Objective ​Safer Healthcare Now!, a program of the Canadian Patient Safety Institute, invites you to participate in the Canadian VTE Audit, designed to establish a national perspective of VTE thromboprophylaxis rates and raise awareness of appropriate VTE prophylaxis. VTE is one of the most common and preventable complications of hospitalization and is a Required Organizational Practice (ROP) of Accreditation Canada. By participating in the national audit day you will be a part of a movement aimed at preventing deep vein thrombosis (DVT) and pulmonary embolism (PE) in hospital patients. Watch the recording: http://bit.ly/1wfinCE

1. NATIONAL VTE AUDIT CALL TO ACTION SEPTEMBER 10, 2014
Artemis Diamantouros, Bill Geerts & Virginia Flintoft
Gina Peck, Anne MacLaurin and Alex Titeu

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5. •
Why participate in the VTE audit?
•
What did we learn last year?
•
How to complete the audit
•
Instructions for getting and using your Data Collection Form
Agenda

6. 
Why participate in the VTE audit?

What did we learn last year?

How to complete the audit

Instructions for getting your Data Collection Form
Agenda

7. Bill Geerts, MD, FRCPC
Thromboembolism Specialist, Sunnybrook Health Sciences Centre
Professor of Medicine, University of Toronto
National lead, VTE Prevention, Safer Healthcare Now!
Why participate in the VTE audit?

8. Why participate in the VTE audit?
1. Because 60% of all venous thromboembolism (VTE) in the population is hospital-acquired

9. Burden of Hospital-Acquired VTE
Population of Canada, 2014
35,428,000
Annual VTE rate
35,428
1/1,000/yr
60%
Hospital-acquired VTE rate 21,300/year

10. Why participate in the VTE audit?
1.
Because 60% of all VTE in the population is hospital-acquired
2.
Because HA-VTE produces substantial patient harm

11. Harms of Hospital-Acquired VTE
•Symptomatic DVT, PE
•Fatal PE
•Prolonged hospital stay (or readmission)
•Harm of therapeutic anticoagulation
•Patient anxiety
•Costs of diagnosis and treatment
•Future consequences

12. Why participate in the VTE audit?
1.
Because 60% of all VTE in the population are hospital-acquired
2.
Because HA-VTE produces patient harm
3.
Because HA-VTE can be prevented (effectively, safely, inexpensively)

13. Why participate in the VTE audit?
4. Because comprehensive thromboprophylaxis programs are expected by Accreditation Canada and are expected by our PATIENTS

14. Why participate in the VTE audit?
4. Because comprehensive thromboprophylaxis programs are expected by Accreditation Canada and are expected by our PATIENTS 5. Because it is essential to measure our compliance with this safety standard of care

15. Thromboprophylaxis improves clinically-important outcomes:
4 examples
Why participate in the VTE audit?

16. QI improves Thromboprophylaxis
1
Maynard – J Hosp Med 2010;5:10
54% 67% 80% 90% 98%

17. QI efforts also reduce VTE
Maynard – J Hosp Med 2010;5:10
2005
P
Patients at risk
9,720
11,207
Appropriate prophylaxis
58%
98%
<0.001
Hospital-acquired VTE
131
92
<0.001
Preventable hospital- acquired VTE
44
7
<0.001
1
2

18. Thromboprophylaxis leads to Fewer Adverse Outcomes
Zeidan – Am J Hematol 2013;88:545
2.5%
1.1%
0%
0.5%
1.0%
1.5%
2.0%
2.5%
Symptomatic VTE
Preventable VTE
Clinical Events at 90 days
Major bleeding
0.7%
0%
0.3%
0.1%
Pre-intervention (N=1,000)
Post-intervention (N=942)
•
Medical patients at Johns Hopkins
2

19. •
QI project at King’s College Hospital launched in 2010 (aligned with national VTE program)
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Development of a local VTE Prevention Program
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Mandatory, documented VTE risk assessment
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VTE prophylaxis guidance
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Mandatory VTE education
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Identification of hospital-associated VTE
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Root cause analysis with targeted QI interventions
Effect of a VTE Prevention Program on Hospital-Assoc VTE
Roberts – Chest 2013;144:1276
3

20. Patients with a VTE Risk Assessment
Roberts – Chest 2013;144:1276
% of patients

21. •
QI project at King’s College Hospital, London, 2010-12
VTE Prevention Program Reduces Hospital-Associated VTE
2010-11
2011-12
p
VTE risk assessment
63% (38-88)
93% (90-97)
HA-VTE
Per 1,000 admissions
236
19.7/mo
1.5
189
15.8/mo
1.0
0.014
Potentially preventable HA-VTE
43%
32%
0.005
Roberts – Chest 2013;144:1276

22. •
All patients admitted to all 163 NHS trusts, 2010-12
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Mandatory reporting of use of the VTE risk tool
Use of the UK National VTE Risk Assessment Tool
Lester – Heart – 2013;99:1734
Rate of VTE risk assessments performed [IQR]
100%
0%
50%
July 2010
March 2012
51% [27,71]
93% [91,96]
4

23. •
All 4 million patients admitted to all 163 NHS hospital trusts >3 days, 2010-12
Hospital-Acquired Fatal VTE is Reduced in Adherent Hospitals
Lester – Heart – 2013;99:1734
Fatal VTE <90 days after hospital discharge
Rel Risk for hospitals with VTE risk assessment >90% vs <90%
All
0.85 [0.75-0.96; p=0.01]
Post-discharge
0.81 [0.67-0.79; p=0.03]
Achieving >90% VTE risk assessment is associated with significant lower VTE mortality

24. National VTE Mortality Data England
Year
VTE listed as
cause of death
2007
6,121
2008
6,170
2009
6,218
2010
6,282
2011
4,562
2012
4,668
From R. Arya - Office for National Statistics, 2013

25. •
Why participate in the VTE audit?
•
What did we learn last year?
•
How to complete the audit
•
Instructions for getting your Data Collection Form
Agenda

26. 2013 National VTE Audit RESULTS

27. •
Audit April, 2013
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118 centers, 4,667 patients, 9 provinces coast to coast
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General medical and general surgical patients
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Analyses conducted by CMT with data from Patient Safety Metrics (PS Metrics)
2013 VTE Audit Day

28. •
Overall, thromboprophylaxis use = 81%
- Very good (but with room for improvement)
Thromboprophylaxis Use

29. Appropriate Thromboprophylaxis - by Province (2013)
% of patients
100%
65%

30. Types of Thromboprophylaxis
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Thromboprophylaxis:
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LMWH 61%
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LMWH or LDH 90%
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Mechanical only 4%
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Variability:
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By Patient Group: Medical: LMWH 70% vs LDH 21% Surgical: LMWH 45% vs LDH 46%
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By province
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By region within provinces

31. •
Overall, 19% did not receive appropriate thromboprophylaxis
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Reasons:
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No thromboprophylaxis 70%
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Delay in start 9%
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Wrong dose 8%
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Modality varied from SHN recommendation 6%
Reasons for not using Thromboprophylaxis

32. Reasons for not using Thromboprophylaxis

33. •
Overall, 55% of patients had preprinted order sets
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Huge differences by province (13%  63%) and region
Order set use

34. Impact of Preprinted Order Sets
N=4,518
Order set used
Order set not used
91%
71%

35. 2014 National VTE Audit

36. •
Why participate in the VTE audit?
•
What did we learn last year?
•
How to complete the audit
•
Instructions for getting your Data Collection Form
Agenda

37. •
When?
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October 1 to 15, 2014*
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Purpose:
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Obtain a current estimate of national VTE prophylaxis rates
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Increase awareness of VTE prophylaxis
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Contribute to the first World Thrombosis Day on October 13, 2014
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Improve experience with the VTE Data Collection Tool and other tools available to support VTE
*Data collected up to Oct. 31st will be accepted
2014 Canadian VTE Audit

38. •
Your commitment:
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Approximately 60 minutes
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Your essential contribution:
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Helping to improve the delivery of safe and effective care for patients
Canadian VTE Audit 2014

39. •
The VTE audit will again focus on:
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Internal Medicine
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General Surgery
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Audit sample can be:
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Both Medical AND General Surgical patients (preferred option)
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OR, either Medical or Surgical patients
Patients include

40. •
At least 20 patients from each group (medical, surgical)
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4 options for determining audit sample:
1.
All eligible medical AND general surgical patients
2.
All eligible medical OR surgical patients
3.
A sample of eligible medical AND surgical patients (consecutive patients, random sample, 1 or more nursing units)
4.
A sample of eligible medical OR a sample of eligible surgical patients
Step 1: Identifying Audit Sample

41. •
Inclusion:
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Patients in hospital on Oct. 1 AND with an actual or expected LOS of more than 2 calendar days
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Patients admitted between Oct. 1-15* with an actual or expected LOS of more than 2 calendar days
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Exclusions:
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Patients in hospital >30 calendar days
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Patients receiving therapeutic doses of anticoagulants
*May extend to Oct. 31st if required
Eligibility Criteria

42. •
Internal Medicine:
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For example, patients admitted with:
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CHF, severe respiratory disease, or confined to bed with active cancer, previous VTE, sepsis, acute neurologic disease, inflammatory bowel disease
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General Surgical Patients:
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All general surgical patients are eligible if they meet the general criteria for eligibility
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Exclude Low risk surgical patients
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Non-major surgery and fully mobile and NO additional VTE risk factors
Eligibility Criteria

43. •
Collect data related to 4 questions:
1.
Were preprinted orders used on admission or after surgery?
2.
What type of thromboprophylaxis was used?
3.
Did the patient receive appropriate thromboprophylaxis?
4.
If no to Q3, why was recommended thromboprophylaxis not used?
Steps for conducting the audit

44. •
Direct Chart Audit!!
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Go to the patient care unit
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Determine patient eligibility
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Chart Review/MAR
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Report from pharmacy system
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Complete VTE data collection form
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More to come . . .
How will you collect the data?

45. 
Case 1: No VTE Prophylaxis was ordered
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Column 1: answer NO
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Column 2: select #12 “No Order”
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Column 3: select NO (no appropriate thromboprophylaxis)
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Column 4: select #1 “No Prophylaxis Ordered”
Reviewing the chart

46. 
Case 2: VTE Prophylaxis has been ordered for the patient
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Column 1: look at whether an order set was used to order the VTE prophylaxis
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Answer YES or NO in column 1
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Column 2: select the thromboprophylaxis ordered from the list of options
Reviewing the chart

47. 
Case 2: VTE Prophylaxis has been ordered for the patient
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Column 3: decide whether the VTE prophylaxis was appropriate for the patient
Reviewing the chart

48. NB: All patients included in the audit sample are eligible for thromboprophylaxis
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Prophylaxis is considered appropriate if:
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It was started within 24 hours (1 calendar day) of admission or after surgery
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Choice is according to evidence-based anticoagulant prophylaxis
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Mechanical thromboprophylaxis if anticoagulant is contraindicated – patient actively bleeding or at high risk of bleeding)
Determining appropriateness

49. 
Case 2: VTE Prophylaxis has been ordered for the patient
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Column 4: if you answered NO to column 3, choose the reason(s) why the order was not appropriate
Reviewing the chart

50. How to participate in the VTE Audit

51. 1.
Use your VTE form from last years VTE Audit www.patientsafetymetrics.ca
2.
Register for VTE audit day and we will create and email your data collection form http://www.saferhealthcarenow.ca/EN/events/other/VTEAudit/Pages/default.aspx
3.
Register for Patient Safety Metrics and create your own Data Collection Tool. www.patientsafetymetrics.ca
Refer to the detailed instructions for more information about each option. http://www.saferhealthcarenow.ca/EN/events/other/VTEAudit/Pages/default.aspx
3 options for getting your form
51

52. 52
How to Request a Data Collection (Audit) Form

53. Completing Audit Form Request

54. Patient Safety Metrics An Overview

55. Features:
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Cloud-based data collection and reporting tool
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User friendly and simple to navigate
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Accessible from website with login details
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Tracks >100 process and outcome measures over 14 interventions
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Provides real time reporting.
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Reduces burden of data collection, entry and analysis
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Capacity to customize measures and reports
Patient Safety Metrics

56. •
Data Collection Forms
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Patient-level data (de-identified) - daily
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Multiple data elements
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Print form  Collect data  Fax form
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Automatic roll-up to Measurement Worksheets
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Measurement Worksheets
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Aggregate data - monthly
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Numerator and Denominator
Worksheets vs Data Collection Forms

57. PS Metrics can be used to support:
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Small and Large Scale Improvement Initiatives
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Roll Up or Drill Down Reports [e.g. Unit Site  Program Corporation Region Province  Node  National]
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Produce automated run charts
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Reporting for accountability
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Possible to customize indicators to meet provincial, regional and local reporting needs
Potential applications of the system

58. Completing Audit Form - #1

59. Completing Audit Form - #1
Virginia Flintoft 416-946-8350, virginia.flintoft@utoronto.ca

60. Access to PS Metrics
60
https://psmetrics.utoronto.ca/metrics/login.aspx https://psmetrics.utoronto.ca/metrics/Login.aspx?language=french

61. •
Fax form in FINE RESOLUTION (setting on fax machine)
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Use Flat-bed Fax Machines – feeder faxes produce lines
•
Do not write or stamp on forms except where allowed
•
Incorrectly Filled HCP Bubbles(pen, pencil, but Sharpie is best)
Beware of Common Errors! 61

62. Thank you … Questions?
62

63. Poll
Sondage

64. Thank you!
For any questions, contact: Virginia Flintoft – 416-946-8350 Artemis Diamantouros– 416-480-6100 x3654 Email: artemis.diamantouros@sunnybrook.ca