VTE Prevention Workflow Processes
VTE Includes both DVT and PE Both PE and VTE remain a significant cause of morbidity and mortality despite the availability of effective therapies for prophylaxis
Current Processes Identify the current processes for VTE risk assessment and prophylaxis Hybrid Clinical Information System (CIS) that included both electronic and paper
Current Process: VTE Screening & Prophylaxis Only visual cues for physician to complete VTE risk assessment
Paper Form: Risk Assessment
Paper Form: Recommended Prophylaxis
Electronic VTE Prophylaxis Order Set Physician would need to complete risk assessment before selecting appropriate order set
New Tool: Discern Advisor It is a proactive and interactive approach to Clinical Decision Support Provides the ability to complete risk assessment and orders with a one step process Can only be done electronically
VTE Discern Advisor VTE Discern Advisor window will appear
VTE Discern Advisor: Risk Factors
VTE Discern Advisor: Contraindications to Pharmacologic Prophylaxis
VTE Discern Advisor: Additional Risk Factors
VTE Discern Advisor:
VTE Discern Advisor: Recommended Prophylaxis Orders
VTE Discern Advisor: Reset or add orders for signature
VTE Discern Advisor: Proceed with signing orders
Entire New Process Since this was a plug and play intervention provided by the vendor, it required us to re-define our processes to implement the new tool
Identifying Stakeholders Physicians Nursing Quality Team Case Management Team Chief Nursing Officer Chief Medical Officer
Questions from Stakeholders? 1. Since this is electronic, how will be make the non-cpoe physicians use this? 2. Do we expect the physicians to use this 100% of the time? 3. By when do we expect a physician to complete this? 4. As a physician, I always order prophylaxis irrespective of risk. Are you telling me that I still have to complete risk assessment
Questions from Stakeholders 5. What if the physician asks nursing to complete the risk assessment? 6. Does nursing have to check with physician to make sure screening and prophylaxis is completed? 7. Are we supposed to do this on all of our patients?
Answers to questions 1. We will give privileges to all physicians so that they could use this tool electronically 2. We encourage the physicians to use this 100% of the time 3. We expect physicians to complete risk assessment and/or prophylaxis within 24 hrs of admission 4. You do not have to use this tool, however we encourage you to use it.
Answers to questions 5. Only physicians should complete the risk assessment using this tool 6. We will have nursing check with physician if risk assessment and/or prophylaxis is not completed 7. We will be doing this on all of our inpatients (>18 yrs)
Input from Stakeholders Nursing: We will need a task to remember which patients to monitor for VTE compliance Can this task become overdue only after a certain period of time? Can this task automatically go away if physician completes risk assessment and/or prophylaxis? Can we document that we contacted the physician for compliance
Input from Stakeholders Physician: Could you remind us to do this before nursing contacts us? If I order a qualified VTE Prophylaxis order, I do not want to be called.
Future Process: After several revisions
Nursing Order: Upon Admission This DVT/PE Prophylaxis Physician Notification order is automatically ordered upon admission for all inpatients aged 18 and greater.
Nursing Task Task becomes overdue after 12 hrs of admission
Nursing Process At this point of time, nursing will initiate a call to the attending physician and recommend completing VTE risk assessment and prophylactic order is required. The physician could at this time give an everbal order for prophylaxis or complete the VTE risk assessment and prophylactic orders on his own by logging into the patient s chart
Nursing Process If physician completes VTE risk assessment or VTE prophylactic orders at any point of time, the nursing order and task is canceled automatically
Post Go-Live: Lessons being learnt It is hard to enforce physicians to utilize the tool There is a lot of difference between seeing a demo or presentation of the tool and actually using the tool on your patients. Hence technical difficulties with using the electronic tool Nursing initiating call to wrong physician
Moving Forward Using a single point of contact for communicating with physician for VTE noncompliance Not making the task for nursing overdue at any point of time Continue to drive this initiative from top down engaging leadership and disseminating information