Things You Can Do To Save Lives

VTE Prevention Program as a Comprehensive Toolkit

Effective agents can reduce the incidence of hospital-acquired venous thromboembolism (VTE) and pulmonary embolism (PE), but they are often underutilized, says Greg Maynard, MD, MS, chief of the division of Hospital Medicine at the University of California at San Diego (UCSD) Medical Center. At many centers, the utilization of appropriate pharmacologic prophylaxis ranges from about 20% to 30%.

When Dr. Maynard and his colleagues were funded by the Agency for Healthcare Research and Quality (AHRQ) to implement a VTE prevention program, the UCSD rate of those on adequate prophylaxis totaled just over 50%. But the definition of what is adequate in this regard is variable and, further, in most previous studies what had been defined as adequate was actually the administration of any prophylaxis.

“The core strategy of this program,” says Dr. Maynard, “is defining what adequate VTE prophylaxis is for all different patients in the hospital based on the VTE risk assessment tool. And our central tenet for the VTE toolkit and for UCSD, in general, is that to get to where you need to go, you need to assess every patient on admission and at a regularly scheduled basis” and that risk assessment “drives everything.”

If the patient is deemed very high risk, says Dr. Maynard, “they’ll be more likely to need low molecular weight heparin. If they are very low risk, they don’t need any pharmacologic prophylaxis. And there’s everybody in between.”

The VTE prevention toolkit provides the rationale and options for building this model of risk assessment, putting together a team, getting institutional buy-in, and identifying measurements that will tell whether you’re making a difference in this regard. It walks people through the process and presents the variables to decide which risk assessment model an institution will use.

“There are several models out there, but none of them have been prospectively validated,” says Dr. Maynard. “So each institution will have to decide which VTE risk assessment model is best for them, which one can be most easily integrated into the flow of work, who will perform the DVT risk assessment, and, after the determination of a patient’s DVT risk, the institution’s preferred best prophylactic choices for each level of DVT risk.

The UCSD results, even before the implementation of the main intervention (that is, a CPOE order set) was initiated, are impressive. “We started with about 50% of patients who were on adequate DVT prophylaxis, and with educational detailing and consensus building over more than a year, the number rose to over 70%.

“On day-one of CPOE order set implementation, we went from 70% to 95% adequate DVT prophylaxis,” he says. “After the center’s main intervention was implemented, the early data [now] suggest we’ll reach 95% adequate DVT prophylaxis.”

Future plans include a mentored collaborative project to implement VTE prevention program in 20 to 30 motivated institutions using this toolkit, expert mentoring, and conference call/e-mail support. Keep an eye on the SHM Web site for invitations to participate in the mentored VTE Prevention Collaborative Project. See the VTE Quality Improvement Resource Room at: www.hospitalmedicine.org/AM/Template.cfm?Section=Quality_Improvement_Resource_Rooms&Template=/CM/HTMLDisplay.cfm&ContentID=6312.—AS

Resources

• Runy LA. 25 things you can do to save lives now. Hospital and Health Networks, hospitalconnect.com. Accessible at: www.hhnmag.com/hhnmag/hospitalconnect/search/article.jsp?dcrpath=HHNMAG/PubsNewsArticle/data/backup/0504HHN_Cover_Story&domain=HHNMAG.
• Joint Commission for the Accreditation: www.jointcommission.org/
• 2006 JCAHO Critical Access Hospital and Hospital National Patient Safety Goals: www.jointcommission.org/AccreditationPrograms/Hospitals/NPSG/06_npsg_cah.htm.
• Institute for Healthcare Improvement: www.ihi.org/ihi.
• National Quality Forum: www.qualityforum.org/. NQF’s Safe Practices for Better Healthcare is available at www.qualityforum.org/txsafeexecsumm+order6-8-03PUBLIC.pdf.
• Dangerous/Unapproved Abbreviations. Stanford Hospitals and Clinics, Lucile Packard Children’s Hospital. Available at www.stanfordhospital.com/pdf/UnapprovedAbbreviations11-10-03.pdf.
• JCAHO Speak Up Initiatives (for involvement of patients and families): www.jointcommission.org/PatientSafety/SpeakUp/.
• Surgical Care Improvement Program (SCIP): www.medqic.org/scip/scip_ homepage.html.
• Safest in America Project: www.safestinamerica.org/.