While VTE sometimes occurs in spite of the best available prophylaxis, there are many lost opportunities to optimize prevention and reduce VTE risk factors in virtually every hospital. Reaching a meaningful improvement in VTE prevention requires an empowered, interdisciplinary team approach supported by the institution to standardize processes, monitor, and measure VTE process and outcomes, implement institutional policies, and educate providers and patients.
In particular, Greg Maynard, MD, MSc, SFHM, director of the University of California San Diego Center for Innovation and Improvement Science, and senior medical officer of the Society of Hospital Medicine’s Center for Hospital Innovation and Improvement, suggests reviewing guidelines and regulatory materials that focus on the implications for implementation. Then, summarize the evidence into a VTE prevention protocol.
A VTE prevention protocol includes a VTE risk assessment, bleeding risk assessment, and clinical decision support (CDS) on prophylactic choices based on this combination of VTE and bleeding risk factors. The VTE protocol CDS must be available at crucial junctures of care, such as admission to the hospital, transfer to different levels of care, and post-operatively.
“This VTE protocol guidance is most often embedded in order sets that are commonly used [or mandated for use] in these settings, essentially ‘hard-wiring’ the VTE risk assessment into the process,” Dr. Maynard says.
Risk assessment is essential, as there are harms, costs, and discomfort associated with prophylactic methods. For some inpatients, the risk of anticoagulant prophylaxis may outweigh the risk
of hospital-acquired VTE. No perfect VTE risk assessment tool exists, and there is always inherent tension between the desire to provide comprehensive, detailed guidance and the need to keep the process simple to understand and measure.
Principles for the effective implementation of reliable interventions generally favor simple models, with more complicated models reserved for settings with advanced methods to make the models easier for the end user.
“Order sets with CDS are of no use if they are not used correctly and reliably, so monitoring this process is crucial,” Dr. Maynard says.
No matter which VTE risk assessment model is used, every effort should be made to enhance ease of use for the ordering provider. This may include carving out special populations such as obstetric patients and major orthopedic, trauma, cardiovascular surgery, and neurosurgery patients for modified VTE risk assessment and order sets, Dr. Maynard says, which allows for streamlining and simplification of VTE prevention order sets.
Successful integration of a VTE prevention protocol into heavily utilized admission and transfer order sets serves as a foundational beginning point for VTE prevention efforts, rather than the end point.
“Even if every patient has the best prophylaxis ordered on admission, other problems can lead to VTE during the hospital stay or after discharge,”
Dr. Maynard says.
- Bleeding and VTE risk factors can change several times during a hospital stay, but reassessment does not occur;
- Patients are not optimally mobilized;
- Adherence to ordered mechanical prophylaxis is notoriously low; and
- Overutilization of peripherally inserted central catheter lines or other central venous catheters contributes to upper extremity DVT.
VTE prevention programs should address these pitfalls, in addition to implementing order sets.
Publicly reported measures and the CMS core measures set a relatively low bar for performance and are inadequate to drive breakthrough levels of improvement, Dr. Maynard adds. The adequacy of VTE prophylaxis should be assessed not only on admission or transfer to the intensive care unit but also across the hospital stay. Month-to-month reporting is important to follow progress, but at least some measures should drive concurrent intervention to address deficits in prophylaxis in real time. This method of active surveillance (also known as measure-vention), along with multiple other measurement methods that go beyond the core measures, is often necessary to secure real improvement.
An extensive update and revision of the Agency for Healthcare Research and Quality/Society of Hospital Medicine VTE Prevention Implementation Guide will be released by early spring. It will provide comprehensive coverage of these concepts.
Karen Appold is a freelance medical writer in Pennsylvania.