Other LMWH CONSIDER add IPC Enox 30 mg q 12 h or Enox 40 q day or Other LMWH or Fondaparinux 2.5 mg q day or Warfarin INR 2-3 AND MUST HAVE IPC 6 IPC needed if contraindication to AC exists Example from UCSD Keep it Simple – A “3 bucket” model

7. Map to Reach Level 3 Implementing an Effective VTE Prevention Protocol Examine existing admit, transfer, periop order sets with reference to VTE prophylaxis. Examine existing admit, transfer, periop order sets with reference to VTE prophylaxis. Design a protocol-driven DVT prophylaxis order set (w/ integrated risk assessment) Design a protocol-driven DVT prophylaxis order set (w/ integrated risk assessment) Vette / Pilot – PDSA Vette / Pilot – PDSA Educate / consensus building Educate / consensus building Place new standardized DVT order set ‘module’ into all pertinent admit, transfer, periop order sets. Place new standardized DVT order set ‘module’ into all pertinent admit, transfer, periop order sets. Monitor, tweak - PDSA Monitor, tweak - PDSA

8. 8 Baseline Consensus building Order Set Implementation & Adjustment Real time ID & intervention Baseline Consensus building Order Set Implementation & Adjustment Real time ID & intervention N = 2,944 mean 82 audits / month In press, JHM 2009In press, Maynard, Morris et al, J Hosp Med

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10. Hierarchy of Reliability No protocol* (“State of Nature”) Decision support exists but not linked to order writing, or prompts within orders but no decision support Protocol well-integrated (into orders at point-of-care) Protocol enhanced (by other QI / high reliability strategies) (by other QI / high reliability strategies) Oversights identified and addressed in real time Level 4 1 2 3 5 Predicted Prophylaxis rate 40% 50% 65-85% 90% 95+% * Protocol = standardized decision support, nested within an order set, i.e. what/when

11. Map to Reach Level 5 95+ % prophylaxis Use MAR or Automated Reports to Classify all patients on the Unit as being in one of three zones: Use MAR or Automated Reports to Classify all patients on the Unit as being in one of three zones: GREEN ZONE - on anticoagulation YELLOW ZONE - on mechanical prophylaxis only RED ZONE – on no prophylaxis Act to move patients out of the RED!

12. Situational Awareness and Measure-vention: Getting to Level 5 Identify patients on no anticoagulation Identify patients on no anticoagulation Empower nurses to place SCDs in patients on no prophylaxis as standing order (if no contraindications) Empower nurses to place SCDs in patients on no prophylaxis as standing order (if no contraindications) Contact MD if no anticoagulant in place and no obvious contraindication Contact MD if no anticoagulant in place and no obvious contraindication – Templated note, text page, etc Need Administration to back up these interventions and make it clear that docs can not “shoot the messenger” Need Administration to back up these interventions and make it clear that docs can not “shoot the messenger”

13. Collaborative Efforts and Kudos SHM VTE Prevention Collaborative I - 25 sites SHM VTE Prevention Collaborative I - 25 sites SHM / VA Pilot Group - 6 sites SHM / VA Pilot Group - 6 sites SHM / Cerner Pilot Group – 6 sites SHM / Cerner Pilot Group – 6 sites AHRQ / QIO (NY, IL, IA) - 60 sites AHRQ / QIO (NY, IL, IA) - 60 sites IHI Expedition to Prevent VTE – 60 sites IHI Expedition to Prevent VTE – 60 sites SHM Team Improvement Award SHM Team Improvement Award NAPH Safety Net Award NAPH Safety Net Award Venous Disease Coalition Venous Disease Coalition