The problem of hospital-acquired venous thromboembolism (VTE): Venous thromboembolic disease, ranging from asymptomatic deep vein thrombosis (DVT) to massive pulmonary embolism (PE), is a significant cause of morbidity and mortality in hospitalized patients. Almost all hospitalized patients are at risk for VTE, and the literature suggests that approximately half of all cases of VTE are hospital-acquired.1-4 PE is recognized as the cause of death for more than 100,000 hospitalized patients in the United States every year and is considered a contributing factor in the death of 100,000 more patients.1
Multiple clinical trials have provided irrefutable evidence that primary thromboprophylaxis reduces the incidence of DVT and PE.5 Unfortunately, numerous studies have also shown that the majority of hospitalized patients with risk factors for DVT do not receive appropriate prophylaxis.6-8
Hospitalists are ideally positioned to reduce the incidence of preventable VTE, both by using known best practices to improve care delivered to their own patients, and, more importantly, by leading hospital-wide QI efforts that improve care for all patients at their home institutions.
SHM is now accepting applications for the VTE Prevention Collaborative, a program that offers individualized assistance to hospitalists who wish to take the lead on this critical quality and patient safety issue. Participants can choose the option that best fits their needs: a full year of distance mentoring or a one-day evaluation and consultation visit to their site.
The SHM Mentoring Program
The Mentoring Program is the perfect option for individuals who are interested in securing ongoing support for their planned or active VTE prevention projects. SHM mentors with VTE and QI experts who work with participants to tackle site-specific issues using proven QI techniques. Instruction is organized around the VTE QI Workbook, SHM’s step-by-step guide for developing a VTE prevention program. Mentoring occurs in eight telephone calls scheduled throughout the yearlong mentoring period. During the calls, mentors offer individualized assistance on any topics, tasks, and barriers that are encountered in the course of designing, implementing, and evaluating a VTE prevention project. As needed, participants can also interact with their mentors through e-mail and in ad hoc telephone calls. Participants receive assistance with:
- Securing institutional support for the project;
- Assembling and leading the project team;
- Developing project goals and aims;
- Mapping current processes for assessing VTE risk and bleeding risk;
- Evaluating current prophylaxis recommendations;
- Developing evidence-based risk assessment and prophylaxis recommendations;
- Redesigning care delivery processes to include high-reliability features that promote adherence to best practices;
- Developing educational/outreach plans to ensure buy-in from key stakeholders; and
- Collecting, analyzing, and reporting outcome data.
Individuals with relatively little QI leadership experience, as well as those whose VTE prevention projects are in the early planning stages, are encouraged to apply for the SHM Mentoring Program.
The SHM On-site Consultation Program
The On-site Consultation Program is the perfect option for individuals who are interested in securing expert evaluation and input on a VTE prevention program but don’t feel they need ongoing, longitudinal support. Through the SHM On-site Consultation Program, SHM consultants with VTE and QI expertise visit applicants’ hospitals to evaluate active or planned VTE prevention programs. The visits will be especially helpful to participants who have existing VTE prevention programs they wish to expand or improve upon.
The consultation visits feature a structured evaluation of the site’s strengths and resources, any potential barriers to improvement, and the design and functioning of active or proposed VTE prevention interventions. Specific consultation visit activities will vary according to participant goals and needs but may include meeting with the local project team, QI leaders, hospital administrators, and hospital medicine group leaders, as well as reviewing project documents—order sets, policies, and procedures—data, and data collection/management tools.
Following the visits, SHM consultants provide participants with a written report of findings and recommendations. Participants also receive one follow-up telephone consultation, which will occur 60-90 days after the visit.
SHM On-site Consultation Program visits will be available starting in May 2007, though interested parties are encouraged to apply early; enrollment is limited, and available slots are expected to fill quickly.
Which Option Is Right for You?
SHM welcomes participation from hospitalists who work in all types of facilities (large and small community hospitals, academic medical centers, public hospitals, and others) and all types of practice settings, including acute care hospitals, skilled nursing facilities, and rehabilitation hospitals. Both VTE Prevention Collaborative programs are appropriate for individuals with all levels of QI experience, from the novice embarking on his or her first QI project to the seasoned QI leader. Individuals who have not yet begun working on a VTE prevention project are encouraged to apply, as are those who wish to expand or improve upon an existing project.
There are no rigid prerequisites for either program, though we expect individuals whose local VTE prevention efforts are already partially developed to derive more benefit from the On-site Consultation option than would an applicant who has yet to start his or her project. Individuals who have not yet begun working on a VTE prevention project are encouraged to apply for the Mentoring Program, which will ensure access to expert assistance during key development and implementation tasks.
How to Apply
Participation in both the Mentoring and On-site Consultation programs is open to hospitalists who are leading proposed or active VTE prevention projects. Participation is free, but enrollment is limited; interested individuals are encouraged to apply early. SHM members can apply to either program by completing the online application available on the VTE Prevention Collaborative Web site: www.hospitalmedicine.org/vte-pc.
Direct questions about VTE Prevention Collaborative programs to firstname.lastname@example.org.
- Goldhaber SZ, Tapson VF. DVT FREE Steering Committee. A prospective registry of 5,451 patients with ultrasound-confirmed deep vein thrombosis. Am J Cardiol. 2004;93:259-262.
- Guidelines on diagnosis and management of acute pulmonary embolism. Task Force on Pulmonary Embolism, European Society of Cardiology. Eur Heart J. 2000 Aug;21(16):1301-1336. Comment in: Eur Heart J. 2000 Aug; 21(16): 1289-1290.
- Stein PD, Huang H, Afzal A, et al. Incidence of acute pulmonary embolism in a general hospital: relation to age, sex, and race. Chest. 1999 Oct;116(4):909-913.
- Silverstein MD, Heit JA, Mohr DN, et al. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study. Arch Intern Med. 1998 Mar 23;158(6):585-593.
- Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004 Sep;126(3 Suppl):338S-400S. Comment in: Chest. 2005 Jun; 127(6):2297-2298.
- Stratton MA, Anderson FA, Bussey HI, et al. Prevention of venous thromboembolism: adherence to the 1995 American College of Chest Physicians consensus guidelines for surgical patients. Arch Intern Med. 2000;160:334-340.
- Anderson FA Jr, Wheeler HB, Goldberg RJ, et al. Changing clinical practice. Prospective study of the impact of continuing medical education and quality assurance programs on use of prophylaxis for venous thromboembolism. Arch Intern Med. 1994 Mar 28;154(6):669-677.
- Walker A, Campbell S, Grimshaw J. Implementation of a national guideline on prophylaxis of venous thromboembolism: a survey of acute services in Scotland. Thromboembolism Prevention Evaluation Study Group. Health Bull (Edinb). 1999 Mar;57(2):141-147.
Benchmarks Committee Update
By Burke Kealey, MD, chair, SHM Benchmarks Committee
The SHM Benchmarks Committee has had a busy schedule with its new special issues survey and wrapping up work on The Dashboard Project, a first-of-its-kind undertaking. Committee members (under the guidance of Editor Leslie Flores) wrote summaries of 10 sample performance metrics. Each article is designed around a given metric and includes an in-depth discussion of why it is important and where to obtain the necessary data. Sample graphs from other programs will also be included.
The intent is for hospitalist leaders and program managers to use The Dashboard Project to learn what kind of metrics their peers use to manage their respective programs. The final draft was reviewed by the entire committee and circulated to SHM leaders, including the board of directors. It will be published through SHM’s publication, The Hospitalist, and promoted at the SHM Annual Meeting in Dallas in May.
In a break from recent tradition, the SHM Benchmarks Committee (with approval from the SHM Board) has changed how it conducts surveys. The committee will now produce shorter, simpler surveys annually—rather than producing a mega-survey every other year. The committee will conduct an individual hospitalist compensation and productivity survey every other year (including later in 2007); in the alternate year (along with baseline practice demographics) the committee will address the special topics of interest discussed below.
With input from SHM’s Palliative Care Task Force, this year’s special interest survey (which was conducted in November and December of 2006) included questions on palliative care and its growing place in the world of hospital medicine. Night and off-hours coverage continue to be topics of interest for membership. Questions in this section examined the scope of night coverage, including providing ICU coverage for intensivists and getting paid for as well as paying providers for this work.
Issues for family medicine hospitalists are also addressed. Anecdotally, the Benchmarks Committee has heard of family medicine hospitalists running into difficulties securing work because they have been barred by hospital contracts and/or bylaws stating that only internal medicine or pediatrics board-certified physicians can occupy those slots. The survey was designed to capture the pervasiveness of this practice.
Finally, in this era of pay for performance and open reporting, quality measures and their relationship to physician revenue and compensation is a topic that every hospital medicine leader needs to understand. The survey contained a section that looked at the degree to which pay-for-performance programs are actually being seen in the hospitals we practice at, and then, even more important, how those dollars are tied to quality incentive programs between hospitals and hospital medicine groups.
The results of this special interest survey are currently being analyzed and will be published later this spring. TH
SHM is now accepting applications for the VTE Prevention Collaborative, a program that offers individualized assistance to hospitalists wishing to take the lead on this critical quality and patient safety issue.