Quality

Prevent Defense


 

Three U.S. medical centers have been recognized for innovative approaches to preventing DVT and its potentially fatal complications, which include pulmonary embolism (PE). Central to each of the DVT prevention strategies is a risk assessment tool that is easy to use, built directly into routine care, and linked directly to guideline-recommended choices for prophylaxis.

The University of California at San Diego (UCSD) Medical Center, Johns Hopkins Hospital in Baltimore, and the Veterans Affairs (VA) Medical Center in Washington, D.C., each received the first DVTeamCare Hospital Award. The North American Thrombosis Forum (NATF), in conjunction with pharmaceutical company Eisai Inc., recognized each center’s accomplishment based upon an evaluation by an independent panel of expert judges.

Having DVT prevention protocols such as these in place allows hospitalists to provide better care with less effort by leaving hospitalists free to focus on more complicated patient-care issues.

—Gregory A. Maynard, MD, FHM, hospital medicine division chief, University of California at San Diego

The award reflects NATF’s goal of enhancing thrombosis education, prevention, diagnosis, and treatment to improve patient outcomes, says NATF Executive Director Ilene Sussman, PhD. Dr. Sussman notes that DVT affects more than 600,000 Americans annually, kills more than 100,000, and is one of the leading causes of preventable deaths in hospitals. Preventable DVT-related complication is on Medicare’s list of “never events,” for which hospitals will no longer be reimbursed.

UCSD, representing medical centers with more than 200 beds, imbedded its VTE prevention protocol into admission, transfer, and perioperative order sets across all medical and surgical services, says Gregory A. Maynard, MD, FHM, hospital medicine division chief. The protocol flags three levels of DVT risk, notes possible contraindications for a particular kind of patient, and presents a set of options for guideline-recommended prophylaxis. The protocol can be paper- or computer-based. Prompting concurrent intervention is a central component of UCSD’s implementation strategy, “identifying in real-time patients who are not receiving the right DVT prophylaxis and having a front-line nurse or pharmacist intervene appropriately,” Dr. Maynard explains.

The percent of UCSD’s patients on adequate prophylaxis rose to more than 98% in the past two years, up from about 50% before the intervention, while preventable VTE dropped by 85%—about 50 fewer cases per year in a hospital with fewer than 300 beds. “Having DVT prevention protocols such as these in place allows hospitalists to provide better care with less effort by leaving hospitalists free to focus on more complicated patient-care issues,” Dr. Maynard says.

UCSD has partnered with SHM to develop DVT prevention toolkits and mentored collaboratives, with which hospitalists can take the lead on QI projects at their local institutions. SHM’s online VTE Implementation Guide is available at www.hospitalmedicine.org/ResourceRoomRedesign/RR_VTE/VTE_Home.cfm.

The University of California at San Diego (UCSD) Medical Center. Dr. Streiff

The University of California at San Diego (UCSD) Medical Center.

Johns Hopkins Hospital, representing medical centers with more than 200 beds, developed a mandatory computer-based decision-support system to facilitate specialty-specific risk-factor assessment and the application of risk-appropriate VTE prophylaxis, says Michael Streiff, MD, FACP, director of Johns Hopkins’ Anticoagulation Management Service and Outpatient Clinic, and a member of its Evidence-Based Practice Center. Before a physician can issue any orders—medications, lab tests, nursing instructions, etc.—using a physician transfer order set, the computerized order-entry system automatically guides them through a concise set of questions about a patient’s DVT risk factors, contraindications for blood thinners, and guideline-recommended prophylaxis choices, Dr. Streiff says.

Dr. Streiff

Since implementing the system, the percent of patients being DVT-risk-stratified within 24 hours of hospital admission rose to more than 90%, and nearly 9 in 10 of the appropriate patients are now receiving risk-appropriate, American College of Chest Physicians-approved DVT prophylaxis, up from about 26% before the intervention, Dr. Streiff notes.

The VA Medical Center in Washington, D.C., representing medical centers with fewer than 200 beds, participated in a mentorship collaborative with UCSD’s Dr. Maynard and designed a seven-step process that walks providers through an evidence-based risk-factor assessment to determine appropriate thromboprophylactic therapy, says Divya Shroff, MD, associate chief of staff, Informatics. The guideline-driven steps are integrated into the VA’s computerized patient medical record system and take no more than 60 seconds to follow, says pharmacy practice resident Jovonne H. Jones, PharmD. The steps include:

  • Assess patient DVT risk level;
  • Educate patient about the order;
  • Identify contraindications, if any;
  • Choose prophylaxis drug or device;
  • Accept order for drug or device;
  • Check if additional prophylactic method is needed; and
  • Accept the final order.
Jovonne Jones

After the intervention, the rate at which patients receive appropriate prophylaxis upon admission more than doubled. Twenty VA medical centers around the country are in the process of implementing the system, Jones says.

The award-winning protocols will be presented at an NATF-hosted program April 9 at Harvard Medical School. The protocols and implementation plans will be made available at www.DVTeamCareAward.com to help other hospitals enhance their efforts to prevent DVT. TH

Chris Guadagnino is a freelance medical writer based in Philadelphia.

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