Venous thromboembolic (VTE) 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 approximately half of all VTEs are hospital-acquired.
Hospitalists are ideally positioned to reduce the incidence of preventable VTEs, both by using known best practices to improve care delivered to their own patients, and, more importantly, by leading hospitalwide efforts that improve care for all patients at their home institutions.
In recognition of this important clinical issue and the role hospitalists can play in addressing it, SHM launched the VTE Prevention Collaborative (VTEPC) in January 2007. The program offers individualized assistance to hospitalists wishing to take the lead in this area.
The VTEPC offers two technical assistance options. Individuals interested in securing ongoing support for their planned or active VTE prevention projects can enroll in the mentoring program. This allows a full year of access to and support from SHM mentors with VTE and quality-improvement (QI) expertise. Mentoring occurs in eight telephone calls, during which mentors offer individualized assistance on any topics, tasks, or barriers commonly encountered in designing, implementing, and evaluating a VTE prevention project.
An on-site consultation program is designed for individuals interested in securing expert evaluation and input on a VTE prevention program but who don’t feel they need ongoing, longitudinal support. In this program, SHM consultants with VTE and QI expertise visit applicants’ hospitals to evaluate active or planned VTE prevention programs. The consultation visits feature a structured evaluation of the site’s strengths and resources, barriers to improvement, and the design and function of active or proposed VTE prevention interventions.
For both programs, support and instruction are organized around the VTE QI workbook, “Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement,” SHM’s step-by-step guide for developing a VTE prevention program. SHM secured the services of Greg Maynard, MD, and Jason Stein, MD, to provide mentoring and conduct consultation visits. Drs. Maynard and Stein have led successful local VTE prevention QI projects, hold QI leadership positions, and have taught QI and VTE prevention principals to local and national audiences. Dr. Maynard is head of the Division of Hospital Medicine and associate clinical professor of medicine at the University of California, San Diego. Dr. Stein is a hospitalist at Atlanta’s Emory University Hospital, assistant professor of medicine at Emory University School of Medicine, and director of quality improvement for the Emory Hospital Medicine Unit.
Both were also instrumental in developing SHM’s online VTE Resource Room and the VTE QI workbook.
Twenty-seven hospitalists enrolled in the VTEPC in its first year of operation, 24 in the mentoring program and three in the consultation program.
Enrollees have broad experience in VTE prevention and QI. Some enrollees have been in practice for two years, others more than 25 years. Some fill QI leadership roles in their hospitals or hospital medicine groups. For others the VTE prevention project is their first experience leading a QI effort. Regional representation (19 states), hospital system representation (18 systems), hospital size (135 to 700 staffed beds), and hospital type (academic centers, community teaching hospitals, and community hospitals) are also broad. One enrollee works at a long-term acute care hospital, all others work at acute-care hospitals.
What They Said
Participants in the mentoring and consultation programs have reported that the support they’ve received has been enormously helpful.
According to feedback from one participant, support from the mentoring program made the potentially overwhelming prospect of launching a hospitalwide improvement effort much more manageable: “The prospect of launching a multihospital VTE Prevention Protocol was extremely daunting; however, with the help of my SHM mentor, we stand ready to pilot the program within the week. Our mentor carefully constructed a step-by-step process that allowed me to investigate the scope of the problem at the local level and develop a protocol that was embraced by our administration and physicians. He supplied me with resources and knowledge that allowed me to successfully handle multiple obstacles that arose along the way. What we have accomplished will have an enormous impact on the quality of care that we provide for our patients.”
Other participants have reported that having access to objective input from an external expert can help transform a slow-developing or ineffective prevention program. As one participant put it: “Mentoring through SHM’s VTE Prevention Collaborative has been an invaluable experience. Through monthly phone calls and frequent e-mails, our mentor focused our previously ineffective efforts and guided us to develop a streamlined tool that was custom-fit to the workflow at our hospital. He has saved us tremendous frustrations by directing us to the appropriate resources in our institution to accomplish tasks we would have attempted ourselves. Since our first phone call, he has been both our coach and cheerleader. The processes and techniques that he has taught us are applicable to every quality endeavor we engage in.”
What Impressed Experts
Drs. Maynard and Stein have been enormously impressed by what VTEPC members have achieved. “What is most impressive to me is how all these hospitalist project leaders in different settings are overcoming a wide variety of intuitional barriers, medical staff barriers, infrastructure barriers—all the obstacles that can challenge the typical big QI project,” says Dr. Maynard. He notes that not only are participants utilizing all the basic QI principles in all the ways that were outlined in the QI workbook, but they also are coming up with innovations and approaches beyond what the workbook authors envisioned.
“We learn from them as they come up with innovations to meet their own challenges,” Dr. Stein says. “It shows the resilience and flexibility of the QI framework. If you really work in your local setting on these things with the improvement framework in mind you can get by almost any barrier.” Drs. Maynard and Stein have noted that participants have been able to design and implement VTE prevention programs at a pace that far outstrips what the two mentors achieved at their home institutions.
Many participants have found real-time ways to identify patients who are not on prophylaxis but should be. At many sites, identification begins with a report generated by the hospital’s inpatient pharmacy service, which typically shows the anti-coagulation regimen for each patient in a given hospital ward. The floor pharmacist or nurse can identify who is not on prophylaxis, assess risk factors and contraindications, and act to mitigate the situation—for example, by placing a call to the patient’s attending physician. Other sites have developed more sophisticated reports that capture information about relative risk for DVT and the absence or presence of contraindications to pharmacologic prophylaxis; these features reduce the effort required to investigate each case.
How to Learn More
The Quality Track at the 2008 Annual Meeting (April 3-5 at the Manchester Hyatt, San Diego, Calif.) includes a session on the “VTE Collaborative Experience” (1-2:25 p.m. April 4). Drs. Maynard and Stein will discuss the initiative, as will collaborative members, who will describe key successes and innovations that furthered their efforts to establish effective VTE prevention programs. Questions about the VTEPC and the Annual Meeting session can be directed to [email protected].
Update on Hand-Offs
SHM task force continues to refine transitions-of-care checklist
by Shannon Roach
Among hospitalists and other organizations, there has been an increasing interest surrounding the improvement of the quality of patient care, especially within transitions of care and patient discharge. As the leader in the hospital medicine field, SHM continues to support and lead initiatives for the improvement of care as related to patient discharge and transitions. Last year’s creation of the Hand-Offs Communication Task Force (HCTF) has upheld SHM’s position of being dedicated to the promotion of the highest quality care for all hospitalized patients.
Derived from members of the Hospital Quality and Patient Safety Committee and the Education Committee, this task force was led by Vineet Arora, MD, MA, assistant professor of medicine, University of Chicago. Collaborating with her were Preetha Basaviah, MD, clinical instructor, Stanford University Medical Center in Calif.; Dan Dressler, MD, instructor of medicine, Emory University School of Medicine in Atlanta; Lakshmi Halasyamani, MD, associate chairperson of the Department of Internal Medicine at St. Joseph Mercy Hospital in Ann Arbor, Mich.; Sunil Kripalani, MD, MSc, an instructor at Emory University in Atlanta; and Efren Manjarrez, MD, assistant clinical professor of medicine at the Miller School of Medicine, University of Miami.
This team set out to create a formally recognized set of recommendations for ensuring optimum communication and continuity of care at the end of a medical professional’s shift or a patient’s change in service.
The task force’s first step was to determine what information was available as a basis for these recommendations. Though data were limited, the group decided that recommendations for effective hand-offs would be broken into three categories: program policy, verbal exchange, and content exchange.
As the need for more evidence-based data for the improvement of in-hospital hand-offs became clear, the group decided a valuable follow-up approach for these recommendations would be to incorporate a research agenda into the findings. This proposal suggests a need for a rigorous evaluation of these recommendations, with an emphasis on controlled interventions. It also encourages the development of patient-based outcomes sensitive to hand-off quality.
As a test run for these recommendations, the HCTF presented its findings at Hospital Medicine 2007 in Dallas. Their session “Developing Communications and Hand-Off Standards for Hospitalists” drew a passionate response. During this session they unveiled a checklist outlining the important elements of an in-hospital physician hand-off. Attendees were encouraged to offer feedback and vote on proposed hand-off elements. They also were encouraged to submit suggestions if they believed something was missing.
Using that feedback, the group produced a final draft of recommendations and distributed it to a multidisciplinary team of experts for a final review. On the panel were Linda Bell, RN, MSN; Emily Patterson, PhD; Erik Van Eaton, MD; and Arpana Vidyarthi, MD. These experts reflect the perspective of nonphysician members of the hospital community, representing the interests of technology, nursing, human factors research, and hospital medicine. They reviewed the paper and hand-off recommendations by participating in conference calls in which they were asked to comment on questions regarding the working paper. These discussions gave the task force invaluable, candid feedback adopted into the working paper to create a more robust set of recommendations.
The final product was reviewed by SHM’s Board of Directors in January; a dissemination plan is in progress. If these recommendations are endorsed by an institution or a hospitalist group, they will act as a guide to ensure the coordination of hand-offs and the mangement of important clinical care issues.
Through their research and interactions with a large number of individuals concerned with this issue, the HCTF discovered that the quality improvement of patient transitions is a complex, global issue. They believe this checklist of hand-off elements is essential to these efforts.