This project was carefully planned. It used a rigorous quality improvement process, involving all appropriate clinicians, nurses, managers, and technical support personnel.
Dr. Maynard and his team anticipated roadblocks and negotiated in advance to reduce their effects. They accepted that when patients are hospitalized, things frequently happen that cause physicians to stop VTE prophylaxis: A hemoglobin or platelet count may fall, the patient may have difficulty taking the drug, or the patient’s status may change abruptly. Or the prophylaxis might be accidentally discontinued—perhaps when a patient is transferred.
The team also looked at other institutions’ solutions. Then, using a basic understanding of the ways in which their process was missing VTE prophylaxis opportunities, they built interventions.
This team considered logistics carefully because it was clear that the only intervention that could decrease risk would have to be repetitive in nature. “The process we ultimately selected is very, very quick, yet valid,” says Dr. Maynard, while acknowledging that presenting any intervention repeatedly has the potential to interfere with care. “Other models require the physician to use math and add points. This one does not, and takes only seconds.”
Beginning April 19, 2006, the University of California, San Diego (UCSD) will introduce an intervention that presents a VTE risk assessment screen on every patient who is admitted. This process inquires about the need for prophylaxis every three days for the duration of hospitalization, and physicians cannot skip the screen. If risk factors are present and bleeding risk is not, the screen presents appropriate VTE options.
For example, the system will suggest enoxaparin 40 mg daily, enoxaparin 30 mg twice daily, or appropriately dosed warfarin for a high-risk orthopedic surgery patient who has no bleeding risk. Every three days, the process repeats itself, making explicit decisions or suggestions about appropriate prophylaxis. (Figure 1, below, shows a sample screen for a patient with moderately high risk.
Much evidence about VTE is still being gathered. For example, opinions vary about when to start prophylaxis or how long to continue it. Dr. Maynard and his team also addressed real versus relative contraindications—another area of debate among clinicians. Many clinicians are uncertain about how soon after surgery to restart VTE prophylaxis. After orthopedic spine surgery, for example, some might start it on day five, while others may not restart prophylaxis even after day 10. At UCSD, clinical stakeholders in the process came to consensus, and now all restart by day seven.
The tool kit UCSD is developing recognizes that every institution is unique. Those that choose to implement a similar program must identify their baseline rate of VTE and monitor change over time to determine if progress is being made. Every institution must define adequate VTE prophylaxis and tailor the tools appropriately.
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Figure 1: A Sample of UCSD’s Risk Assessment Screen
Wait? No Need
One compelling aspect of Dr. Maynard’s project is that some of UCSD’s VTE tools are already available on the SHM Web site in the “VTE Resource Room.” With or without AHRQ funding, UCSD planned to develop and implement a VTE awareness program. UCSD’s grant department provided the support Dr. Maynard and his colleagues needed to apply for the AHRQ funding, and Dr. Maynard says the funding they received helped UCSD “disseminate the program better and to carry it out with more rigor.”
UCSD worked with SHM to develop the tool kit. In return, SHM is providing and promoting the VTE tool kit at no charge to interested parties. Additionally, SHM recently received funding via an unrestricted sponsorship to create a mentored implementation project for the “VTE Resource Room.” Interested institutions will be mentored by UCSD staff who have experience with the tool kit.