reduing VTEs with hospitals

1. SQIL TEAM 1 – PRESENTATION 1
Care Process Model
VENOUS THROMBO – PROPHYLAXIS TO IP- PATIENTS
Team 1: Michelle Hunter
Peter
Hanouv
Ammad Tamimi
Molly
Zhen Wang,
Xin Whang
Mode:
Case Study
Team Meetings
Skype
What's App group

2. Rationale
The U.S. Story: VTE Is Highly Prevalent
• Estimated 260,000 cases of clinically recognized VTE
occur each year in patients hospitalized for acute care1
• PE is associated with high mortality rates2
and is
considered one of the most common preventable
cases of hospital death3
• DVT is associated with a high risk of recurrence and
post-thrombotic syndrome (PTS)4
• Effective thrombus prophylaxis is underutilized5
1. Anderson FA Jr et al. Arch Intern Med. 1991;151:933-8. 2 Goldhaber SZ et al. Lancet. 1999; 353:1386-9. 3
Clagett GP et al. Chest. 1995; 108(4 suppl):312S-334S. 4 Prandoni P et al. Haematologica. 1997; 82:423-8. 5
Geerts WH et al. Chest. 2008; 133(6 suppl):381S-453S.

3. Womens Hospital VTE Process Map for Protocol / Order Form
PharmacistAssignedNursePhysicianChargeNursePatient
Ensure supply of
Assessment Order
Form in nursing
station
Ensure the
Assessment Order
Form in medical
record file
Moderate /
High
Low
Chooses
Prophylaxis
Completes order
Signs
+
stamps
Processes order
Mechanical
Pharmaceutical
Administer
stockings or
pneumatic
compression
Photocopy order
and send to
Pharmacy
Dispense as per
inpatient policy
Assesses risk
within 8 hour (not
more than 24
hour)
Yes
No
Ambulate and
educate
Carry out
instruction
Yes
Yes
Yes
No
No
Yes
Return all
Forms to
patient file(s)
Keep copy of
Order Form
for data
collection
Is admitted to ward with
documents received from
admission office
Clinical
Pharmacist Input
Administer medication to
patient as per policy
A
Photocopy low risk
order form for data
collection
Reassess the
patient daily
Exhibit 1A – VTE Care Process Model

4. Sequence and relationship of steps in QI project aimed at reducing incidence of VTEs
(63%)
(27%)
A framework for
Quality Improvement
Evidence
Base
VTE Order
sheet
High reliability
QI Strategies
Step 4: Introduce VTE order sheet,
then augment with other high
reliability strategies
Step 5: Perfect QI strategies and
performance tracking through
cycles of PDSA
Step 1: Draft a VTE
protocol using best
available evidence
Step 2: Analyze Care
Delivery
Step 3: Set up
performance
tracking
Care Delivery
Care Delivery Care Delivery
Performance Tracking
A VTE order sheet offers decision support
for risk stratification and a menu for of
appropriate prophylaxis options for each
level of risk
Key Metrics# 1% of patients
risk assessed for VTE

5. Framework for improvement
• Multidisciplinary team
• Identify current practice
• Describe best practices
• Formulate protocol
• Operationalize protocol (order set, checklist,
multifaceted approach, etc.)
• Measurement system – monitor and adjust
• Account for special patients and situations
• Gain institutional support - make compelling case
Discuss how you would implement the CPM?

6. • Knowledge gaps
• False beliefs
– VTE strikes infrequently
– VTE incidence is declining
• Lack of familiarity with guidelines
• Guidelines not always in agreement
for certain patient groups
• Concerns about adverse effects and
patient safety
What challenges
would you anticipate
Order Sheet

7. VTE Prevention Strategies & Predicted Success
High Reliability
Redundant, Real-time
Interventions >95%
Reinforced (audits and
education) 70%-90%
Simple, integrated with work
flow 60%-85%
Protocol exists 50%
Audit
Feedback
State of Nature
Data
Alert the
users
Educate the masses
Link the protocol to orders
Develop and implement a
protocol
Assimilate a Consensus Building
Team
40%-50%
PDCA
Maynard G, Stein J. Agency for Healthcare Research and Quality. August 2008.
How would you overcome these?

8. All patients screened and considered
for VTE prophylaxis
Risk factor assessment
Prophylaxis management
Exclusion criteria
Does the patient have restricted mobility and
at least 1 VTE risk factor present?
Pharmacological prophylaxis for VTE indicated
Are exclusion criteria for pharmacological
prophylaxis present?
Yes
No
Yes
Yes
Patient should be
reassessed daily for
development of VTE
risk factors during
hospitalization
VTE risk factors develop
during hospitalization
Mechanical measures
indicated (IPC)
IPC = intermittent pneumatic compression.

9. What metrics would you use to
track success of the CPM?
• Measure Name: VTE Risk Assessment /VTE 1
• Description:
– The number of patients who received VTE risk assessment with in 24 hours of admission
• Measure Name: VTE Prophylaxis /VTE 2
• Description:
– The number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis
was given the day of or the day after hospital admission
• Or surgery end date for surgeries that start the day of or the day after hospital admission
– Not applicable if patient refuses therapy
• Measure Name: VTE with in 30 days of surgery /VTE 3
• Description:
- The number of patients diagnosed with confirmed VTE during hospitalization (not present at
admission) who did not receive VTE prophylaxis between hospital admission and the day before the VTE
diagnostic testing order date.

10. What alternative approaches/modifications
might you anticipate
• Standardize VTE and anticoagulant risk
assessment into the process of admission and
transfers
• “Prompts for VTE risk assessment at point-of-
care
• Scheduled reassessments
• Redundant responsibility and prompts

11. Patient admitted to hospital
MD orders appropriate VTE
prophylaxis at admission
Nurse ensures VTE prophylaxis
administered
Change in patient’s VTE risk level,
contraindications, or site/unit of
care
Patient discharged
35% of
failures
20% of
failures

12. VTE prophylaxis can be
complicated!
Patient admitted to hospital
MD orders appropriate VTE
prophylaxis at admission
Nurse ensures VTE prophylaxis
administered
Change in patient’s VTE risk level,
contraindications, or site/unit of
care
Patient discharged
Pharmacy dispenses and delivers drug
MD performs VTE risk
assessment
MD links patient’s VTE
risk level to menu of
appropriate VTE
prophylaxis options
Support staff ambulates patient 3X/day
Central Supply delivers sequential compression
devices or graduated compression stockings
Analyze Care Delivery: Delivering Appropriate VTE Prophylaxis
35% of failures 30% of failures
15% of failures
20% of failures
Mean Baseline Performance: 50%
(% of patients on appropriate VTE
prophylaxis in the hospital)
Maynard G, Stein J. Agency for Healthcare Research and Quality.
August 2008.