St. David's Prophylaxis Program


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

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St. David's Prophylaxis Program

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