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St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
St. David's Prophylaxis Program
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St. David's Prophylaxis Program

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Dr. Steve Berkowitz presents "Going from a 'known' complication to 'no' compilcaton.

Dr. Steve Berkowitz presents "Going from a 'known' complication to 'no' compilcaton.

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  • 1. Going from a KNOWNcomplication….
    .... To KNOWN complication.
    NO
    VTE Prophylaxis Program2003 - 2010
    Copyright SMB and Co.
  • 2. St. David’s VTE Prophylaxis Program7 Year Follow-up -- since January 2003
    Endorsed as significant by our leadership
    Physician-driven and literature-based
    Sustained, superior results over a 7-year period:
    Over two-thirds reduction in hospital-acquired:
    DVT and Pulmonary Embolus
    Substantial cost-avoidance savings
    (more than off-setting Rx costs)
  • 3. St. David’s-- A Community Hospital System
  • 4. Our Greatest Challenge in Clinical Medicine
    Eliminate the “DEADLY” Delay !!
    Copyright SMB and Co.
  • 5. 17 Years !!
    The Deadly Delay…From Clinical Trials to Clinical Practice…
  • 6. Good News.. We are Doing BetterScurvy and the British Navy
    1601-- Lancaster shows that lemon juice supplement eliminates scurvy among sailors
    1747-- Lind shows that citrus juice supplement eliminates scurvy
    1795 -- British Navy implements citrus juice supplement
    194 Years !!
  • 7. Core Measures:
    Acute Myocardial Infarction
    Heart Failure
    Pneumonia
    Surgical Care Improvement
    HCAHPS
  • 8. 1981- Beta-Blocker for Acute MI
    The Evidence is Published
  • 9. Goal:
    100% Compliance !!
    Core Measures:
    Acute Myocardial Infarction
    Heart Failure
    Pneumonia
    Surgical Care Improvement
    HCAHPS
  • 10. Standard of Care ? !!
    Core Measures:
    Acute Myocardial Infarction
    Heart Failure
    Pneumonia
    Surgical Care Improvement
    HCAHPS
  • 11. The Happy Medium:Previously “accepted” practices currentlyNot Recommended
    Aggressive surgery for early breast cancer
    Hormone replacement for post-menopausal women
    Vioxx for pain and inflammation
    Drug eluting stents in off-label indications
    Not too fast....
  • 12. Gaining Physician Buy- InChanging the Mind-Set
    Today you are a medical student.
    However…
    ..…You will be a student of medicine the rest of you’re career.
    Dean of Students
    I hope there is no physician in this room who is….
    ….too old a dog to learn a new trick!
  • 13. Venous Thrombo-Embolic Disease
    DVT and Pulmonary Embolism
  • 14. The Problem of VTE Prophylaxis is Significant
    “Deep Vein Thrombosis and Pulmonary Embolism represent a major
    public health problem, exacting a significant toll on the Nation”
    -- Surgeon General Call to Action, 2008
    “[Thromboprophylaxis]…is the number-one strategy
    to improve patient safety in hospitals” – ACCP Guidelines, 2008
    “…a vast number of randomized clinical trials over the past 30 years
    provide irrefutable evidence that primary thromboprophylaxis
    reduces DVT and pulmonary embolism” – ACCP Guidelines, 2008
    DVT-related PE kills more Americans annually than
    AIDS and breast cancer combined – Gerotziafas, 2004
  • 15. Literature ReviewProphylaxis Works !!
    NewEnglandJournalofMedicine1988:
    Prophylaxis can reduce:
    PE’s by one half
    DVT’s by two thirds
    Deaths in hospitals
    NewEnglandJournalofMedicine1999:
    Prophylaxis in acute medical illness can reduce:
    • Thromboembolism by 63%
    • 16. No increase in bleeding
    • 17. Long term mortality reduction
  • Major Risk Factors--- DVT/ PE
    Age over 40, especially over 70
    Previous DVT
    Prolonged bed rest/ immobilization
    Surgery
    Trauma-especially long bone fractures
    ICU
    Ventilator
    Acute spinal cord injury
    Smoking
    Medical Conditions:
    MI/ Heart failure
    Stroke
    Malignancy
    Hypercoagulable states
    Chronic lung disease
    Obesity
    Pregnancy
    Estrogen use
  • 18. VTE DemographicsMedical Opportunity Exceeds Surgical Opportunity
    Annual number at risk for VTE in US hospitals:
    7.7 million medical service inpatients1
    4.3 million surgical service inpatients 1
    Medical Patients:
    50%-70% of symptomatic VTEs 2
    70%-80% of fatal PEs4
    Anderson, Am J Hematol. 2007
    Geerts, Chest. 2008
  • 19. 38.3 x
    greater
    DVT/PE Risk
    2.8 X greater
    1.7 X greater
    LVEF >45%
    LVEF 20-44%
    The Medical Patient and VTE RiskHeart Failure
    LVEF <20%
    Howell, J Clin Epidemiol, 2001
  • 20. The Medical Patient and VTE RiskAcute Respiratory Disease
    The prevalence of thromboembolic disease in patients hospitalized for respiratory disease is estimated at 8%-25% 1
    COPD patients with DVT are older, more likely to be inpatients, more likely to be in the ICU and mechanically ventilated, and more often have concomitant PE 2
    Shetty, J Throm Thrombolysis. , 2008
    Fraisse, Am J Respir Crit Care Med., 2000
  • 21. The Medical Patient and VTE RiskCancer
    Cancer patients are at increased risk for VTE
    Cancer increases risk 4.1-fold
    Chemotherapy increases risk 6.5-fold
    Khorana, J Thromb Haemost. 2007
    Heit, Arch Intern Med. 2000
  • 22. The Medical Patient and VTE RiskCancer
    Khorana, Journ Thromb Haem, 2007
  • 23. Long Term Sequella of DVTNot just an isolated incident !!
    For patients with a single episode of DVT,
    In an 8 year follow-up:
    Subsequent DVT: 30%
    Post-Thrombotic Syndrome: 29%
    In a 10 year follow up:
    Subsequent DVT: 40%
    Prandoni, Ann Int Med, 1996
    Prandoni, Hematologica, 2007
  • 24. The Medical Patient and VTE RiskOther Acute Medical Illnesses
    Copyright SMB and Co.
  • 25. DVT/ PE Prophylaxis Reporting
    Agencies Upping the Ante !!
    2000 2001 2002 2003 2004 2005 2006 2007 2008 2
    009 2010 2011
    2000 2001 2002 2003 2004 2005 2006 2007 2008 2
    009 2010 2011
    2000 2001 2002 2003 2004 2005 2006 2007 2008 2
    0092010 2011
  • 26. DVT/ PE Prophylaxis Reporting
  • 27. Why are Core Measures so Important ?
    1. They are evidence-based. Implementing these practices will improveclinicaloutcomes
    2. Performance is tracked publicly
    3. Hospital (and perhaps physician) reimbursement is based upon performance
  • 28. DVT and Pulmonary Embolism
    Surf the Legal Websites
  • 29. Clinical
    Safety
    Regulatory
    The Right
    Thing !!
    Legal
    DVT Prophylaxis
    Experience
    Is the Problem of VTE Prophylaxis Significant ?
  • 30. VTE Prophylaxis Program Development
    DVT/ PE Prophylaxis Program
    A. Increase the awareness of DVT/ PE
    B. Identify and treat patients at risk
  • 31. VTE Prophylaxis Program Development
    A. Increase the awareness of DVT/ PE
    Get the leadership “On-Board”
    Communications/ education strategy
    Dissemination of ACCP treatment protocols
  • 34. 8th ACCP Guidelines for DVT Prophylaxis (2008)
  • 35. Conflicting Guidelines in the Role of Aspirin:8th ACCP Guidelines for DVT Prophylaxis (2008) 2006 AAOS Consensus Guidelines
    Evidence: Grade I A vs Grade III B
  • 36. Guidelines for Guidelines
    There will be MORE guidelines in clinical medicine
    Guidelines wereNEVERintended to apply to all patients and do NOT take the place of individual physician judgment
    Expect physicians to occasionally deviate from guidelines in the daily practice of prudent medical care
    When so…
    … DOCUMENTIn the medical recordthat:
    The patient was seen and evaluated
    The options were thoughtfully considered
    The best clinical judgment was used
    Discussed with the patient
  • 37. Adverse
    Outcomes
    Adverse
    Outcomes
    protocols
    Do Guidelines Help or Hurt?
    We keep missing the point…..
    Simply put…
    Protocols reduce adverse outcomes !
    Guidelines improve patient care !
  • 38. 100
    98
    96
    Intervention group
    Freedom From DVT or PE, %
    94
    92
    Control group
    90
    0
    30
    60
    90
    0
    Days
    Education is Not Enough—The Importance of Hardwiring
    Kucher , NEJM, 2005
  • 39. First: Risk Factor Assessment Tools
  • 40. Then: Nursing Risk Factor Profiler  Physician Order Sets
  • 41. For2010: Screening by Exclusion Criteria
  • 42. For2010: St. David’s HealthCareExclusion CriteriaSCIP-Compliant Order Sets
  • 43. Determine what outcomes should be tracked
    How have we done ??
    Measure the Results
    a. Incidence of Hospital-Acquired:
    DVT
    Pulmonary Embolism
    b. Cost Avoidance
  • 44. Incidence of Hospital-Acquired DVT and PE Total Cases and Cases Avoided
    Copyright SMB and Co.
  • 45. Moment of Truth !!
    All we really did was
    reproduce the literature…
    ….. 20 years later !!
  • 46. St. David’s HealthCare Cost for VTE Prophylaxis
    Heparin, LMWH, Fonduparinux for VTE Prophylaxis:
    Approximately $900,000 per year
    For seven years: $ 6,300,000
  • 47. PE
    $12,595
    DVT
    $9,337
    $9,643
    MI
    $6,367
    Stroke
    12500
    0
    5000
    10000
    2500
    7500
    Average Cost per Admission
    Cost Avoidance for DVT/ PE1.Average Cost per Admission
    Bick RL. Clin Appl Thrombosis/ Hemostasis 1999
  • 48. 7 Year Cost Avoidance
    Savings:
    $ 2,980,000
    PE
    $12,595
    $ 3,651,000
    $ 6,631,000
    DVT
    $9,337
    $9,643
    MI
    $6,367
    Stroke
    12000
    0
    5000
    10000
    2500
    7500
    Average Cost per Admission
    Costs trended at 7% per year
    Cost Avoidance for DVT/ PE 1.Average Cost per Admission
    Bick RL. Clin Appl Thrombosis/ Hemostasis 1999
  • 49. Cost Avoidance for DVT/ PE 2.Total IP/ OP Costs per Year
    MacDougall, Am J Health-System Pharm, 2006
  • 50. 7 Year Cost Avoidance Savings:
    $2,903,000
    $4,556,000
    $7,459,000
    Cost Avoidance for DVT/ PE 2.Total IP/ OP Costs per Year
    Costs trended at 7% per year
    MacDougall, Am J Health-System Pharm, 2006
  • 51. St. David’s HealthCare Cost for VTE ProphylaxisBalance Sheet
    Cost of Rx:$ 6,300,000
    Cost-Avoidance: $ 6,631,000
    Potential Cases Avoided: 380
  • 52. More than just the Cost of DrugsDVT Prophylaxis May Reduce the Overall Cost of Care
    Schumoch, Ann Pharm, 2005
  • 53. What is the Opportunity for Your Hospital ?A Simple Predictive Model
    Two things to measure:
    Annual Med-Surg Admissions
    Equals Total Admissions minus OB Admissions minus Peds Admissions
    Baseline % pharmaco-prophylaxis in Med-Surg patients
    Randomly pull 50 charts and determine the percentage of patients receiving prophylaxis
    Avoidable DVTs:
    = (90- Baseline %) X (Med-Surg Admissions) / 80,000
    Avoidable PEs:
    = (90- Baseline %) X (Med-Surg Admissions) / 145,000
    Copyright SMB and Co.
  • 54. Typical Example of a 250 Bed Hospital
    Copyright SMB and Co.
  • 55. DVT
    PE
    4. Honor the Data—Take it to the Next Level
    The Lessons Learned
  • 56. WhyBedRest??…. a DVT/ PE RedFlag
    • Eliminate the term
    • 57. Daily ambulation strategy
    • 58. Regular exercises-- Airlines
  • PICCLines…. Another DVT/ PE RedFlag
    Specialized PICC insertion teams
    • Patient assessment
    • 59. appropriateness
    • 60. site
    • 61. SiteRite ultrasound insertion
    • 62. verify vein size
    • 63. minimize insertion trauma
    • 64. Regular follow-up/ documentation
  • VaginalDeliveriesandC-Sections
    VTE is the leading cause of preventable maternal death
    C-Section Patients:
    Mechanical compression devices until ambulatory
    Chemoprophylaxis if other risk factors present
    New
  • 65. Full Course of Prophylaxis…Expanding our Horizon
    New
    73% of patients develop DVT in the out-patient setting
    Of those, 60% were hospitalized in past 3 months
    Of those, 67% had the event the first month
    Spencer, Arch Int Med 2007
  • 66. VTE Incidence After Hip and Knee ReplacementThe Risk Continues Well After the Hospital Discharge
    Sikorski, J Bone Joint Surg, 1981
    White, Arch Int Med, 1998
  • 67. The Duration of Prophylaxis Exceeds the Typical Length of Stay
  • 68. From Known Complication……
    To Known Complication
    NO !
    Chemoprophylaxis does not prevent VTE;
    It does eliminate 2/3 of all cases
    New
    Almost all VTE’s at
    St. David’s Healthcare now occur in patients
    who are alreadyreceiving chemoprophylaxis
  • 69. Why Wait?VTE Prophylaxis in the Emergency Department
  • 70. Continuous Improvement CycleNext Steps for 2010 and Beyond
    Clinical improvement focus areas:
    AComprehensivePreventionProgram
    Daily ambulation plan for all patients
    Prophylaxis initiated in the ED
    Screening for Exclusion Criteria
    Prophylaxis throughout the Continuum of Care
    New
  • 71. Infection Rates of Zero !Pipe Dream or Reality?National Healthcare Safety Network (NHSN) Report
  • 72. Change
    Perfection is unobtainable. But if we chase it,
    we can catch excellence.
    Vince Lombardi
    Change
    Change
  • 73. Change
    Change
    To the world you may be just one person,
    But to one person you may just be the world.Unknown
    Change
    Change

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