HANYS’2010 Pinnacle Award for Quality and Patient Safety

Submission Template and Guidelines

Section I:

A. Contact information required for publication and feedback. Please type in white space only.

Required Information Complete below:

Full Name Maryann Demeo

RN, BSN, MPA

Assistant Vice President Quality and Resource Management

South Nassau Communities Hospital

One Healthy WayOceanside, NY 11572

516-632-3890

mdemeo@snch.org

Credentials

Title

Organization Name

Organization Address

Telephone

E-mail

B. Check applicable submission category:

[ ] System or multi-level entity [ x ] Large Hospital (> 100 mean daily patient census)[ ] Small Hospital or Outpatient Organization [ ] Division, Specialty, or Unit-based entity

C. Check if you are a Nassau-Suffolk Hospital Council (NSHC) member and would like this entry to also be submitted for the NSHC Annual Quality Award.

[ x ] Yes

Section II: See brochure for directions. This project narrative section should be (1) written and reviewed for potential publication, (2) must not include any facility-identifying information for the judges’ review, and (3) cannot exceed this one page format using just the white space section, single spaced, and11 pt. Times New Roman.

Information Required Please Complete in This Column

Name of Initiative

This section is between 25 and 30 words.

Redesigning Processes to Prevent Hospital Acquired Venous Thromboembolism (VTE)

Project Description(Narrative Summary)

This section is between 150 and 225 words, depending on use of space and bullets.

Nationally, pulmonary embolism (PE) resulting from deep vein thrombosis (DVT) is a leading cause of death for hospitalized patients. Many of these deaths can be prevented with the appropriate pharmacological prophylactic measures, facts which are well-publicized and supported by The Agency for Healthcare Research and Quality and The Joint Commission among others. Still, the national rate of appropriate VTE prophylaxis approaches only 40%. Our institutional incidence of VTE, as well as compliance with existing protocols, was reviewed. Standardizing protocol, simplifying the protocol order set, designing the order set’s integration into the clinician workflow and presentation of mandatory physician education regarding the problems associated with hospital-acquired VTE were all key to the project’s success. Data were collected during all of 2008 and 2009. The project began during 2008 and new protocols were fully implemented by July 2009. Prior to implementation, our rate of hospital-acquired VTE was 0.43 for 1,000 patient days. A rate of 0.35 for 1,000 patient days was achieved in the first six months after implementation. The percentage of appropriate prophylaxis was initially 66%, increasing to 86%, for the six months following implementation.

Outcomes Achieved Please use bullets A one-page Word document can

also be submitted containing one or more graphics.

• Increased physician awareness of the need for VTE prophylaxis in the majority of hospitalized patients as evidenced by:

• Percentage of patients receiving appropriate VTE prophylaxis was increased by 30%

• Incidence of hospital-acquired VTE declined by 18.6%

Lessons Learned Top three lessons learned utilizing

bullets.

This section is approximately 45 words when using bullets.

• “The simpler, the better” • For the program to be effective, hospital administration, clinical

leadership and the medical staff must be aligned and committed to the improvement initiative

• Physician compliance increases with ongoing education and awareness programs for medical staff

Section III: Additional supporting information cannot exceed two pages. Please do not include identifying information for judges’ review.

Information Required

Please Complete in This Column

Problem Statement The hospital identified several missed opportunities to provide appropriate prophylaxis to medical patients. The missed opportunities were found to be due to the lack of uniform level of knowledge about VTE prophylaxis, differing opinions regarding the standard of care and perceived additional work with form completion.

Aim-Goals Determine baseline measurements for the assessment of the incidence of hospital acquired venous thromboembolism (VTE) and assessment of appropriate VTE prophylaxisOnce baseline was determined, the following goals were set:• Design a protocol / form based upon best practice that includes exclusions, risk factors,

chemoprophylactic dosage options, renal dose adjustments and additional mechanical prophylaxis options for high risk patients, that is limited to one page and is simple and user-friendly.

• Select standard low-molecular-weight heparin; eliminate unfractionated heparin• Improve the percentage of patients receiving appropriate VTE prophylaxis by 25% in

the six months following the selected intervention implementation.• Reduce the rate of hospital-acquired VTE by 10% from the baseline rate of 0.43

hospital acquired VTE per 1000 patient days.Methodologies and Change Principles

The Performance Improvement Department identified an opportunity for improvement in the process for assuring appropriate VTE prophylaxis for our patients. Senior leadership was apprised of the data collection and findings and provided support and prioritization for this initiative. Two multidisciplinary teams (medical and surgical) were charged with evaluating the current processes for VTE prophylaxis. Each team was led by a physician team leader who the medical staff held in high regard and who had expertise in VTE prevention and prophylaxis. The teams utilized a modified failure mode and effects analysis approach to identify the possible reasons that the current VTE prophylaxis may be underutilized. Once the major issues were identified the team employed the P-D-M-A-I (plan, design, measure, assess, improve) methodology for the project. Baseline data were reviewed and the team developed measurable goals and metrics with accompanying timeframe of 12 to 18 months for project completion. Data regarding the incidence of VTE were run utilizing coded data in the Midas+ database on a monthly basis and were sorted by PE, upper and lower extremity DVT and VTE-present-on-admission vs. hospital-acquired. Performance Improvement staff reviewed all open available medical records for during one week in each quarter to assess for the appropriateness of risk identification and appropriate prophylaxis (approximately 250-300 records per quarter). Exclusion criteria included obstetrical, psychiatric and pediatric patients.The team conducted a literature search to identify best practices and identify existing protocols. The current process for VTE prophylaxis was analyzed and a new standardized one-page protocol/order form was drafted. Key clinical leaders were recruited to evaluate the protocol/order. In the prior protocol, physicians could select treatment with either unfractionated heparin, dalteparin or enoxaparin. Following literature research, the team revised the protocol and limited the prophylaxis to enoxaparin. The revised protocol was designed to be well-integrated into the clinician workflow and utilized for all admitted patients as well as allow for automatic re-assessment of VTE risk with condition changes or transfer orders. Mandatory physician education regarding the problems associated with hospital-acquired VTE was developed and presented. Ongoing evaluation and monitoring have shown continued improvement and achievement of goals.

Additional Outcomes Not

• Standardized chemoprophylaxis orders, combined with a risk assessment, increased physician compliance with appropriate ordering

Listed in Section II • There was increased surgical prophylaxis for patients with major abdominal surgery including administration of chemoprophylaxis 2 hours prior to the planned procedure

• Bleeding risk assessments became part of the surgical staff standards• Daily (or twice daily) administration of enoxaparin offered lower complication rates

than heparin given three times a day, and offered advantages for nursing time and effort.

Sustainability Strategies

• Scheduled medical staff educational meetings continue and staff are apprised of goal achievement.

• Data continues to be collected for both measures and reported to the Clinical Chairs• Individual physician re-education is provided in any area that does not meet

expectations• All new physicians have a complete orientation including all aspects of VTE

prophylaxis and requirementsBusiness Case Information

While there was an additional cost associated with the change from dalteparin and unfractionated heparin use to enoxaparin, the cost was balanced by the program’s impact. Each hospital-acquired DVT provides an incremental cost of $10,000 while each PE represents an additional cost of about $20,000. VTE prevention reduces length of stay and readmission as well as morbidity and mortality.

Conclusion, Recommendations, or Next Steps

In addition to maintaining the gain and continuing to improve our VTE prevention program, the initiative also includes the necessity of continued therapy for at risk patients during the post-hospital stage. As lengths of stay decrease, it is imperative to assure that clinicians prescribe continued anticoagulation prophylaxis for the recommended timeframes. Patient education regarding discharge medications, especially continued prophylaxis, is provided with full educational kits that are supplied by the pharmaceutical company. Case Managers, Social Workers and Home Health Care nurses have partnered with the physicians as well as local pharmacies to assure that patients have the necessary medications and resources to obtain those medications.

A one-page Word document containing one or more graphics can also be submitted.