Two pharmacist-hospitalist teams each won $50,000 grants June 12 from the American Society of Health-System Pharmacists (ASHP) Research and Education Foundation (Bethesda, Md.) to support development of screening tools and order sets to prevent and treat hospital-acquired venous thromboembolism (VTE).
The grant winners and lead co-investigators from each team:
- Robert Weibert, PharmD, health sciences clinical professor and director of the Anticoagulation Clinic, School of Pharmacy, and Gregory Maynard, MD, MS, head of the Division of Hospital Medicine and associate clinical professor of medicine at the University of California-San Diego (UCSD); and
- Rachel Hroncich, PharmD, pharmacy clinical coordinator of Presbyterian Healthcare Service, and Randle Adair, DO, PhD, a PMG hospitalist in adult medicine from Albuquerque, N.M.
The ASHP, a nonprofit organization, fosters safe medication use.
“We are thrilled that our grant application was selected by the ASHP and excited about the opportunity for our research to improve patient care,” says Dr. Hroncich.
The ASHP Research and Education Foundation grant program, sponsored by Sanofi-Aventis, supports research by hospitalists and hospital pharmacists to treat VTE, with a focus on hospitalized patients and post-discharge follow-up. The grants are geared to help hospitalists and pharmacists reduce hospital-acquired VTE, a significant cause of morbidity and mortality in hospitals.
VTE-related treatment costs $1.5 billion a year, according to researchers at the University of Washington School of Pharmacy in Seattle. ASHP statistics indicate VTE affects more than 450,000 hospitalized patients annually. The condition—an amalgam of deep vein thrombosis (DVT) and pulmonary embolism (PE)—affects a range of hospitalized patients. Gynecologic, orthopedic, urologic, vascular, trauma, and cancer patients all are at risk—as are those with other medical conditions such as congestive heart failure, severe respiratory disease, and obesity, or those who are bedridden.
The ASHP grants help pharmacist-hospitalist teams find tools to screen for VTE. Such tools let clinicians intervene early with at-risk patients. Better screening and intervention requires sound clinical, administrative, and IT processes.
The trick is to encourage busy hospitalists to use a consensus-based VTE screening tool for all hospitalized patients.
While most VTE research involves retrospective chart review of diagnostic codes, Drs. Weibert and Maynard’s grant research goes beyond such studies by identifying patients at risk concurrent with their hospitalizations. Dr. Maynard says the need is urgent: “Hospitals grossly underestimate the risk of VTE. In a 300-bed hospital, at least 150 patients are at risk of hospital-acquired VTE at any time.”
The UCSD team hopes to improve VTE screening by integrating an order set into the hospital’s computer physician order entry (CPOE) system. “The literature points to a bundle of best practices for VTE,” says Dr. Maynard, “including baseline lab work, use of compression stockings, using heparin for an optimal time period, patient education for those on anticoagulants, timely follow-up post discharge, the Society of Hospital Medicine collaborative, etc.”
Based on that body of knowledge and the input of its 15 full-time equivalent hospitalists, UCSD stakeholders in VTE screening debate what is practical and workable, conduct small, paper-based pilot projects, and fine-tune the protocol to integrate it with patient flow through admissions. “As we transition fully to a CPOE in our health system, we will incorporate a VTE order set that is doable and user-friendly,” adds Dr. Maynard.
UCSD’s pharmacist-hospitalist collaboration also encourages residents from both disciplines to work together on integrating protocols into clinical care processes. The team hopes that the VTE protocol will go beyond the inpatient stay by wrapping the protocol into the discharge plan. Dr. Weibert’s anticoagulation and pulmonary embolism clinics also help “build on our strengths,” he says.
The second team is led by newcomers to the grant winner’s circle, Drs. Hroncich (pharmacist) and Adair (hospitalist) from Presbyterian Healthcare Services, Albuquerque, N.M. They base their research on this question: Is it more efficient for the system’s 34 hospitalists to screen out those at low risk of VTE than to screen everyone for high risk?
The investigators have been collecting baseline data on compliance with VTE screening since 2003. Hospitalist use of a VTE screening tool on admissions was 60%, improving to 88% with reminders. “The implication is that 12% of the hospitalists didn’t use the screening tool,” says Dr. Adair. “We found that they were resistant to another piece of paper.” PHS data also showed that seven out of 10 patients had some VTE risk, that co-morbidities and hospitalization increase VTE risk, and that the age at which patients fall prey to VTE is dropping to between 50 and 60.
For the ASHP grant, Drs. Hroncich and Adair will monitor VTE screening on admission to all PHS general medical units. All patients 18 or older admitted to those units during a three-month period will be routinely screened on admission for VTE risk. Drs. Hroncich and Adair will make two VTE-related admission order sets available to hospitalists to complete. The current screening tool is designed to identify patients at risk of developing a VTE based on the presence of risk factors. The second, shorter admission order set will contain a screening tool that assumes that all patients need VTE prophylaxis, except low-risk patients and those with VTE prophylaxis contraindications. “The shorter tool should take only one or two minutes to complete,” says Dr. Hroncich.
The PHS team hopes that the shorter screening tool will overcome resistance to VTE screening. Dr. Hroncich says there are many barriers to VTE screening. They include lack of consensus on the best screening tool on admission, the misperception that VTE isn’t a big problem, lack of reliable processes so at-risk patients don’t fall through the cracks, and a misperception that anti-coagulant therapy is dangerous.
“It’s one thing to treat COPD and heart failure,” adds Dr. Adair, “but if I can prevent VTE with less than a 60-second screening, I can prevent a disease state from happening.” TH
Marlene Piturro is a frequent contributor to The Hospitalist.