HRET HIIN Venous Thromboembolism (VTE) VIRTUAL EVENT Reliability and Teamwork: Assess it, Order it, Do it February 7, 2017 1
Marina Levin, MPH Program Manager HRET WELCOME AND INTRODUCTIONS 2
Agenda for Today Time Objectives Speakers 11:00 a.m. 11:05 a.m. Welcome and Introductions Housekeeping information, reviewing relevant HIIN resources, change packages and LISTSERV 11: 05 a.m. 11: 10 a.m. HIIN VTE Data Update Review HEN 2.0 performance related to VTE reductions include national percent reduction and percent reporting. 11:10 a.m. 11: 20 a.m. Driving Results Through Reliable Risk-Based Protocols Provide most recent updates and results from national efforts to support evidence-based standardized VTE risk assessment and prophylaxis ordering, along with prompt, reliable execution of orders. 11:20 a.m. 11: 30 a.m. Leveraging Collaboration to Hardwire VTE Prevention Review Parkview s journey to build successful strategies that combine strong interprofessional teamwork and electronic record solutions. 11: 30 a.m. 11: 55 a.m. What is the Secret Sauce? Participants will join the presenters to explore the relative merits of quantitative vs. qualitative risk assessment approaches, along with strategies to address common barriers to hardwiring reliable VTE processes. 11: 55 a.m. 12: 00 p.m. Bring it Home HRET HIIN upcoming events 3 Marina Levin, MPH Program Manager, HRET Vrinda Mahishi Data Analyst, HRET Ian Jenkins, MD, SFHM Professor of Medicine UCSC Hospital Medicine San Diego, CA Chris Liston, PharmD, CPHISM Clinical Informatics Pharmacist Sarah Pfaehler, PharmD, MBA, BCPS Clinical Pharmacy Manager Parkview Regional Medical Center Fort Wayne, IN Steve Tremain, MD and Betsy Lee, RN, MSPH Improvement Advisors, Cynosure Health Ian Jenkins, MD, SFHM Parkview Regional Medical Center Marina Levin, MPH Program Manager, HRET
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 http://www.hret-hiin.org/engage/listserv.shtml 4
VTE Resources HRET HIIN website 5
VTE Resources - Checklist http://www.hret-hen.org/topics/ade/2016-eliminating-harm-checklist-hrethen.pdf 6
VTE Resources Change Package http://www.hret-hen.org/topics/vte/hrethen_change%20package_vte.pdf 7
Vrinda Mahishi Data Analyst HRET VTE DATA UPDATE 8
Data Definition 9
HEN 2.0 VTE Results 10
HEN 2.0 VTE Results 33 percent relative reduction (baseline was 4.51 VTEs per 1000 patient days; final month was 2.98) with 563 hospitals reporting in June 2016. 73 percent of hospitals across 16 states met/exceeded the reduction target. 11
HEN 2.0 Lessons Learned Need to understand that VTE can impact both medical and surgical patients. Physicians need to acknowledge and use a validated simple VTE risk assessment on every patient. Need standing written orders that link risk assessment results to specific prophylaxis options. Include pharmacists to provide real-time support for prophylaxis selection to understand contraindications. Continue to implement mobility programs like UP campaign. 12
Betsy Lee RN, MSPH Improvement Advisor Cynosure Health FRAMING THE IMPACT OF VTE PREVENTTION IN THE CONTEXT OF HIGH-RELIABILITY 13
Who is Flying Under the Radar? 14
Reliability Failure free operation over time David Garvin 15
OPTIMIZING VTE PROPHYLAXIS IN 2017: Controversies and Implementation Speaker Title Institution Contact info Ian Jenkins, MD, SFHM Professor of Medicine UCSD Hospital Medicine ihjenkins@ucsd.edu 16
Controversies for VTE Prophylaxis ACP 2012 guideline No guidance Use IPC and not compression stockings Use drugs when benefit > risk (How?) Ninth ACCP guideline Use Padua score for medical patients Use Caprini score for surgical patients Menu of options for orthopedics Three complex systems per hospital Society of Hospital Medicine (SHM) experience is that doctors do not reliably use these tools SHM Mentorship Model Based on bucket model for ease of implementation Improved VTE rates at numerous hospitals Not guideline advised or RCT proven
Principles of QI: The Journey Form a team Physicians, pharmacists, information technology, executive sponsors and stakeholders Assess baseline performance Prioritize and define areas for improvement Obtain institutional support Business, safety, regulatory and human rationales for project Identify best practices and an aim statement Choose metrics and plan data collection Existing (The Joint Commission) measures; automated vs. chart review Plan and deploy interventions Learn and refine (PDSA / Kaizen) 18
The Bones A well-rounded, supported team Education (sessions and environmental) Reliable risk assessment...paired with a menu of options Additional steps to improve adherence: Pharmacy or nurse check for drugs / device Performance evaluation... Prophy, event rates; RCA Response: feedback, PDSA cycles, etc. 19
From Good to Great Self-assessment What are my prophylaxis and VTE rates? Is there preventable HA-VTE? Consider outpatient and ER cases. What were the failure modes? Aggressive mobilization programs Reduction in central lines, particularly PICC Compliance programs for mechanical prophylaxis Target high-risk patients for extended prophylaxis Orthopedic surgery patients Abdominal/pelvic cancer surgery: four weeks low-molecular weight heparin (LMWH) unless high-bleed risk* Measure-vention: Fold into daily safety checklist for inpatients 20 *Bergqvist D et al. N Engl J Med. 2002; 346:975-80, CHEST 2012 guidelines
UC-Wide VTE Collaborative, 2011-2014 Ordersets, education, and support 51 percent less 35 percent less 24 percent less UCLA UCI UCD UCSD UCSF ALL Overall only significant in surgical patients Total benefit 170 VTE / year CA = 50 percent higher risk, but rates fell less Jenkins I, White R, Amin A et al. J Hosp Med 2016
Dignity Health Collaborative, 2011-2014 35 community hospitals (nine with individual mentoring, measure-vention) Most VTE before DC Most VTE post DC 428 VTE prevented, about one-third of 1,342 / year Clearer benefit seen in medical patients, but only ~1/1,000 Jenkins, Maynard, O Bryan, Holdych; SHM 2017 Annual Meeting
AHRQ VTE Improvement Guide
SHM VTE Resource Room
Questions
Sarah Pfaehler, PharmD, MBA, BCPS Clinical Pharmacy Manager Chris Liston, PharmD, CPHIMS, Clinical Informatics Pharmacist PARKVIEW REGIONAL MEDICAL CENTER FORT WAYNE, INDIANA 26
About Us Speakers Sarah Pfaehler, Pharm D, MBA, BCPS, Clinical Pharmacy Manager Chris Liston, Pharm D, CPHIMS, Clinical Informatics Pharmacist Other team members Tara Jellison, MBA, FASHP, Pharmacy Manager Paul Conarty, MD, Chief Medical Officer Diane Barnes, BS, CPHQ, Director of Quality and Accreditation Judy Boerger, MBA, MSN, RN, NEA-BC, Chief Nursing Executive Pamela Bland, RN, MSN, CENP, Nursing Director of IP Surgical Service Line Jackie Myers, RN, MSN, CPPS, CENP Nursing Director, Inpatient Medical Services Karen Dunkelberger, RPh, CPPS, Medication Safety Coordinator 27
Parkview Regional Medical Center Not-for-profit community health care system Serves northeast Indiana and northwest Ohio Two acute care campuses 4,700 employees 757 medical staff members 305 physicians 650 total beds
VTE Interventions - Progress 25 Perioperative Pulmonary Embolism or DVT 25 Rate - Perioperative Pulmonary Embolism or DVT - Per 1000 Inpatients Count - Perioperative Pulmonary Embolism or DVT Linear (Count - Perioperative Pulmonary Embolism or DVT ) 20 18 21 19 15 10 5 12 8 11 9 11 6 10 3 4 3 13 9 5 6 11 3 3 5 6 5 6 6 3 5 4 6 7 7 11 9 0 1 1 Pharmacist Assessment and Recommendation Pharmacist to Nurse Transition Nurse Assessment on Admission with Physician Follow-up Physician Assessment and Completion through CPOE
VTE Prophylaxis Summary 2008-2009: pharmacy review and recommendations Electronic medical records (EMR) generated reports with documented risk factors in order for all admitted patients to receive appropriate recommendations for risk based VTE prophylaxis measures. Recommendations were completed using paper chart recommendation forms. 2009-2011: pharmacy and nursing transition Pharmacy recommendations to nursing admission assessment went live, unit by unit, after provider and nursing education was completed per unit (14 month process). 2011-2013: nursing admission assessment and follow-up Nursing performed admission assessment documenting patient status on all risk factors. EMR generated risk category which populated an order set for printing and placement on chart. Order set included listing of prophylaxis choices with text guidance. Daily reports for nursing about which patients had not received prophylaxis orders. 2013-2016: physician assessment and orders EMR provided alerts to complete assessment. Risk factors were listed as text for provider to review along with listing of prophylaxis choices with text guidance on appropriate direction. 2017 smart functionality included in VTE choices Using documented patient parameters to provide the risk category along with the recommended prophylaxis choice.
Ian Jenkins, MD, SFHM Professor of Medicine UCSD Hospital Medicine Steve Tremain, MD and Betsy Lee, RN, MSPH Improvement Advisors Cynosure Health WHAT IS THE SECRET SAUCE? 31
Strong QI Interventions Standardize work One order set, or few exceptions (orthopedic) Guidance at the point of care: protocols / experts / warnings Embed advice about risk level, plus glomerular filtration rate (GFR), weight and age Ideally, computerized physician order entry (CPOE) advises Redundancy for key processes Physician, CPOE or pharmacist check GFR Default the best choice? Don t pre-check a drug Force function Do require risk level Do require an intervention
Suggested Risk Levels HIGH: The Three Bucket Model* -- Our approach but not the only one -Major orthopedic surgery -Multiple major trauma/acute cord injury with paresis -Intraperitoneal, craniotomy or spine CA surgery -Critical illness MEDIUM: LOW: -Moderate/major surgery plus impaired mobility or any other risk factor -Active CA plus acute illness or other risk factor -Acute medical illness plus reduced mobility, prior VTE or thrombophilia -Expected length of stay< 48 hours or observation status -No longer/never ill or awaiting placement -Ambulatory CA patient in for chemotherapy -Ambulatory patients not meeting MEDIUM or HIGH criteria Modified from AACP 8 and updated for ACCP 2012
Dialogue and Questions 34
Marina Levin, MPH Program Manager HRET BRING IT HOME 35
Upcoming HRET HIIN Virtual Events I Screen, You Screen, Let s All Screen for Sepsis! February 9 11:00 a.m. 12:00 p.m. CT Download agenda Register here Adjuncts and Alternatives to Opioids for Pain: It s All About Love February 14 12:00 p.m. 12:50 p.m. CT Download agenda Register here Up Campaign: The Way Up February 16 11:00 a.m. 11:50 a.m. CT Register here 36
Thank You! Find more information on our website: www.hret-hiin.org Questions or Comments: HIIN@aha.org 37