HRET HIIN VTE Virtual Event. VTE Prophylaxis: Strategies to Decrease Patient Refusals August 15, 2017
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1 HRET HIIN VTE Virtual Event VTE Prophylaxis: Strategies to Decrease Patient Refusals August 15,
2 WELCOME AND INTRODUCTIONS Lisandra Cuadrado, Program Manager HRET 2
3 Webinar Platform Quick Reference Mute computer audio Today s presentation Chat with participants Download slides/resources Register for upcoming events 3
4 Agenda for Today 4
5 Poll: How did you hear about this event? How did you hear about today s virtual event? a. HRET HIIN flyer b. HRET HIIN website c. HRET LISTSERV d. State hospital association e. QIN-QIO f. Your organization/colleague g. Other, please specify 5
6 HIIN VTE DATA REVIEW TBD, Data Analyst HRET 6
7 VTE Rates 7
8 Steve Tremain, MD, FACPE Improvement Advisor, Cynosure Health LET S GET FOCUSED! FRAMING THE DISCUSSION 8
9 Polling Question Do you have a standard VTE risk assessment that drives prophylaxis orders? a. Yes, it is built into the physicians workflow and it must be used. b. Yes, but it is optional. c. No. 9
10 Polling Question Do you track patient refusals for VTE prophylaxis, AND have a process to reduce refusals? a. Yes. b. No. c. Never really thought much about this. 10
11 Effective VTE Prophylaxis 3 parts: Standard Risk Assessment + Risk Assessment drives orders + Orders reliably implemented. Any one failure in this cascade undermines VTE prevention. 11
12 Effective VTE Prophylaxis = Prophylaxis No Partial Credit 12
13 WHAT DO WE DO WHEN THE PATIENT SAYS NO? HRET HIIN VTE Virtual Event August 15, 2017 Anthony D. Yang MD, MS, FACS Assistant Professor of Surgery, Division of Surgical Oncology, Dept. of Surgery Associate Director, Surgical Outcomes and Quality Improvement Center Feinberg School of Medicine, Northwestern University & Associate Director, Illinois Surgical Quality Improvement
14 Essential Partners Thanks to: Arley Weitman, RN (Clinical Nurse, 12West Feinberg, Northwestern Memorial Hospital) Sarah Cummins, RN (Clinical Coordinator, 12West Feinberg, Northwestern Memorial Hospital) Lindsey Werth, RN (Patient Care Manager, 12West Feinberg, Northwestern Memorial Hospital) Units: 12 West, 11 East, 14 East, 13 West, 14 West SOQIC Team: Julie Johnson, Lindsey Kreutzer, Brock Hewitt, Christina Minami, Karl Bilimoria
15 Disclosures Supported by grant funding from the American College of Surgeons
16 VTE is Important Clinically Deep venous thrombosis / pulmonary embolism 10,000 deaths per year #1 Cause of Preventable Inpatient Death Increased LOS, costs, morbidity
17 Ideal VTE Prophylaxis 1. Early Ambulation Ordered Ambulation occurs 2. Mechanical Prophylaxis (SCDs) Ordered Applied Working 3. Chemoprophylaxis Ordered Correct dose Correct frequency No missed doses 1. Kinnier, et al; Medical Care, Haut, et al; JAMA Surgery, ACCP Guidelines, 9 th Ed; Chest, 2012
18 VTE Prophylaxis Composite Measure Customized process measure based on overall adherence to all 3 components of best-practice VTE prophylaxis ( composite ) Well-defined definitions Appropriate exceptions Designed to identify actionable failures based on the 3 components
19 Reasons for Chemoprophylaxis Failure
20 Patient Refusals of VTE Chemoprophylaxis by Unit General Medicine Unit A General Medicine Unit B General Medicine Unit C 15.5 Surgical Unit A 9.9 Surgical Unit B 6.1 Best Practice Unit (Surgical) % of doses refused by patient
21 NURSING LEVEL INTERVENTIONS A CASE STUDY FROM ONE HOSPITAL
22 Stakeholder Support 4 units with highest rates of patient refusal: 2 medical 2 surgical Multidisciplinary team Nurse Managers Clinical Coordinators Floor nurses Residents Qualitative Researchers Quality Improvement Experts
23 Qualitative Evaluation Observations of chemoprophylaxis administration 1-3 per unit Focus groups with day and night shift nurses 3 per unit Topic areas covered: Perceptions on VTE guideline-recommended care How nurses discuss prophylaxis with patients How nurses handle patient refusals
24 2 Knowledge Barriers Misconception that all 3 components of prophylaxis are not necessary If they [patients] are independent, then I ll be like if you re going to be up and walking, that s okay. But you know if they re not getting up and walking, then that s another ballgame where you have to say hey, we need you to either walk or you re going to have to get a shot -[high patient refusal rate unit nurse]
25 Barriers: Patient Education Resources Lack of patient education materials to supplement nurse speech Lack of materials to entice patients to walk the unit and help them keep track of distance travelled
26 Skill Barriers Nurses felt unprepared for patient refusals in nursing school I don t really remember them talking about patients refusing things and... I just thought nursing was like okay, here I m coming with your medicine and everybody takes it. -[high patient refusal rate unit nurse] Nurses were not aware of their patient refusal rates
27 Customized Interventions Bundle 1. Updated patient/family education materials
28 Customized Interventions Bundle 1. Updated patient/family education 2. Ambulation bulletin boards on units
29 Customized Interventions Bundle 1. Updated patient/family education 2. Ambulation bulletin boards on unit 3. Johns Hopkins online nurse education module
30 Unblinded Unit-Based Nurse-Level Patient Refusal Reports
31 Chemoprophylaxis Administration Report Venous Thromboembolism Prophylaxis Feinberg 12 W Unit June Update In order to provide each unit with information on the rates of patient refusal for chemoprophylaxis administration, we have developed this initial report. Your individual performance and performance relative to other NM nurses in your unit is shown. It is reported in the format: Name (number of refusals/number of administrations). If you want to see your real time performance, please ask your manager who can access that data through the VTE report on the EDW. A handout titled Preventing Blood Clots While in the Hospital is available as a resource to provide to patients and their families if they want additional information or are refusing VTE prophylaxis. It is available on NMI or on the revised nm.org website within the overview for the Am Having Surgery section. If you scroll to the bottom of the page, there is a section titled related resources.
32 Chemoprophylaxis Patient Refusal Rate over Time January June 2017
33 Outstanding Nurses with 0 Patient Refusals in the month of June Tirza Hernandez leads with 0 refusals out of 62 administrations! Hernandez, Tirza (0/62) Rochester, Laura (0/58) Mara, Meridith J (0/57) Manierski, Sarah (0/49) Wimmer, Alexandria (0/49) Mathieson, Ella (0/34) Labordo-Nava, Lilibeth (0/30) Pardee, Ann (0/30) Valadez, Erika (0/28) Weitman, Arley (0/28) Badu, Abena (0/26) Edades, Maria (0/26) Griesmaier, Elizabeth (0/26) Bachman, Amy (0/18) Konz, Beth (0/11) Awolola, Yejide (0/8) Johnson, Mauvette (0/3) Toure, Deborah (0/3) Cummins, Sarah (0/2) Davis, Shelby (0/2) Friel, Kelly (0/2) Lipes, Lauren (0/2) Valadez, Veronica (0/2) Hanshaw, Kristen M (0/1) Haymon, Tracy (0/1) Quandt, Reagan (0/1) Schleicher, Rebecca (0/1) Wcislo, Anne (0/1)
34 Chemoprophylaxis Patient Refusal Rate June 2017 NMH Best Performing Unit, Feinberg 14 W (Refusal Rate 1.7%) Feinberg 12 W Average Patient Refusal Rate (Refusal Rate 4%)
35 Customized Interventions Bundle 1. Updated patient/family education 2. Ambulation bulletin boards on unit 3. Johns Hopkins online nurse education module 4. Unblinded Unit-Based Nurse-Level Patient Refusal Reports
36 Interactive patient refusal simulation sessions
37 Interactive patient refusal simulation sessions
38 Effectiveness Do you intend to do anything differently as a result of today s workshop? Rating Comfort with VTE Proph Conversation PRIOR to session Comfort with VTE Proph Conversation AFTER session 0 Yes No N = 122 nurses, # Sessions = 17
39 Customized Interventions Bundle 1. Updated patient/family education 2. Ambulation bulletin boards on unit 3. Johns Hopkins online nurse education module 4. Unblinded unit-based nurse-level patient refusal reports 5. Interactive patient refusal simulation sessions
40 Effect of Interventions Unit VTE Chemoprophylaxis Refusal Rate Refusal Rate (Data) Lower Limit Upper Limit Average Refusal Rate
41 Celebrating Victories
42 Next Steps Working into curriculum How to deal with turnover Work with physicians (residents and attendings) More patient input
43 HOW CAN NURSES IMPROVE PATIENT ACCEPTANCE OF PROVEN PROPHYLAXIS METHODS? Arley Weitman, BSN, RN, Clinical Nurse, 12 West Feinberg Sarah Cummins, BSN, RN, Clinical Coordinator, 12 West Feinberg Lindsey Werth, BSN, RN, CMSRN, Patient Care Manager, 12 West Feinberg Northwestern Memorial Hospital 43
44 HOW CAN NURSES IMPROVE PATIENT ACCEPTANCE OF PROVEN PROPHYLAXIS METHODS IN COMMUNITY HOSPITALS? Cindy Lee, RN, Director of Orthopedics, St. Alexius Medical Center Jacqueline Maklezow, RN MSN ONC, 3E Nursing Director, Alexian Bros Med Ctr AMITA Health, Illinois 44
45 Open Discussion 45
46 BRING IT HOME Lisandra Cuadrado, Program Manager HRET 46
47 VTE CHANGE PACKAGE Link to VTE Change Package: For more resources on VTE prevention, see 47
48 VTE TOP 10 CHECKLIST Link to VTE Top 10 Checklist: ecklist.pdf 48
49 LISTSERV Join the LISTSERV Ask questions Share best practices, tools and resources Learn from subject matter experts Receive follow up from this event and notice of future events Sign up at 49
50 Thank You! Find more information on our website: Questions or Comments: 50
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