Simple 'Three Bucket' Tool Helps Prevent Huge Cause of Inpatient Death

Cheryl Clark, June 9, 2010

What preventable hospital-acquired condition causes the most hospital mortality, or an estimated 100,000 to 200,000 acute care deaths a year, more than the number dying annually from breast cancer, AIDS, and traffic accidents combined?

If you answered falls or infections or medication errors, you'd be incorrect. But if you answered blood clots, by which we mean venous thromboembolism (VTE), you would be right on the money.

VTEs, including pulmonary embolism and deep vein thrombosis, are a growing nightmare for hospitals, not just because they are potentially preventable, but also because patients who survive them have inpatient costs of an additional $10,000 to $20,000 per year.

The Centers for Medicare and Medicaid now does not reimburse hospitals when they occur in hip or knee surgery orthopedic patients in inpatient settings.

Unfortunately, only about half or fewer of hospitalized patients who are at risk of VTE are getting the preventative care they should, says Greg Maynard, MD, chief of the Division of Hospital Medicine at the University of California San Diego Medical Center.

With so few hospitals looking to enact solutions, the problem is not going away. In 2008, acting U.S. Surgeon General Steven K. Galson, MD, issued a VTE "Call To Action" in which he said, "There's a big, big gap between what could be and should be, and what is," and "the majority of individuals who could benefit from such proven services do not receive them."

The report continued, "Too few health care professionals are aware of the evidence-based practices for identifying high-risk patients and providing preventive, diagnostic, or therapeutic services."

Not all VTE can be prevented, but Maynard says that 30% to 60% can be averted if the right patients are given prevention medications, and are monitored every day by a physician to make sure the patient's risk factors have not changed.

The key, he says, is to make the assessment process simple and fast, one that's built right into the admissions and transfer order sets.

That's what he and his colleagues at UCSD have developed. And so far it has successfully reduced hospital-acquired VTE incidents by 40%, and preventable hospital-acquired VTE by more than 85%.

"The last thing you want is a three-page VTE prevention order set," which he says hospital staff find difficult to use so they don't.

With funding from the Agency for Health Research and Quality (AHRQ), Maynard and colleagues tested an extremely simple "Three Bucket" tool (Venous Thromboembolism (VTE) Prevention in the Hospital: Slide Presentation) that allows hospital providers to categorize patients easily into one of three groups, based on whether they are at low, moderate or high risk of getting VTE.

The Assessment Model for VTE Risk comes in the form of physician order sheet that easily fits on a 3" x 5" index card.

"This can be completed by the physician in seconds," he says.

  • Low Risk – Patients under observation, with an expected length of stay less than 48 hours, patients being treated with minor ambulatory surgery or patients who are under age 50 with no other risk factors, or patients who are already on anticoagulation medications.
  • Moderate Risk – This moderate risk category is the largest group of patients, representing most general medical / surgery patients. Representative risk factors are congestive heart failure, pneumonia, active inflammation disease, advanced age, dehydration, varicose veins, limited ambulation, and obesity. In other words, this large category describes all inpatients not in the low or high-risk categories.
  • Highest Risk – Patients undergoing hip or knee arthroplasty, those with acute spinal cord injury with paresis, multiple major trauma or those undergoing abdominal or pelvic surgery for cancer.

Physicians prescribing for the patients in the highest risk category can offer more aggressive pharmacologic prophylaxis (low molecular weight heparin or fondaparinux, for example) and mechanical prophylaxis, while unfractionated heparin every 8 hours or low molecular weight heparin are offered to those in the moderate risk category.

Patients at risk of VTE with contraindications to pharmacologic prophyhlaxis are routinely placed on mechanical prophylaxis (sequential compression devices or graduated compression stockings), and education and early ambulation are offered to all patients.

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