“There was strong emotional buy-in from everyone on the team,” recalls Dr. Franko, “because almost everyone has a family member or friend who have had an experience with a blood clot.”
Dr. Franko and other members of the team proceeded to gather information on the rates of use and made projections for prophylaxis. They also reviewed the first attempt to increase use.
“We realized that it was necessary to make this a mandatory approach, or there would be no improvement whatsoever,” says Dr. Franko.
One possibility the team explored and then rejected was incorporating VTE prophylaxis with a patient’s admission. “When patients are admitted, we fill out a very thorough nursing assessment form,” explains Dr. Franko. “This is a good point to gather the information, but we decided it was just too cumbersome.”
The team decided on the inclusion of a form with each patient’s medical chart that would lead the nursing staff through simple questions to determine whether the person should receive VTE prophylaxis. (See “VTE Prophylaxis Assessment Form [Adult],” at right.) The default is prophylaxis. “This was a bold step,” says Dr. Franko. With the form, “your patients are going to get VTE prophylaxis unless you tell us not to give it to them.”
Creating the VTE Prophylaxis Assessment Form
The multidisciplinary team needed to build the form using basic, easy-to-understand information. They began by breaking down the hospital’s patient population to determine who most needed the VTE prophylaxis. They found four groups:
- All trauma patients;
- All patients in ICU;
- Anyone with a diagnosis of cancer; and
- Anyone with a history of cancer. (See step 1 on the “VTE Prophylaxis Assessment Form,” at right.)
They also agreed that patients over age 40 with one other risk factor, such as smoking or drinking, would be considered at risk for DVT. (See step 2 on the “VTE Prophylaxis Assessment Form,” at right.)
“That is a significant percentage of our patients,” Dr. Franko points out. Because the women’s and children’s hospital is separate, a full 87% of Carilion’s patients are over 40.
The team then worked on exclusion factors that would eliminate patients in these groups from receiving prophylaxis. They agreed that patients with any of these exclusion criteria would automatically not receive prophylaxis. (See step 4 on the “VTE Prophylaxis Assessment Form,” at right.)
“We really struggled with how to administer the VTE prophylaxis,” admits Dr. Franko. “It was projected at one point that if we put all at-risk patients on low-molecular-weight heparins, we would increase our pharmacy’s budget by $3 million.”
With a great deal of reliance on the American College of Chest Physicians (ACCP) guidelines for VTE prophylaxis, the charter team decided on three treatment categories: low-molecular-weight heparins (enoxaparin, specifically), unfractionated heparins, and sequential compression devices (SCDs). (See step 5 on the “VTE Prophylaxis Assessment Form,” at right.)
“We use a lot of SCDs on our trauma patients,” says Dr. Franko, “but we still had to order more.” After talking to the hospital’s vascular surgeons and other staff, the charter team decided on patients to exclude from medications, including amputees and those who’d had recent vascular surgery. (See step 6 on the “VTE Prophylaxis Assessment Form,” at right.)
If the form indicates that prophylaxis is necessary, then the last step in completing the form is to have a physician add a bright pink sticker with his or her initials and the date and time.
“The pharmacy will prescribe with only that sticker on the chart,” says Dr. Franko. “Patients can get treatment earlier rather than later.”