SHM Launching VTE Reduction Collaborative

Hospitals that have been lagging on prevention of venous thromboembolism (VTE) might find themselves increasingly at risk for lower reimbursement or downgrades in quality ratings, but a new Society of Hospital Medicine (SHM) program may help some facilities start measuring up.

The Joint Commission is close to implementing a set of VTE measures looking at whether prophylaxis is in place within 24 hours of admission. The Centers for Medicare and Medicaid Services already refuses to pay for any VTE incurred as a complication of hip or knee replacement.

But these sticks have not been huge motivating factors for facilities when it comes to VTE, said Dr. Gregory A. Maynard, chief of the division of hospital medicine at the University of California, San Diego.

The biggest hurdle still seems to be the lack of physician awareness about which populations are vulnerable, said Dr. Maynard, who has been involved in collaboratives backed by the Institute for Healthcare Improvement (IHI) and the Agency for Healthcare Research and Quality (AHRQ). That’s partly because while these events are common, an individual physician might not have many VTEs in his or her own practice, he said.

Dr. Maynard has been a key architect of the SHM’s efforts to help hospitalists improve VTE prevention. The VTE Prevention Collaborative, which launches in September, is supported in part by Sanofi-Aventis U.S. Participants will have access to a toolkit, resources, and individualized mentoring and support, as part of the program developed by Dr. Maynard and Dr. Jason Stein, director of the Clinical Research Program for the section of hospital medicine at Emory University, Atlanta.

According to Dr. Maynard, nearly every hospitalized patient is at risk for VTE, which includes deep vein thrombosis (DVT) and pulmonary embolism (PE). Most patients have four to six risk factors, he said. The three big risk categories are stasis (related to age greater than 40 years, immobility, anesthesia, obesity, stroke, or heart failure), hypercoagulability (associated with cancer, sepsis, smoking, and pregnancy), and endothelial damage (surgery, central lines, trauma, or prior VTE).

PE is the cause of death in more than 100,000 hospitalized patients each year, and a contributing factor in the death of 100,000 additional inpatients annually, the SHM estimates.

And yet, studies have found that only about 30%-50% of inpatients are given appropriate prophylaxis – this, despite the availability of guidelines and protocols that make the process more efficient, and of effective pharmacologic agents. The ENDORSE trial, for instance, found that among 70,000 inpatients, only 59% of surgical patients and 40% of medical patients were given appropriate prophylaxis (Lancet 2008;371:387-94).

At UCSD, Dr. Maynard and Dr. Stein (who was previously at UCSD) leveraged an AHRQ grant to build a protocol for VTE prevention. It was designed with the aim that it would be universally applicable to any and all hospitalist programs, he said. The protocol increased prophylaxis rates from 50% of patients in 2005 to 98% in 2007 at UCSD (J. Hospital Medicine 2010;5:10-8).

Essentially, it was a simple model that stratified patients into low-, moderate- and high-risk categories. Almost no patients fall into the low-risk category; most are classified as moderate risk, Dr. Maynard said.

The risk assessment can be completed by a physician in seconds and can be done either on paper or as part of an electronic health record. Once determined, the risk level is linked to a menu of prophylaxis options, either in chart form, on paper, or electronically. Importantly, these options very specifically say which pharmacologic agents, and at what dose, are most appropriate for the patient, given their risk and taking into account other factors. The protocol also recommends that mechanical prophylaxis only be used as an adjunct, not as a first-line therapy.

To ensure the protocol was followed, Dr. Maynard and Dr. Stein created a method they dubbed “Measure-vention” – that is, the prophylaxis is monitored on a real-time basis and the intervention is done in real time, as well. The program also automatically collects data that can be used for quality improvement.

If a patient is indicated to need prophylaxis but is not identified as having received it on the medication record, the nurse or pharmacist receives an automated note. They in turn notify the physician via text message or page. About half the time, the physician changes the order, and the rest of the time, there is a valid reason for no prevention – or the physician simply does not want to be told what to do, Dr. Maynard observed.

At Emory, the Measure-vention strategy was adopted in 2009 as the final piece of the VTE prevention program, which started in 2006. Patients are color coded on a “dashboard” that is refreshed hourly. Red means no prophylaxis ordered, yellow means mechanical only has been ordered, and green means the patient is receiving a pharmacologic agent.

Six months after it was implemented, the dashboard helped pull prophylaxis rates above 90% in the 15 inpatient units at Emory University Hospital that were using the strategy, triple the rate before the dashboard, Dr. Stein said.

A year after starting the real-time monitoring in 2008, one 20-bed intensive care unit had a 75% reduction in potentially preventable hospital-acquired VTE, “attributable to a similarly significant rise in VTE prophylaxis from 73% to 94%,” he said.

There were nine fewer clots in that unit, which “represents real morbidity prevention and real cost savings, and very possibly represents preventable deaths from pulmonary embolism,” he said.

The implementation of the dashboard – which is now available to nurses and physicians at five Emory hospitals – has created new channels of communication between clinical and information services and contributed to an increased sense of pride in frontline nurses and clinicians, Dr. Stein observed.

“Ultimately, we’ve developed a new mindset for how performance is measured and improved at Emory,” he said.

Emory was recognized at the SHM annual meeting in April with an Excellence in Teamwork in Quality Improvement Award.

SHM hopes that other facilities can replicate the Emory experience. It has enrolled 80 facilities in the Prevention Collaborative.

Dr. Maynard said that awareness may also increase throughout the Department of Veterans Affairs, which initially had six hospitals take part in a pilot that he and Dr. Stein helped launch. Now, “many, many sites in the VA” are using the VTE prevention toolkit, he said.

The IHI and AHRQ also have enrolled dozens of hospitals in collaborations to reduce VTE.

VTE prophylaxis has been “suboptimal for a long time,” said Dr. Maynard. But, “it’s getting there.”

Hospitals that have been lagging on prevention of venous thromboembolism (VTE) might find themselves increasingly at risk for lower reimbursement or downgrades in quality ratings, but a new Society of Hospital Medicine (SHM) program may help some facilities start measuring up.

The Joint Commission is close to implementing a set of VTE measures looking at whether prophylaxis is in place within 24 hours of admission. The Centers for Medicare and Medicaid Services already refuses to pay for any VTE incurred as a complication of hip or knee replacement.

But these sticks have not been huge motivating factors for facilities when it comes to VTE, said Dr. Gregory A. Maynard, chief of the division of hospital medicine at the University of California, San Diego.

The biggest hurdle still seems to be the lack of physician awareness about which populations are vulnerable, said Dr. Maynard, who has been involved in collaboratives backed by the Institute for Healthcare Improvement (IHI) and the Agency for Healthcare Research and Quality (AHRQ). That’s partly because while these events are common, an individual physician might not have many VTEs in his or her own practice, he said.

Dr. Maynard has been a key architect of the SHM’s efforts to help hospitalists improve VTE prevention. The VTE Prevention Collaborative, which launches in September, is supported in part by Sanofi-Aventis U.S. Participants will have access to a toolkit, resources, and individualized mentoring and support, as part of the program developed by Dr. Maynard and Dr. Jason Stein, director of the Clinical Research Program for the section of hospital medicine at Emory University, Atlanta.

According to Dr. Maynard, nearly every hospitalized patient is at risk for VTE, which includes deep vein thrombosis (DVT) and pulmonary embolism (PE). Most patients have four to six risk factors, he said. The three big risk categories are stasis (related to age greater than 40 years, immobility, anesthesia, obesity, stroke, or heart failure), hypercoagulability (associated with cancer, sepsis, smoking, and pregnancy), and endothelial damage (surgery, central lines, trauma, or prior VTE).

PE is the cause of death in more than 100,000 hospitalized patients each year, and a contributing factor in the death of 100,000 additional inpatients annually, the SHM estimates.

And yet, studies have found that only about 30%-50% of inpatients are given appropriate prophylaxis – this, despite the availability of guidelines and protocols that make the process more efficient, and of effective pharmacologic agents. The ENDORSE trial, for instance, found that among 70,000 inpatients, only 59% of surgical patients and 40% of medical patients were given appropriate prophylaxis (Lancet 2008;371:387-94).

At UCSD, Dr. Maynard and Dr. Stein (who was previously at UCSD) leveraged an AHRQ grant to build a protocol for VTE prevention. It was designed with the aim that it would be universally applicable to any and all hospitalist programs, he said. The protocol increased prophylaxis rates from 50% of patients in 2005 to 98% in 2007 at UCSD (J. Hospital Medicine 2010;5:10-8).

Essentially, it was a simple model that stratified patients into low-, moderate- and high-risk categories. Almost no patients fall into the low-risk category; most are classified as moderate risk, Dr. Maynard said.

The risk assessment can be completed by a physician in seconds and can be done either on paper or as part of an electronic health record. Once determined, the risk level is linked to a menu of prophylaxis options, either in chart form, on paper, or electronically. Importantly, these options very specifically say which pharmacologic agents, and at what dose, are most appropriate for the patient, given their risk and taking into account other factors. The protocol also recommends that mechanical prophylaxis only be used as an adjunct, not as a first-line therapy.

To ensure the protocol was followed, Dr. Maynard and Dr. Stein created a method they dubbed “Measure-vention” – that is, the prophylaxis is monitored on a real-time basis and the intervention is done in real time, as well. The program also automatically collects data that can be used for quality improvement.

If a patient is indicated to need prophylaxis but is not identified as having received it on the medication record, the nurse or pharmacist receives an automated note. They in turn notify the physician via text message or page. About half the time, the physician changes the order, and the rest of the time, there is a valid reason for no prevention – or the physician simply does not want to be told what to do, Dr. Maynard observed.

At Emory, the Measure-vention strategy was adopted in 2009 as the final piece of the VTE prevention program, which started in 2006. Patients are color coded on a “dashboard” that is refreshed hourly. Red means no prophylaxis ordered, yellow means mechanical only has been ordered, and green means the patient is receiving a pharmacologic agent.

Six months after it was implemented, the dashboard helped pull prophylaxis rates above 90% in the 15 inpatient units at Emory University Hospital that were using the strategy, triple the rate before the dashboard, Dr. Stein said.

A year after starting the real-time monitoring in 2008, one 20-bed intensive care unit had a 75% reduction in potentially preventable hospital-acquired VTE, “attributable to a similarly significant rise in VTE prophylaxis from 73% to 94%,” he said.

There were nine fewer clots in that unit, which “represents real morbidity prevention and real cost savings, and very possibly represents preventable deaths from pulmonary embolism,” he said.

The implementation of the dashboard – which is now available to nurses and physicians at five Emory hospitals – has created new channels of communication between clinical and information services and contributed to an increased sense of pride in frontline nurses and clinicians, Dr. Stein observed.

“Ultimately, we’ve developed a new mindset for how performance is measured and improved at Emory,” he said.

Emory was recognized at the SHM annual meeting in April with an Excellence in Teamwork in Quality Improvement Award.

SHM hopes that other facilities can replicate the Emory experience. It has enrolled 80 facilities in the Prevention Collaborative.

Dr. Maynard said that awareness may also increase throughout the Department of Veterans Affairs, which initially had six hospitals take part in a pilot that he and Dr. Stein helped launch. Now, “many, many sites in the VA” are using the VTE prevention toolkit, he said.

The IHI and AHRQ also have enrolled dozens of hospitals in collaborations to reduce VTE.

VTE prophylaxis has been “suboptimal for a long time,” said Dr. Maynard. But, “it’s getting there.”

Hospitals that have been lagging on prevention of venous thromboembolism (VTE) might find themselves increasingly at risk for lower reimbursement or downgrades in quality ratings, but a new Society of Hospital Medicine (SHM) program may help some facilities start measuring up.

The Joint Commission is close to implementing a set of VTE measures looking at whether prophylaxis is in place within 24 hours of admission. The Centers for Medicare and Medicaid Services already refuses to pay for any VTE incurred as a complication of hip or knee replacement.

But these sticks have not been huge motivating factors for facilities when it comes to VTE, said Dr. Gregory A. Maynard, chief of the division of hospital medicine at the University of California, San Diego.

The biggest hurdle still seems to be the lack of physician awareness about which populations are vulnerable, said Dr. Maynard, who has been involved in collaboratives backed by the Institute for Healthcare Improvement (IHI) and the Agency for Healthcare Research and Quality (AHRQ). That’s partly because while these events are common, an individual physician might not have many VTEs in his or her own practice, he said.

Dr. Maynard has been a key architect of the SHM’s efforts to help hospitalists improve VTE prevention. The VTE Prevention Collaborative, which launches in September, is supported in part by Sanofi-Aventis U.S. Participants will have access to a toolkit, resources, and individualized mentoring and support, as part of the program developed by Dr. Maynard and Dr. Jason Stein, director of the Clinical Research Program for the section of hospital medicine at Emory University, Atlanta.

According to Dr. Maynard, nearly every hospitalized patient is at risk for VTE, which includes deep vein thrombosis (DVT) and pulmonary embolism (PE). Most patients have four to six risk factors, he said. The three big risk categories are stasis (related to age greater than 40 years, immobility, anesthesia, obesity, stroke, or heart failure), hypercoagulability (associated with cancer, sepsis, smoking, and pregnancy), and endothelial damage (surgery, central lines, trauma, or prior VTE).

PE is the cause of death in more than 100,000 hospitalized patients each year, and a contributing factor in the death of 100,000 additional inpatients annually, the SHM estimates.

And yet, studies have found that only about 30%-50% of inpatients are given appropriate prophylaxis – this, despite the availability of guidelines and protocols that make the process more efficient, and of effective pharmacologic agents. The ENDORSE trial, for instance, found that among 70,000 inpatients, only 59% of surgical patients and 40% of medical patients were given appropriate prophylaxis (Lancet 2008;371:387-94).

At UCSD, Dr. Maynard and Dr. Stein (who was previously at UCSD) leveraged an AHRQ grant to build a protocol for VTE prevention. It was designed with the aim that it would be universally applicable to any and all hospitalist programs, he said. The protocol increased prophylaxis rates from 50% of patients in 2005 to 98% in 2007 at UCSD (J. Hospital Medicine 2010;5:10-8).

Essentially, it was a simple model that stratified patients into low-, moderate- and high-risk categories. Almost no patients fall into the low-risk category; most are classified as moderate risk, Dr. Maynard said.

The risk assessment can be completed by a physician in seconds and can be done either on paper or as part of an electronic health record. Once determined, the risk level is linked to a menu of prophylaxis options, either in chart form, on paper, or electronically. Importantly, these options very specifically say which pharmacologic agents, and at what dose, are most appropriate for the patient, given their risk and taking into account other factors. The protocol also recommends that mechanical prophylaxis only be used as an adjunct, not as a first-line therapy.

To ensure the protocol was followed, Dr. Maynard and Dr. Stein created a method they dubbed “Measure-vention” – that is, the prophylaxis is monitored on a real-time basis and the intervention is done in real time, as well. The program also automatically collects data that can be used for quality improvement.

If a patient is indicated to need prophylaxis but is not identified as having received it on the medication record, the nurse or pharmacist receives an automated note. They in turn notify the physician via text message or page. About half the time, the physician changes the order, and the rest of the time, there is a valid reason for no prevention – or the physician simply does not want to be told what to do, Dr. Maynard observed.

At Emory, the Measure-vention strategy was adopted in 2009 as the final piece of the VTE prevention program, which started in 2006. Patients are color coded on a “dashboard” that is refreshed hourly. Red means no prophylaxis ordered, yellow means mechanical only has been ordered, and green means the patient is receiving a pharmacologic agent.

Six months after it was implemented, the dashboard helped pull prophylaxis rates above 90% in the 15 inpatient units at Emory University Hospital that were using the strategy, triple the rate before the dashboard, Dr. Stein said.

A year after starting the real-time monitoring in 2008, one 20-bed intensive care unit had a 75% reduction in potentially preventable hospital-acquired VTE, “attributable to a similarly significant rise in VTE prophylaxis from 73% to 94%,” he said.

There were nine fewer clots in that unit, which “represents real morbidity prevention and real cost savings, and very possibly represents preventable deaths from pulmonary embolism,” he said.

The implementation of the dashboard – which is now available to nurses and physicians at five Emory hospitals – has created new channels of communication between clinical and information services and contributed to an increased sense of pride in frontline nurses and clinicians, Dr. Stein observed.

“Ultimately, we’ve developed a new mindset for how performance is measured and improved at Emory,” he said.

Emory was recognized at the SHM annual meeting in April with an Excellence in Teamwork in Quality Improvement Award.

SHM hopes that other facilities can replicate the Emory experience. It has enrolled 80 facilities in the Prevention Collaborative.

Dr. Maynard said that awareness may also increase throughout the Department of Veterans Affairs, which initially had six hospitals take part in a pilot that he and Dr. Stein helped launch. Now, “many, many sites in the VA” are using the VTE prevention toolkit, he said.

The IHI and AHRQ also have enrolled dozens of hospitals in collaborations to reduce VTE.

VTE prophylaxis has been “suboptimal for a long time,” said Dr. Maynard. But, “it’s getting there.”