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St. David's Prophylaxis Program
 

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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    St. David's Prophylaxis Program St. David's Prophylaxis Program Presentation Transcript

    • Going from a KNOWNcomplication….
      .... To KNOWN complication.
      NO
      VTE Prophylaxis Program2003 - 2010
      Copyright SMB and Co.
    • 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)
    • St. David’s-- A Community Hospital System
    • Our Greatest Challenge in Clinical Medicine
      Eliminate the “DEADLY” Delay !!
      Copyright SMB and Co.
    • 17 Years !!
      The Deadly Delay…From Clinical Trials to Clinical Practice…
    • 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 !!
    • Core Measures:
      Acute Myocardial Infarction
      Heart Failure
      Pneumonia
      Surgical Care Improvement
      HCAHPS
    • 1981- Beta-Blocker for Acute MI
      The Evidence is Published
    • Goal:
      100% Compliance !!
      Core Measures:
      Acute Myocardial Infarction
      Heart Failure
      Pneumonia
      Surgical Care Improvement
      HCAHPS
    • Standard of Care ? !!
      Core Measures:
      Acute Myocardial Infarction
      Heart Failure
      Pneumonia
      Surgical Care Improvement
      HCAHPS
    • 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....
    • 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!
    • Venous Thrombo-Embolic Disease
      DVT and Pulmonary Embolism
    • 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
    • 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%
      • No increase in bleeding
      • 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
    • 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
    • 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
    • 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
    • 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
    • The Medical Patient and VTE RiskCancer
      Khorana, Journ Thromb Haem, 2007
    • 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
    • The Medical Patient and VTE RiskOther Acute Medical Illnesses
      Copyright SMB and Co.
    • 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
    • DVT/ PE Prophylaxis Reporting
    • 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
    • DVT and Pulmonary Embolism
      Surf the Legal Websites
    • Clinical
      Safety
      Regulatory
      The Right
      Thing !!
      Legal
      DVT Prophylaxis
      Experience
      Is the Problem of VTE Prophylaxis Significant ?
    • VTE Prophylaxis Program Development
      DVT/ PE Prophylaxis Program
      A. Increase the awareness of DVT/ PE
      B. Identify and treat patients at risk
    • VTE Prophylaxis Program Development
      A. Increase the awareness of DVT/ PE
      Get the leadership “On-Board”
      Communications/ education strategy
      • Physicians
      • Nursing
      • Patients
      Dissemination of ACCP treatment protocols
    • 8th ACCP Guidelines for DVT Prophylaxis (2008)
    • 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
    • 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
    • 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 !
    • 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
    • First: Risk Factor Assessment Tools
    • Then: Nursing Risk Factor Profiler  Physician Order Sets
    • For2010: Screening by Exclusion Criteria
    • For2010: St. David’s HealthCareExclusion CriteriaSCIP-Compliant Order Sets
    • Determine what outcomes should be tracked
      How have we done ??
      Measure the Results
      a. Incidence of Hospital-Acquired:
      DVT
      Pulmonary Embolism
      b. Cost Avoidance
    • Incidence of Hospital-Acquired DVT and PE Total Cases and Cases Avoided
      Copyright SMB and Co.
    • Moment of Truth !!
      All we really did was
      reproduce the literature…
      ….. 20 years later !!
    • 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
    • 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
    • 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
    • Cost Avoidance for DVT/ PE 2.Total IP/ OP Costs per Year
      MacDougall, Am J Health-System Pharm, 2006
    • 7 Year Cost Avoidance Savings:
      $2,903,000
      $4,556,000
      $7,459,000
      Cost Avoidance for DVT/ PE 2.Total IP/ OP Costs per Year
      Costs trended at 7% per year
      MacDougall, Am J Health-System Pharm, 2006
    • St. David’s HealthCare Cost for VTE ProphylaxisBalance Sheet
      Cost of Rx:$ 6,300,000
      Cost-Avoidance: $ 6,631,000
      Potential Cases Avoided: 380
    • More than just the Cost of DrugsDVT Prophylaxis May Reduce the Overall Cost of Care
      Schumoch, Ann Pharm, 2005
    • 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.
    • Typical Example of a 250 Bed Hospital
      Copyright SMB and Co.
    • DVT
      PE
      4. Honor the Data—Take it to the Next Level
      The Lessons Learned
    • WhyBedRest??…. a DVT/ PE RedFlag
      • Eliminate the term
      • Daily ambulation strategy
      • Regular exercises-- Airlines
    • PICCLines…. Another DVT/ PE RedFlag
      Specialized PICC insertion teams
      • Patient assessment
      • appropriateness
      • site
      • SiteRite ultrasound insertion
      • verify vein size
      • minimize insertion trauma
      • 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
    • 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
    • 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
    • The Duration of Prophylaxis Exceeds the Typical Length of Stay
    • 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
    • Why Wait?VTE Prophylaxis in the Emergency Department
    • 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
    • Infection Rates of Zero !Pipe Dream or Reality?National Healthcare Safety Network (NHSN) Report
    • Change
      Perfection is unobtainable. But if we chase it,
      we can catch excellence.
      Vince Lombardi
      Change
      Change
    • Change
      Change
      To the world you may be just one person,
      But to one person you may just be the world.Unknown
      Change
      Change