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VTE Awareness Month

From: The Hospitalist, March 2009

SHM urging hospitalists to put a dent in dangerous, preventable disease

by Brendon Shank

Jason Stein, MD, knows he could walk into almost any nursing unit in any hospital in the country, ask a simple question, and get blank stares in return.

“I would ask, ‘Which patients here in the nursing unit don’t have an order for VTE prophylaxis?’ ” says Dr. Stein, associate director for quality improvement and assistant professor of medicine at Emory University School of Medicine in Atlanta. “And they would tell me, ‘What kind of place do you think this is? How can we possibly know that?’ ”

It’s not idle chat. Venous thromboembolism (VTE) is a condition known throughout HM for three things: It runs rampant in hospitals; it can be deadly; and it’s easily preventable.

This month, SHM—along with dozens of other healthcare organizations, including the Agency for Healthcare Research Quality (AHRQ)—is highlighting the dangers of VTE and deep vein thrombosis (DVT), and promoting best practices to prevent them.

“SHM’s leadership of awareness efforts and championing VTE [prevention] has played an important role in keeping this on everybody’s mind,” Dr. Stein says.

VTE: A Hospital-Based Epidemic

Although it is easy to target at-risk populations and prevent it, VTE is widespread and dangerous.

“By published estimates, each year VTE kills more people than HIV, car accidents, and breast cancer combined,” says Gregory A. Maynard, MD, Ms, chief of the division of hospital medicine and clinical professor of medicine at the University of California at San Diego.

The risk of VTE in hospital patients should give hospitalists and their colleagues pause. Here’s why:

  • According to the American Heart Association, more than 200,000 cases of VTE are reported each year, and VTE occurs for the first time in approximately 100 out of every 100,000 persons each year;
  • Research published last year in The Lancet estimates 52% of hospitalized patients are at risk for VTE;
  • 1 in 3 VTE patients experiences a pulmonary embolism;
  • 30% of new VTE patients die within three days;
  • 20% of new VTE patients die suddenly from pulmonary embolus; and
  • DVT is responsible for approximately 8,000 hospital discharges every year. Pulmonary embolism accounts for nearly 100,000.

DVT Facts and Figures

  • More people suffer from DVT annually than from heart attack or stroke;
  • Approximately 600,000 people are hospitalized in the U.S. each year for DVT and its primary complication, pulmonary embolism (PE);
  • DVT-related PE is the most common cause of preventable hospital death;
  • Only one-third of hospitalized patients with risk factors for blood clots receive prophylactic DVT treatments;
  • Without prophylactic DVT treatment, up to 60% of patients who undergo total hip replacement surgery may develop DVT;
  • Cancer patients undergoing surgical procedures have at least twice the risk of postoperative DVT and more than three times the risk of fatal PE than non-cancer patients undergoing similar procedures; and
  • In the elderly, DVT is associated with a 21% one-year mortality rate, and PE is associated with a 39% one-year mortality rate.

Source: The Coalition to Prevent Deep-Vein Thrombosis

Risk Factors and Prevention

In a hospital setting, VTE risk factors are especially straightforward to monitor and prevent, but Dr. Maynard sees room for improvement.

“We don’t need to do better things; we need to do things better,” he told colleagues at a recent grand rounds. “Pharmacologic prophylaxis is the preferred way to prevent VTE in the hospital, which can reduce DVT and pulmonary embolism by 50% to 65%.”

Most hospital patients have at least one of these VTE risk factors, which are sorted into three categories:

  • Stasis: conditions such as advanced age, immobility, paralysis, or stroke;
  • Hypercoaguability: smoking, pregnancy, cancer, or sepsis; and
  • Endothelial damage: surgery, prior VTE, central lines, or trauma.

Because the potential VTE risk is so high in hospital patients, the assessment must go hand in hand with prophylaxis, says Dr. Maynard and other hospitalists working with VTE.

Recent research has shown that prescribing medications to prevent VTE before it begins is safe, effective, and cost-effective.

The Hospitalist’s Role

Ray Grover/Alamy
One of the goals of SHM’s VTE Prevention Collaborative is to get physicians to order a shot in the abdomen once per day for hospitalized VTE patients.

The responsibility for VTE risk assessment and prevention often falls to hospitalists. In its online VTE Resource Room, SHM provides information for hospitalists working to assess and prevent VTE in their patients. It also provides a complete toolkit for hospitalists interested in addressing VTE prevention systematically throughout their hospitals. The toolkit is part of a comprehensive VTE Prevention Collaborative, which provides real-world mentoring and materials to hospitalists as they develop VTE monitoring and prevention programs.

“In 2005, when SHM set up the Quality Improvement resource room, we began with VTE prophylaxis,” Dr. Stein says. “VTE is the No. 1 cause of preventable death in hospitals, and preventing it is a fundamentally simple thing for hospitalists to do. We’re trying to get physicians to order a shot in the abdomen once a day. … If we can’t do that, we’re in trouble. On the flipside, if we can figure that out, we can derive mechanisms that we can apply to more complex problems in care.”

VTE PREVENTION COLLABORATIVE:

The Model Program for Quality Improvement

As any successful hospitalist will tell you, technical and medical expertise are only half the formula for a safe, efficient practice. The other half is expertise in interpersonal collaboration and program management.

That’s the lesson Kathleen Kerr, SHM senior advisor and senior research analyst at the University of California San Francisco Department of Medicine, learned as one of the program leaders of SHM’s VTE Prevention Collaborative (VTEPC). The VTEPC pairs hospitalists who are starting VTE prevention initiatives with mentors who provide support and advice.

“Hospitalists across the country really found value in getting guidance from experienced mentors,” Kerr explains. “The hospitalists who are starting these VTE prevention programs are some of the brightest and innovative in their practices, but they still benefit from mentors who can advise them. Project management, leadership, the interpersonal aspects of guiding a multidisciplinary team—these are challenges that can be especially daunting for a new hospitalist who is looking to lead a hospitalwide quality improvement effort.”

Launched in 2007, the VTEPC mentorship program has been a success. The program already has a full roster of participants for this year, and plans are in the works to expand in the coming months.

Kerr recommends SHM members interested in participating should visit the online VTE Resource Room for program updates.

The mentorship program’s positive impact has encouraged SHM to explore new quality improvement issues.

“Our success here should not be limited to VTE prevention,” Kerr explains. “We’re looking forward to using this model to overcome other challenges facing hospitalists and their patients.”—BS

Together with SHM, Drs. Stein and Maynard have pioneered a two-pronged approach known as “measure-vention.” The underlying principal of measure-vention is that monitoring for VTE risk in real time can empower hospital staff to remedy issues in real time. In most hospitals, VTE risk can only be measured retrospectively through quality improvement data, which can take months to collect.

SHM and Dr. Stein have implemented an information technology approach at five of Emory’s hospitals. Each facility assesses patients who don’t have VTE prophylaxis every hour. The data is distributed to nursing stations, where nurses and other providers can apply VTE interventions within minutes. The program has driven Emory’s VTE prophylaxis rates to more than 90%, and Dr. Stein is working to make the program exportable to other hospitals, with the help of funding and assistance from SHM.

“As the leader of the VTE prevention program at Emory hospitals, I hear lots of stories about preventable VTE—not just about patients, but from friends of friends and family members,” he says. “It’s extraordinary.” TH

Brendon Shank is a freelance writer based in Philadelphia.


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