1. 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

2. 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 ante- mortem 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%

3. VTE Prevention- We are failing our patients! 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 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 (%)

4. Joint Commission Standards for VTE Management 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

5. Hopkins Surgical Services: DVT Prophylaxis Baseline Adherence 2005 ACCP Guideline Adherence (%) Data courtesy of Deb Hobson RN Center for Innovations in Quality Patient Care

7. Physical Medicine & Rehabilitation VTE Prophylaxis Performance N=914 ACCP Adherence (%) Data courtesy of S Mayer MD PM&R & Deb Hobson RN Center for Innovations in Quality Patient Care

8. General Surgery Overall Compliance with Recommended VTE Prevention N= 297 cases reviewed 11/2006 (35 cases contraindicated for pharmacologic prophylaxis) 42/161 178/262 2/2 9/19 72/103 95/138 ACCP Compliance (%) Data courtesy of Deb Hobson RN Center for Innovations in Quality Patient Care

9. 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 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

10. Impact of the POE VTE Order set on Compliance on the Orthopedic Spine Service N= 15 40 35 42 37 21 42 40 37 Admissions (%)

11. Impact of the POE VTE Order set on Compliance on the Medicine Service N=20 N=1059 N=1039 N=1097

12. Annual Incidence of VTE at JHH VTE (% of discharges)

13. 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… –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

14. 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

15. Acknowledgments 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 Durrette- Smith, 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

16. Questions ?