Venous Thromboembolism (VTE)

Southern New Hampshire Medical Center

Lynda Pittenger, RN, CPHQKathy Helberg, BSN,RN, CPHQ

188-bed community hospital located in Nashua, NH; part of SNHHS with multi-specialty group practice, Foundation Medical Partners.

• Level III Trauma Center• > 45,000 ED visits /year • > 5,500 surgeries / year• 24/7 Hospitalist program• Minimally invasive surgery

program with daVinci• 11 Bed ICU

• Angioplasty / STEMI • 2 MRI and 2 CT scanners• Magnet (re-designated 2011)• American College of Surgeons

– Cancer, Breast Center• Stroke Program- AHA/GWTG-

Gold + award

VTE Measures Tracked and Trended at SNHMC

Process Measures:VTE 1: % Inpatients with VTE

prevention in place day of or dayVTE 2: % ICU Inpatients with VTE

prevention in placeVTE 3: % VTE patients on coumadin

who received overlap therapyVTE 4: % VTE patients on heparin

and PTT monitored as per order set

VTE 5: % VTE patients received d/c instructions re: coumadin

Outcome Measure:VTE 6: % Patients who develop VTE

during hospitalization

Process Measures;SCIP VTE 1: % surgery patients with

recommended VTE prophylaxis ordered

SCIP VTE 2: % surgery patients who received appropriate VTE prophylaxis within 24 hours prior to surgery to 24 hours after surgery

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VTE Tools in Use at SNHMC

Prevention:• VTE Risk and Prevention Supplemental Order Set for admissions• Surgical Order Sets with built in mechanical /pharmacological

prevention• DVT prevention cue built into EMR to remind staff that if pt is not

ambulating, they are at risk.Treatment (for Dx of VTE):• Transitional Care Coordinators round on patients with VTE • Patient Education Information:

– DVT/ PE etiology, care, treatment and prevention– Coumadin Patient Education and Discharge Instruction– Nutrition Guidelines 4

Equipment Barriers

Inconsistent use of pneumatic compression stockings •Differing opinions by physicians on when to use recommendations - pneumatic + TEDs•Not enough equipment•Nurses concern with trip factor- may prevent patients from getting OOB. •Patient dissatisfaction - comfort

Solutions:Medical: Clarified order sets

to remove TEDs Surgical: Kept TEDs option on

order set and used in conjunction with SCD.

• Purchased more equipment• Promoted a healthy respect

for role of pneumatic compression stockings in VTE prevention– Memos, unit rounding

and staff education– Enhanced pre-op teaching

& expectations for patients

Medication Barriers

Variation in med use for chemoprophylaxis:

• Use of lovenox vs heparin for prevention– $$$$ difference– Daily vs. bid/tid dosing

• Physician concern with bleeding risk in peri op pts– Some surgeon hold outs– Hospitalists co-managing

“twitch”• NEW- anticoagulant for

arthroscopy-Rivaroxaban

Solutions:• Endorsed use of SQ heparin for

VTE prevention thru P&T

• Updated VTE evidence based order set

• Enhanced surgeon & hospitalist partnership

• Created a new order set in partnership with pharmacy

Medication Barriers cont.

Inconsistent use of post op surgical order sets – VTE anticoagulation prophylaxis during off-shifts / weekends.

Lack of clarity with overlap– CMS definition states

minimum 5 days and INR > than 2

– Physicians reluctant to continue overlap > 48-72H if INR > than 2

• Embedded VTE prompts in transfer orders from PACU to nursing units

Proposed Solution• Provide Physician education• Build cue into CPOE• Engage Transitional Care

Coordinators

SNHMC Performance Measures

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Quality Measures SNHMCQ4 2011

SNHMCQ1 2012

VTE 1: % Inpatients with VTE prevention100% 100%

VTE 2: % ICU Inpatients with VTE prevention 100% 100%

VTE 3: % VTE patients on coumadin who

received overlap therapy89% 91.6%

VTE 4: % VTE patients on heparin and PTT monitored as per order set 100% 100%

VTE 5: % VTE patients received d/c instructions re: coumadin 100% 90.9%

VTE 6: % Patients who develop VTE during hospitalization

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VTE 1&2: Sample PopulationVTE 3-6 All Cases

SNHMC SCIP Performance Measures

*Source: www.NHQualityCare.org - a partnership between the Foundation for Healthy Communitiesand the Northeast Health Care Quality Foundation Q310-Q211 (Composite does not include Card2 or Inf10)(National Average obtained from Hospital Quality Alliance Report)** Source: Northeast Health Care Quality Foundation - Qtr 4, 2011 (NHCQF Composite score includes the following: 1,2,3,4,6,9,10 VTE1&2, Card2)

Quality Measures SNHMCQ1

2012

SNHMC* 2011

SNHMC 2010

SNHMC 2009

NH*Q4 10- Q3 11

National*AverageQ4 10- Q3 11

National Benchmark(top 10% of

hospitalsQ1 11)

VTE 1- Recommended VTE Prophylaxis Ordered for Surgery Patients

96%

97%

91% 93% 98% 97% 99.9%

VTE 2 - Surgery Pts who Received Appropriate VTE Prophylaxis within 24 hrs Prior to Surgery to 24 hrs After Surgery

96%

97%

91% 92%

97% 96% 99.8%

What Can Others Learn From Our Journey?

• Engage a physician champion and form a multidisciplinary team

• Research best practice• Create evidence based tools - order sets and checklists• Test the tool- round, encourage feedback and make changes

– PDCA

• Roll out to a larger group• Implement and include 1:1 feedback • ROUND- to scan the environment for opportunities

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