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  • Venous Thromboembolism (VTE) Prevention in the Hospital

    Greg Maynard MD, MScClinical Professor of Medicine and Chief,Division of Hospital MedicineUniversity of California, San Diego

  • VTE: A Major Source of Mortality and Morbidity350,000 to 650,000 with VTE per year100,000 to > 200,000 deaths per year Most are hospital related. VTE is primary cause of fatality in half- More than HIV, MVAs, Breast CA combinedEquals 1 jumbo jet crash / day 10% of hospital deathsMay be the #1 preventable causeHuge costs and morbidity (recurrence, post-thrombotic syndrome, chronic PAH)Surgeon Generals Call to Action to Prevent DVT and PE 2008 DHHS

  • Risk Factors for VTEStasisAge > 40ImmobilityCHFStrokeParalysisSpinal Cord injuryHyperviscosityPolycythemiaSevere COPDAnesthesiaObesityVaricose VeinsHypercoagulability CancerHigh estrogen statesInflammatory BowelNephrotic SyndromeSepsisSmokingPregnancyThrombophilia

    Endothelial DamageSurgeryPrior VTECentral linesTrauma

    Anderson FA Jr. & Wheeler HB. Clin Chest Med 1995;16:235.

  • Risk Factors for VTEStasisAge > 40ImmobilityCHFStrokeParalysisSpinal Cord injuryHyperviscosityPolycythemiaSevere COPDAnesthesiaObesityVaricose VeinsHypercoagulability CancerHigh estrogen statesInflammatory BowelNephrotic SyndromeSepsisSmokingPregnancyThrombophilia

    Endothelial DamageSurgeryPrior VTECentral linesTrauma

    Anderson FA Jr. & Wheeler HB. Clin Chest Med 1995;16:235. Bick RL & Kaplan H. Med Clin North Am 1998;82:409.Most hospitalized patients have at least one risk factor for VTE

  • Failure to Do Simple Things WellWash Hands 60% Reliable Patients Understand Meds / Problems40% ReliableCentral Lines Placed w/ Proper Technique60% ReliableBasal Insulin for Inpt Uncontrolled DM40% ReliableVTE Prophylaxis50% Reliable

  • Registry DataHighlight the Underuse of Thromboprophylaxis

    Goldhaber SZ, Tapson VF. Am J Cardiol 2004;93:259-62.Monreal M, et al. J Thromb Haemost 2004;2:1892-8.Tapson V, et al. Blood 2004;104:11. Abstract #1762.

  • Endorse ResultsOut of ~70,000 patients in 358 hospitals, appropriate prophylaxis was administered in:58.5% of surgical patients39.5% of medical patientsCohen, Tapson, Bergmann, et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet 2008; 371: 38794.

  • The Stick is coming.NQF endorses measures already

    Public reporting and TJC measures coming soon:Prophylaxis in place within 24 hours of admit or risk assessment / contraindication justifying its absenceSame for critical care unit admit / transfersTrack preventable VTE

    CMS DVT or PE with knee or hip replacement reimbursed as though complication had not occurred.

  • Why dont we do better? Lack of awareness or buy in of guidelinesUnderestimation of clot risk, overestimation of bleeding riskLack of validated risk assessment model Translating complicated guidelines into everyday practice is difficult

  • E-Alerts Can Increase Prophylaxis2506 hospitalized patientsVTE risk score 4Randomized to intervention or controlKucher N, et al. N Engl J Med. 2005;352:969-977.

    InterventionTreatment ReceivedMechanical, %Pharmacologic, %E-Alert1023.6Control1.513P-value0.0010.001

  • InterventionControl Time (days)0306090% Freedom from DVT/ PE9092949698100E-Alerts Decrease VTE Kucher N, et al. N Engl J Med. 2005;352:969-977.InterventionControlNumber at risk1255977900125197689383985341%P = 0.001

  • Effectiveness can wane over timeLecumberri R, et al. Thromb Haemost. 2008;100:699-704.*P < 0.05*

  • Human Alerts Increase Prophylaxis2493 hospitalized patientsVTE risk score 4Randomized to intervention or controlPiazza G, et al. Circulation. 2009;119:2196-2201.

    InterventionTreatment ReceivedMechanical, %Pharmacologic, %Hu-Alert2128Control81495% CI10.6-16.010.5-16.8

  • % Freedom from DVT/ PEHuman Alerts Decrease VTETime After Initial Enrollment (days)P = 0.31Piazza G, et al. Circulation. 2009;119:2196-2201.

  • Bottom Line - AlertsA Useful StrategyE Alerts and Human Alerts can workNot a panaceaAlert fatigue can be a problem

    Need a multifaceted approach

  • Medical Admission Order Sets Can Improve DVT ProphylaxisBaseline- Only 11% of inpatients on any VTE prophylaxis

    Intervention A simple prompt for UFH or Mechanical Prophylaxis placed into voluntary admission order sets.

    Post intervention:44% on any prophylaxis26% pharmacologic prophylaxisO'Connor C, Adhikari N, DeCaire K, Friedrich Jan. Medical Admission Order Sets to Improve Deep Vein Thrombosis Prophylaxis Rates and Other Outcomes. J Hosp Med 2009

  • but not enough by themselves, and design of the order set mattersBest practice prophylaxis not defined Prompt Protocol No protocol = No guidance at the point of carein order set, heparin, mechanical devices, and no prophylaxis presented as equal choicesImplementation / ReliabilityAt 15 months, only about half of inpatient admissions utilized standardized order set. Other methods needed to enhance performance!

  • Education alone is not sufficient

    .but it is essential to optimize other strategies that are effective

    Standardized order setsComputerized decision supportE-alertsHuman alertsRaising situational awarenessAudit and feedback

  • *BaselineConsensus buildingOrder Set Implementation & AdjustmentReal time ID & interventionN = 2,944 mean 82 audits / month UCSD experience

  • UCSD VTE Protocol ValidatedEasy to use, on direct observation a few secondsInter-observer agreement 150 patients, 5 observers- Kappa 0.8 and 0.9Predictive of VTE Implementation = high levels of VTE prophylaxisFrom 50% to sustained 98% adequate prophylaxisRates determined by over 2,900 random sample auditsSafe no discernible increase in HIT or bleedingEffective 40% reduction in HA VTE86% reduction in risk of preventable VTE

  • *

    Chart2

    552113

    810110

    831113

    44008

    32005

    11002

    23005

    15006

    02002

    Medicine

    Surgery

    Ortho

    Other

    Total

    Quarter

    # of Patients

    UCSD - Decrease in Patients with Preventable HA VTE

    Audits

    UCSD - Percentage of Patients on Adequate VTE Prophylaxis by Service

    200520062007

    Q 1 '05Q2 '05Q3 '05Q4 '05Q1'06Q2 '06Q3 '06Q4 '06Q1 '07

    Medicine544860716482859292

    Surgery545562717577768088

    Ortho6355596064887194100

    Other5350544075704581100

    Overall

    Audits

    Medicine

    Surgery

    Ortho

    Other

    Quarter

    % Adequate Prophylaxis

    UCSD - % Adequate VTE Prophylaxis

    Cases

    MedicineSurgeryOrthoOther

    Q1 '05Pt w/ VTE1616

    Pt w/ HA VTE813

    Pt w/ prevent.HA VTE55Preventable HA VTE

    % Preventable63

    Q2 '05Pt w/ VTE3513Q 1 '05Q2 '05Q3 '05Q4 '05Q1'06Q2 '06Q3 '06Q4 '06Q1 '07

    Pt w/ HA VTE1610Medicine588431210

    Pt w/ prevent.HA VTE81Surgery513421352

    % Preventable50Ortho201000000

    Q3 '05Pt w/ VTE3329Other111000000

    Pt w/ HA VTE1422Total131013852562

    Pt w/ prevent.HA VTE83

    % Preventable

    Q4 '05Pt w/ VTE2220

    Pt w/ HA VTE1316

    Pt w/ prevent.HA VTE44

    % Preventable

    Q1 '06Pt w/ VTE3118

    Pt w/ HA VTE1417

    Pt w/ prevent.HA VTE32

    % Preventable

    Q2 '06Pt w/ VTE2217

    Pt w/ HA VTE715

    Pt w/ prevent.HA VTE11

    % Preventable

    Q3 '06Pt w/ VTE3332

    Pt w/ HA VTE1630

    Pt w/ prevent.HA VTE23

    % Preventable

    Q4 '06Pt w/ VTE3538

    Pt w/ HA VTE1433

    Pt w/ prevent.HA VTE15

    % Preventable

    Q1 '07Pt w/ VTE1512

    Pt w/ HA VTE412

    Pt w/ prevent.HA VTE02

    % Preventable

    MedicineSurgeryOrthoOther

    Pt w/ VTEPt w/ HA VTEPt w/ prevent.HA VTEPt w/ VTEPt w/ HA VTEPt w/ prevent.HA VTEPt w/ VTEPt w/ HA VTEPt w/ prevent.HA VTEPt w/ VTEPt w/ HA VTEPt w/ prevent.HA VTE

    2005106512578611398377123

    200612151710595116404940

    Q1 2007154012210001810

    Cases

    Medicine

    Surgery

    Ortho

    Other

    Total

    Quarter

    # of Patients

    UCSD - Decrease in Patients with Preventable HA VTE

    Sheet3

  • Dr. Maynard, the CIs are different here and in the proof. Which are correct?Maynard GA, et al. J Hosp Med. 2009; Hospital Acquired VTE by Year200520062007Patients at Risk9,7209,92311,207Cases w/ any VTE13113892Risk for HA VTE1 in 761 in 731 in 122Unadjusted RR1.01.030.61# (95% CI)(0.81-1.31)(0.47- 0.79)Cases with PE212215Risk for PE1 in 4631 in 4511 in 747Unadjusted RR 1.01.020.62 (95% CI)(0.54-1.86)(0.32-1.20)Cases with DVT (and no PE)11011677Risk for DVT1 in 881 in 851 in 146Unadjusted RR 1.01.030.61* (95% CI)(0.80-1.33)(0.45-0.81)Cases w/ Preventable VTE44217Risk for Preventable VTE1 in 2211 in 4731 in 1,601Unadjusted RR 1.00.47#0.14*(95% CI)(0.28-0.79)(0.06-0.31)# p < 0.01 *p < 0.00120088012686

  • VTE Prevention Guides Modeling a Multifaceted Approachhttp://ahrq.hhs.gov/qual/vtguide/http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_VTE/VTE_Home.cfm

  • VTE QI Resource Room www.hospitalmedicine.org

  • Collaborative EffortsSHM VTE Prevention Collaborative I - 25 sitesSHM / VA Pilot Group - 6 sitesSHM / Cerner Pilot Group 6 sitesAHRQ / QIO (NY, IL, IA) - 60 sitesIHI Expedition for VTE Prevention 60 sites

    Effective across wide variety of settingsPaper and Computerized / Electronic Small and large institutionsAcademic and community

  • Basic Ingredients for Success

    Institutional support, will to standardize the process Designated multidisciplinary team with physician leadershipSpecific go