SQIL TEAM 1 – PRESENTATION 1

Care Process Model

VENOUS THROMBO – PROPHYLAXIS TO IP- PATIENTS Team 1: Michelle Hunter

Peter Hanouv Ammad Tamimi Molly Zhen Wang, Xin Whang

Mode: Case StudyTeam MeetingsSkypeWhat's App group

Rationale The U.S. Story: VTE Is Highly Prevalent

• Estimated 260,000 cases of clinically recognized VTE occur each year in patients hospitalized for acute care1

• PE is associated with high mortality rates2 and is considered one of the most common preventable cases of hospital death3

• DVT is associated with a high risk of recurrence and post-thrombotic syndrome (PTS)4

• Effective thrombus prophylaxis is underutilized5

1. Anderson FA Jr et al. Arch Intern Med. 1991;151:933-8. 2 Goldhaber SZ et al. Lancet. 1999; 353:1386-9. 3 Clagett GP et al. Chest. 1995; 108(4 suppl):312S-334S. 4 Prandoni P et al. Haematologica. 1997; 82:423-8. 5 Geerts WH et al. Chest. 2008; 133(6 suppl):381S-453S.

Exhibit 1A – VTE Care Process Model

Framework for improvement • Multidisciplinary team • Identify current practice• Describe best practices• Formulate protocol• Operationalize protocol (order set, checklist,

multifaceted approach, etc.) • Measurement system – monitor and adjust• Account for special patients and situations • Gain institutional support - make compelling case

Discuss how you would implement the CPM?

• Knowledge gaps• False beliefs

– VTE strikes infrequently– VTE incidence is declining

• Lack of familiarity with guidelines• Guidelines not always in agreement

for certain patient groups• Concerns about adverse effects and

patient safety

What challenges would you anticipateOrder Sheet

VTE Prevention Strategies & Predicted Success

High Reliability

Redundant, Real-time Interventions >95%

Reinforced (audits and education) 70%-90%

Simple, integrated with work flow 60%-85%

Protocol exists 50%

Audit Feedback

State of Nature

Data

Alert the users

Educate the masses

Link the protocol to orders

Develop and implement a protocol

Assimilate a Consensus Building Team

40%-50%PDCA

Maynard G, Stein J. Agency for Healthcare Research and Quality. August 2008.

How would you overcome these?

All patients screened and consideredfor VTE prophylaxis

Risk factor assessment

Prophylaxis management

Exclusion criteria

Does the patient have restricted mobility andat least 1 VTE risk factor present?

Pharmacological prophylaxis for VTE indicated

Are exclusion criteria for pharmacological prophylaxis present?

Yes

No

Yes

Yes

Patient should be reassessed daily for development of VTErisk factors during

hospitalization

VTE risk factors developduring hospitalization

Mechanical measuresindicated (IPC)

IPC = intermittent pneumatic compression.

What metrics would you use to track success of the CPM?

• Measure Name: VTE Risk Assessment /VTE 1• Description:

– The number of patients who received VTE risk assessment with in 24 hours of admission

• Measure Name: VTE Prophylaxis /VTE 2• Description:

– The number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission• Or surgery end date for surgeries that start the day of or the day after hospital admission

– Not applicable if patient refuses therapy

• Measure Name: VTE with in 30 days of surgery /VTE 3• Description:

- The number of patients diagnosed with confirmed VTE during hospitalization (not present at admission) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnostic testing order date.

What alternative approaches/modifications might you anticipate • Standardize VTE and anticoagulant risk

assessment into the process of admission and transfers

• “Prompts for VTE risk assessment at point-of-care

• Scheduled reassessments • Redundant responsibility and prompts

Patient admitted to hospital

MD orders appropriate VTE prophylaxis at admission

Nurse ensures VTE prophylaxis administered

Change in patient’s VTE risk level, contraindications, or site/unit of

care

Patient discharged

35% of failures

20% of failures

VTE prophylaxis can be complicated!

Patient admitted to hospital

MD orders appropriate VTE prophylaxis at admission

Nurse ensures VTE prophylaxis administered

Change in patient’s VTE risk level, contraindications, or site/unit of

care

Patient discharged

Pharmacy dispenses and delivers drug

MD performs VTE risk assessment

MD links patient’s VTE risk level to menu of

appropriate VTE prophylaxis options

Support staff ambulates patient 3X/day

Central Supply delivers sequential compression devices or graduated compression stockings

Analyze Care Delivery: Delivering Appropriate VTE Prophylaxis

35% of failures 30% of failures

15% of failures

20% of failures

Mean Baseline Performance: 50%(% of patients on appropriate VTE

prophylaxis in the hospital)

Maynard G, Stein J. Agency for Healthcare Research and Quality. August 2008.