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Prevention of Venous Thromboembolism Surgical Care Improvement Project

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Prevention of Venous Thromboembolism Surgical Care Improvement Project Dale W. Bratzler, DO, MPH President and CEO Oklahoma Foundation for Medical Quality – PowerPoint PPT presentation

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Title: Prevention of Venous Thromboembolism Surgical Care Improvement Project


1
Prevention of Venous ThromboembolismSurgical
Care Improvement Project
Dale W. Bratzler, DO, MPH President and
CEO Oklahoma Foundation for Medical Quality
Dale W. Bratzler, DO, MPH QIOSC Medical Director
2
Why is there a need to measure the quality of
hospital care?
  • The passive strategy of guideline publication and
    dissemination does not effectively change
    clinical practice
  • The time lag between publication of evidence and
    incorporation into care at the bedside is very
    long
  • Variations in care and delivery of care that is
    not consistent with evidence-based
    recommendations is well documented

Bratzler DW. Development of national performance
measures on the prevention and treatment of
venous thromboembolism. J Thromb Thrombolysis.
2009 (in press)
3
Prevention of Venous Thromboembolism (VTE) an
example
  • The American College of Chest Physicians
    published their first consensus conference on
    antithrombotic therapy in 1986
  • In 2008 published their 8th edition of the
    evidence-based guideline
  • Despite all of these published editions..

VTE - the most common preventable cause of
hospital death - 2/3 of all cases occur in
recently hospitalized patients - up to 3/4 of
all cases of PE death are a result of
hospitalization
4
Prevention of Venous Thromboembolism an example
  • Multiple studies that have included hospital
    medical record audits show consistent underuse of
    VTE prophylaxis
  • Up to 2/3 of patients with hospital-acquired VTE
    did not receive prophylaxis
  • Audits of patients receiving treatment for
    confirmed VTE show non-compliance with
    guideline-recommended treatment

Bratzler DW. Development of national performance
measures on the prevention and treatment of
venous thromboembolism. J Thromb Thrombolysis.
2009 (in press)
5
  • The best estimates indicate that 350,000 to
    600,000 Americans each year suffer from DVT and
    PE, and that at least 100,000 deaths may be
    directly or indirectly related to these diseases.
    This is far too many, since many of these deaths
    can be avoided. Because the disease
    disproportionately affects older Americans, we
    can expect more suffering and more deaths in the
    future as our population agesunless we do
    something about it.

6
Risk Factors for DVT or PENested Case-Control
Study (n625 case-control pairs)
Surgery Trauma Inpatient Malignancy with
chemotherapy Malignancy without
chemotherapy Central venous catheter or
pacemaker Neurologic disease Superficial vein
thrombosis Varicose veins/age 45 yr Varicose
veins/age 60 yr Varicose veins/age 70 yr CHF, VTE
incidental on autopsy CHF, antemortem VTE/causal
for death Liver disease
0
5
10
15
20
25
50
Odds ratio
7
Risk Factors for VTE
Most hospitalized patients have at least one
additional risk factor for VTE
  • Surgery
  • Trauma
  • Immobility, paresis
  • Malignancy
  • Cancer therapy
  • hormonal therapy, chemotherapy or radiotherapy
  • Previous VTE
  • Increasing age
  • Pregnancy and post-partum period
  • Estrogen-containing oral contraception or HRT or
    SERM
  • Acute medical illness
  • Heart failure
  • Respiratory failure
  • Inflammatory bowel disease
  • Nephrotic syndrome
  • Myeloproliferative disorders
  • Obesity
  • Smoking
  • Varicose veins
  • Central venous catheterization
  • Inherited or acquired thrombophilia
  • Travel

Geerts W et al. Chest. 2004126338S-400S.
8
VTE Facts
  • Almost half of the outpatients with VTE had been
    recently hospitalized
  • Less than half of the recently hospitalized
    patients had received VTE prophylaxis during
    their hospitalizations
  • About half had a length of stay (LOS) of lt 4 days

Days After Discharge
0-29
30-59
60-90
70
60
50
40
Outpatients With VTE,
30
20
10
0
Hospitalization with Surgery
Medical Hospitalization Only
Goldhaber S. Arch Intern Med. 20071671451-2. Spe
ncer FA et al. Arch Intern Med.
2007167(14)1471-5.
9
Categories of Risk for Venous Thromboembolism in
Patients
  • Low risk
  • Minor surgery in mobile patients
  • Moderate risk
  • Most medically ill, general, open gyn or
    urologic surgery patients
  • High risk
  • Cancer surgery, hip or knee arthroplasty, hip
    fracture surgery, major trauma or spinal cord
    injury

Geerts W et al. Chest. 2008133381S-453S.
10
Mechanical Methods of VTE Prevention
  • Graduated Compression Stockings (GCS)
  • Intermittent Pneumatic Compression Devices (IPCs)
  • Venous Foot Pump (VFP)

11
Pharmacologic Options for VTE Prevention
  • Unfractionated Heparin (UFH)
  • Low-Molecular Weight Heparins (LMWHs)
  • Pentasaccharide (Fondaparinux)
  • Warfarin

12
Prophylaxis Against Fatal Post-Operative PE With
LDUH A Multicenter, Prospective, Randomized
Trial
  • Study population 4,121 patients age gt 40 y
    undergoing a variety of elective major surgical
    procedures

P lt 0.005
0.9
0.77
0.8
0.7
0.6
0.5
Patients with PE ()
0.4
0.3
0.2
0.097
0.1
0
Control (N 2,076)
UFH (N 2,045)
  • 5,000 IU SC 2 hours preoperatively and 8 hours
    thereafter for 7 days.

Kakkar VV et al. Lancet. 1975245-51.
13
Mechanical Thromboprophylaxis
  • For particularly high-risk surgery patients with
    multiple risk factors, pharmacologic method
    should be combined with mechanical method (GCS,
    IPC) (1C)
  • Use mechanical methods for patients with high
    bleeding risk (1A), when bleeding risk decreases
    substitute or add pharmacological
    thromboprophylaxis (1C)

Geerts WH et al. Chest. 2008133(6
Suppl)381S-453S.
14
Problems with Mechanical Prophylaxis
  • Non-compliance
  • 50 of med-surg floors
  • 80 in intensive care units
  • Most common reasons for non-compliance
  • 80 of the time, not on the patient
  • 20 of the time, on the patient but not turned on

15
VTE ProphylaxisGrade 1 Recommendations
Limited to those patients who have an anesthesia
duration of at least 60 minutes, and a hospital
stay of at least three calendar days (two nights
in the hospital).
Open surgical procedure gt 30 minutes requiring
in-hospital stay gt 24 hours postoperative.
16
VTE ProphylaxisGrade 1 Recommendations
17
VTE ProphylaxisGrade 1 Recommendations
Open surgical procedure gt 30 minutes requiring
in-hospital stay gt 24 hours postoperative.
18
Performance Measurement Does Not Happen without
Controversy
19
(No Transcript)
20
What else does the AAOS guideline say?
  • They do NOT recommend the use of aspirin alone
  • They recommend the use of mechanical prophylaxis
    started in the operating room or immediately
    postoperatively in all patients continued to
    discharge
  • They recommend pharmacologic prophylaxis with
    LMWH, factor Xa inhibitor, or warfarin in high
    risk patients
  • previous history of cancer, thromboembolism,
    hypercoagulable states such as polycythemia,
    spinal cord injury patients, multi-trauma
    patients, and genetic predisposition

21
VTE Prophylaxis
  • Other issues
  • Timing of prophylaxis
  • Neuraxial anesthesia
  • Renal insufficiency
  • Duration of prophylaxis

22
(No Transcript)
23
Venous ThromboembolismStatement of Organization
Policy
  • Every healthcare facility shall have a written
    policy appropriate for its scope, that is
    evidence-based and that drives continuous quality
    improvement related to VTE risk assessment,
    prophylaxis, diagnosis, and treatment.

24
Measure specifications available at
www.qualitynet.org
25
Electronic Submission of Performance Measures
  • In the recently published final IPPS rule for
    fiscal year 2010, CMS has announced that through
    an interagency agreement with the Office of the
    National Coordinator for Healthcare Information
    Technology, they are developing interoperable
    standards for electronic medical record
    submission of the newly-endorsed VTE measures.
    Vendors of electronic medical record systems
    would be able to code their systems with the new
    specifications by the end of 2009.

Centers for Medicare Medicaid Services.
Medicare Program Changes to the Hospital
Inpatient Prospective Payment Systems for Acute
Care Hospitals and Fiscal Year 2010 Rates and
Changes to the Long-Term Care Hospital
Prospective Payment System and Rate Years 2010
and 2009 Rates. Available at http//www.federalre
gister.gov/OFRUpload/OFRData/2009-18663_PI.pdf.
Accessed 10 August 2009.
26
Improving Use of VTE Prophylaxis
27
Strategies to Improve VTE Prophylaxis
  • Hospital policy of risk assessment or routine
    prophylaxis for all admitted patients
  • Most will have risk factors for VTE and should
    receive prophylaxis
  • Preprinted protocols for surgical patients

28
Electronic Alerts to Prevent VTE among
Hospitalized Patients
  • Hospital computer system identified patient VTE
    risk factors
  • RCT no physician alert vs physician alert

Control Alert group group
P No. 1,251 1,255 Any prophylaxis
15 34 lt0.001 VTE at 90 days
8.2 4.9 0.001 Major bleeding
1.5 1.5 NS
NNT 30
Kucher NEJM 2005352969
29
Improving Compliance with Treatment Protocols
  • Use of standardized protocols, nomograms,
    algorithms, or preprinted orders
  • Address overlap (either 5 days in hospital or
    discharge on overlap)
  • When used, UFH should be managed by
    nomogram/protocol, and the protocol should ensure
    routine platelet count monitoring

30
Essential Elements for Improvement
  • Institutional support
  • A multidisciplinary team or steering committee
  • Reliable data collection and performance tracking
  • Specific goals or aims
  • A proven QI framework
  • Protocols

SHM Resource Room. http//www.hospitalmedicine.org
. Accessed September 2009.
31
Maynard GA, et al. J Hosp Med 2009 Sep 14. Epub
ahead of print
32
Maynard GA, et al. J Hosp Med 2009 Sep 14. Epub
ahead of print
33
Maynard GA, et al. J Hosp Med 2009 Sep 14. Epub
ahead of print
34
Maynard GA, et al. J Hosp Med 2009 Sep 14. Epub
ahead of print
35
Attention to Transitions of Care
  • Ensure adequate training of the patient
  • Education on medications, diet, follow up
    appointments, lab monitoring, dietary
    precautions, and adverse reactions or drug-drug
    interactions
  • Education for family
  • Referral to anticoagulation clinic
  • Hospital abstractors must find explicit
    documentation of this training/education in the
    chart

36
Does public reporting accelerate quality
improvement?
37
Changes in National Performance Baseline to Q1,
2009
//
National sample of 19,497 Medicare patients
undergoing surgery in US hospitals during the
first quarter of 2005. (Bratzler, unpublished data
38
Hospital-acquired ConditionsBackground of the
Never Events
  • Deficit Reduction Act (DRA) of 2005 requires the
    Secretary of HHS to identify conditions that are
  • High cost or high volume (or both) and
  • Result in the assignment of a case to a DRG that
    has a higher payment when present as a secondary
    diagnosis and
  • Could reasonably have been prevented through the
    application of evidence-based guidelines.

39
Hospital-acquired Conditions
  • Deep vein thrombosis/pulmonary embolism
    following
  • Total knee replacement
  • Hip replacement

40
Conclusions
  • VTE remains a substantial health problem in the
    US
  • VTE prophylaxis remains underutilized
  • National performance measures will address both
    prophylaxis and treatment of VTE across broad
    hospital populations

41
dbratzler_at_ofmq.com
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