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.