Jason Stein, MD, knows he could walk into almost any nursing unit in any hospital in the country, ask a simple question, and get blank stares in return.
“I would ask, ‘Which patients here in the nursing unit don’t have an order for VTE prophylaxis?’ ” says Dr. Stein, associate director for quality improvement and assistant professor of medicine at Emory University School of Medicine in Atlanta. “And they would tell me, ‘What kind of place do you think this is? How can we possibly know that?’ ”
It’s not idle chat. Venous thromboembolism (VTE) is a condition known throughout HM for three things: It runs rampant in hospitals; it can be deadly; and it’s easily preventable.
This month, SHM—along with dozens of other healthcare organizations, including the Agency for Healthcare Research Quality (AHRQ)—is highlighting the dangers of VTE and deep vein thrombosis (DVT), and promoting best practices to prevent them.
“SHM’s leadership of awareness efforts and championing VTE [prevention] has played an important role in keeping this on everybody’s mind,” Dr. Stein says.
VTE: A Hospital-Based Epidemic
Although it is easy to target at-risk populations and prevent it, VTE is widespread and dangerous.
“By published estimates, each year VTE kills more people than HIV, car accidents, and breast cancer combined,” says Gregory A. Maynard, MD, Ms, chief of the division of hospital medicine and clinical professor of medicine at the University of California at San Diego.
The risk of VTE in hospital patients should give hospitalists and their colleagues pause. Here’s why:
- According to the American Heart Association, more than 200,000 cases of VTE are reported each year, and VTE occurs for the first time in approximately 100 out of every 100,000 persons each year;
- Research published last year in The Lancet estimates 52% of hospitalized patients are at risk for VTE;
- 1 in 3 VTE patients experiences a pulmonary embolism;
- 30% of new VTE patients die within three days;
- 20% of new VTE patients die suddenly from pulmonary embolus; and
- DVT is responsible for approximately 8,000 hospital discharges every year. Pulmonary embolism accounts for nearly 100,000.
Risk Factors and Prevention
In a hospital setting, VTE risk factors are especially straightforward to monitor and prevent, but Dr. Maynard sees room for improvement.
“We don’t need to do better things; we need to do things better,” he told colleagues at a recent grand rounds. “Pharmacologic prophylaxis is the preferred way to prevent VTE in the hospital, which can reduce DVT and pulmonary embolism by 50% to 65%.”
Most hospital patients have at least one of these VTE risk factors, which are sorted into three categories:
- Stasis: conditions such as advanced age, immobility, paralysis, or stroke;
- Hypercoaguability: smoking, pregnancy, cancer, or sepsis; and
- Endothelial damage: surgery, prior VTE, central lines, or trauma.
Because the potential VTE risk is so high in hospital patients, the assessment must go hand in hand with prophylaxis, says Dr. Maynard and other hospitalists working with VTE.
Recent research has shown that prescribing medications to prevent VTE before it begins is safe, effective, and cost-effective.
The Hospitalist’s Role
The responsibility for VTE risk assessment and prevention often falls to hospitalists. In its online VTE Resource Room, SHM provides information for hospitalists working to assess and prevent VTE in their patients. It also provides a complete toolkit for hospitalists interested in addressing VTE prevention systematically throughout their hospitals. The toolkit is part of a comprehensive VTE Prevention Collaborative, which provides real-world mentoring and materials to hospitalists as they develop VTE monitoring and prevention programs.
“In 2005, when SHM set up the Quality Improvement resource room, we began with VTE prophylaxis,” Dr. Stein says. “VTE is the No. 1 cause of preventable death in hospitals, and preventing it is a fundamentally simple thing for hospitalists to do. We’re trying to get physicians to order a shot in the abdomen once a day. … If we can’t do that, we’re in trouble. On the flipside, if we can figure that out, we can derive mechanisms that we can apply to more complex problems in care.”
Together with SHM, Drs. Stein and Maynard have pioneered a two-pronged approach known as “measure-vention.” The underlying principal of measure-vention is that monitoring for VTE risk in real time can empower hospital staff to remedy issues in real time. In most hospitals, VTE risk can only be measured retrospectively through quality improvement data, which can take months to collect.
SHM and Dr. Stein have implemented an information technology approach at five of Emory’s hospitals. Each facility assesses patients who don’t have VTE prophylaxis every hour. The data is distributed to nursing stations, where nurses and other providers can apply VTE interventions within minutes. The program has driven Emory’s VTE prophylaxis rates to more than 90%, and Dr. Stein is working to make the program exportable to other hospitals, with the help of funding and assistance from SHM.
“As the leader of the VTE prevention program at Emory hospitals, I hear lots of stories about preventable VTE—not just about patients, but from friends of friends and family members,” he says. “It’s extraordinary.” TH
Brendon Shank is a freelance writer based in Philadelphia.