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How Hospitals Prevent VTE

 |  By cclark@healthleadersmedia.com  
   November 27, 2012

This article appears in the November 2012 issue of HealthLeaders magazine.

It's been four years since the U.S. Surgeon General stunned providers with these numbers about rates of preventable death and harm:

 

 

  • 350,000 to 600,000 Americans a year suffer poor health outcomes because of blood clots, and 100,000 of them die
  • The single biggest risk factor is the care provided in hospitals
  • Far too few clinicians use interventions such as drugs that could prevent more than one-third of these clots

Still, hospital-associated venous thromboembolism remains a major preventable public health problem during and within 90 days of acute care.

"There has been a lot of movement, and hospitals are starting to see some results," says Greg Maynard, MD, a nationally recognized champion in acute care VTE prevention and director of the Center for Innovation and Improvement Science for the University of California, San Diego, where he previously served as chief of hospital medicine.

But in most hospitals across the country, this major problem persists. Maynard says that based on his success at UCSD, half of hospital-associated blood clots occurring today could be prevented with better patient risk assessment and tighter adherence to appropriate drug or mechanical prevention strategies.

"For the majority of hospitals, they think they've done something because they've created an order set for VTE prophylaxis, but they don't know if it's working. They haven't been tracking the numbers. And they're really not measuring anything significant," Maynard says. Joint Commission and Surgical Care Improvement Project measures, now being reported for some conditions, set the bar for success far too low, he says.

"For example, the Joint Commission measures say that to 'pass' you have to have your patient on some prophylaxis in the first 24 hours or say why they're not." Compliance with guidelines is met for even the highest-risk patients if they are on any prophylaxis, rather than on the right prophylaxis, he says, even if they are on a mechanical compression device when a more appropriate anticoagulant medication is safer.

And, Maynard says, requirements today don't push clinicians to change the orders if the patient's situation changes a few days after admission. "In fact, TJC measures don't look at any point in time except the day of admission or transfer to the ICU."

Maynard has tried to simplify risk assessment for all patients with his three-bucket model, which he says led to a 40% reduction in UCSD's rates of VTE over four years. Patients are put into low-, moderate-, or high-risk categories on admission, with only the lowest-risk patients not receiving some form of prophylaxis.

Daily color-coded reports classify all inpatients according to what kind of VTE prophylaxis is in place. This provides measurement on prophylaxis patterns, and allows frontline staff to focus on patients who are on no prophylaxis or mechanical methods only. "This daily measurement, linked with concurrent intervention to address lapses in care, is a powerful strategy we call measure-vention," Maynard says.

Several organizations have started incorporating Maynard's three-bucket model, including the 650-bed Banner Good Samaritan Hospital in Phoenix.

"We've seen a drop in preventable VTE from 45% in 2009 to 25% in 2011," says Lori Porter, DO, head of Banner's VTE prevention initiative. "We were rather aggressive in saying anyone over 40, acutely ill, or having surgery qualified for pharmacologic therapy and some mechanical compression devices," and without an increased risk of hemorrhage or heparin-induced cytopenia.

Now, she says, "we can say with confidence, the three-bucket model is working."

Costs of caring for VTE events can be huge, and Medicare refuses to pay for extra care when VTE occurs in patients undergoing total hip or knee replacements. 

One study of hospitalization costs paid by 30 managed care organizations 10 years ago described costs of $7,594 to $16,444 per patient for added care related to VTE. In another study by UC Irvine researchers in 2010, appropriate VTE prophylaxis resulted in a nearly $2,000 lower cost per discharged patient for 21.7% of patients, compared to the cost for caring for the 78.3% of patients who received partial prophylaxis.

But barriers to VTE prevention are numerous. Many clinicians don't want to administer blood-thinning medications like heparin because they have an exaggerated fear of causing a bleed or a hemorrhage, Maynard and other VTE experts explain. And if patients look healthy, physicians may underestimate the VTE risk, they say. Compounding the problem is the failure to reassess patients' risk routinely during their hospital stay, Maynard says.

"We have failed at providing adequate DVT/PE prophylaxis on a more standardized way across the country," says Geno Merli, MD, chief medical officer and senior vice president of 969-bed Thomas Jefferson Hospital in Philadelphia. "We have a few great places that are champions, but the great majority of hospitals don't do it effectively."  He adds that doctors worry about many other issues first, such as infections.

But with more aggressive federal mandates for public reporting of certain blood clot measures expected, followed by pay-for-performance and bundling incentives, the heat is on for hospitals to improve their hospital-associated VTE rates. This is a concern for increased lengths of stay, 30-day mortality, and readmissions penalties, especially since 30 days postdischarge is when many of these events occur.

"Readmission rates for VTE are just about as high as they are for congestive heart failure, in the 20% range," Maynard says.

In February, the American College of Chest Physicians produced its 9th edition thrombosis guidelines. But it's a lengthy document with multiple chapters and more than 600 recommendations, and VTE prevention is only a small part of it. Besides, several VTE experts say, the document is too complicated for the average clinician to follow.

"In an effort to be more rigorous, the new guidelines avoid giving strong recommendations for certain patient groups, leaving improvement teams to standardize practice in the face of guidelines that provide less guidance than previous versions of the ACCP's reviews," Maynard says.

Mark Metersky, MD, chair of the ACCP's Guidelines Oversight Committee, acknowledges the complaints, but says critics have exaggerated the issue, and that the summary has a specific section on VTE prophylaxis.

"Nevertheless, a guideline is only as useful as it is accessible, and we're taking steps to improve that" with development of Web-based tools with yearly updates instead of every three or four years, and creation of applications for handheld devices, he says, adding that the guidelines were less specific in many areas because the committee determined that research was lacking or didn't meet its strict criteria. 

Scott Grosse, PhD, a VTE expert with the Centers for Disease Control and Prevention, says that concerns the ACCP's guideline is "hard to implement" and lacked "a clear protocol" for how to do risk-based screening, prompted the CDC to weigh in. It's a concern for the CDC, which wants to develop a national hospital VTE reporting system similar to that in place for central-line bloodstream infections through the National Healthcare Safety Network, Grosse says.

As the associate director for health services research and evaluation in the division of blood disorders of the CDC's National Center on Birth Defects and Developmental Disabilities, Grosse would like to see a nationally run reporting system for hospital-acquired VTE.

With an eye to that project, the CDC has asked Merli to develop two documents. The first is a one-page simplification of the VTE problem. This will gear to the C-suite, specifically the CEO, CMO, COO, or CNO, expected before the end of the year.

Merli says the new guideline for the C-suite will explain on one sheet "what the problem is, what government regulations are coming, such as requirements for reporting, and what information, tools, and guidelines are out there."

He adds that most hospital executives don't have this on their radar yet. They don't realize that not only does VTE increase patient length of stay, which increases costs, but soon, VTE also will become a reportable hospital-acquired condition, which will be reported nationally in Hospital Compare. "CEOs need to drive this process," Merli says.

"The CEO will read this and say, 'We have got to do this,' will take it to their technology people and say, 'Let's put this in our electronic health record system, or if we don't have an EHR, let's do order sets or pathways.' "

By mid-November, Merli's group will complete a second document, this one a 10- to 15-page synopsis about VTE prevention geared to clinicians and the C-suite. Merli says that VTE experts around the country are working to create a three-part document that offers practical recommendations for VTE risk assessment, bleeding risk assessment, and recommendations for preventing VTE.

"We're going to make it easy for them to follow the process; give them something that's not confusing.

The guidance may not pass the ACCP's strict standards for guidance, but it's based on the best experts'
clinical judgment.

Merli says that because the problem is still so enormous but preventable, "what I think this is all going to come to is that every hospital in the country is going to have to report its VTE hospital-acquired condition rate, like we report infections."

At Jefferson, Merli says, VTE prophylaxis and risk assessment systems are so strict, the computer system will not let physicians place further orders unless the patient is risk assessed and appropriate prophylaxis against VTE is placed.

"Our model is such that it pushes the physician through the process," Merli says. "The first thing it asks you is, what is the patient's risk of DVT? The second thing it asks is if the patient has some risk, what surgery are they having, and if it's orthopedics, for example, you click on that and it tells you the recommended prophylaxis."

At Jefferson today, Merli says, 98% of patients who should receive prevention strategy get it. Another benefit of this strategy is that it helps reduce the need for purchasing drugs and compression sleeves that aren't needed, an attractive motivation for hospitals today.

Gregory Piazza, MD, a member of the 793-bed Brigham & Women's Hospital VTE research group in Boston and a director of the North American Thrombosis Forum, agrees with Merli and Maynard that complex guidelines and patients keep many hospitals from preventing VTE death and morbidity in their patients.

"We haven't isolated one risk stratification tool that everybody can use, and some of the tools we have are
very complex."

Because of that, he says, "we still have a lot of work to do yet to educate the medical community about how serious in-hospital VTE is. Physicians and other providers just have so much on their plates, and to be truthful, the type of patients they see in the hospital or in the ER are so incredibly complicated. It's not just pneumonia, but also blood sugars out of control, kidney function, impaired heart failure.

"VTE prophylaxis is not one of the top five or 10 things that need to be addressed. But what we need to do is remind them it has to be a priority."

But times are changing rapidly for this field of medicine, he says. "You'll be hard-pressed to find another field in medicine that's undergoing the frequency and extensive changes that VTE is. And we have new medications coming out every month and new studies showing efficacy and safety of each agent."

At Brigham & Women's, one important project several years ago used an electronic alert system that notifies providers when their patients were at risk of VTE, but weren't on appropriate prophylaxis.

"We devised a computer program that could look at a patient's chart online, pull out risk factors and generate a score, and if they fell into a certain risk category, an electronic alert would show up on the screen," Piazza says.

Over a 90-day study period, physicians not only raised the number of patients who received appropriate prophylaxis, but "also reduced symptomatic DVT and PE by over 41%" for as long as 90 days after patients left the hospital, an important measure since hospital-associated VTE risk factors are increased just after discharge.

But Piazza says there's still room for improvement in three major areas.

Just because there's an electronic alert doesn't mean physicians followed it, and in some cases providers didn't agree with the computer's assessment of the patient's risk. "Maybe the patient looked to the physician to be a lot better than the risk score implied."

Also, he says, in hospitals throughout the United States, often patients refuse doses of anticoagulants, perhaps because they were anxious about getting an injection. To deal with that, Brigham & Women's implemented a 500-patient study. "Pharmacists visited each patient and explained why they personally were at risk for VTE, and why they needed this anticoagulation medicine. We were able to increase the number of patients who got all their doses to 95%."

Another priority is trying to follow high- or moderately high-risk patients after they leave the hospital, who often end up back in the hospital with a "present on admission" VTE. "We know that because of pressure to discharge patients and shorter lengths of stay that some patients go home earlier, and while that's safe, they're recovering and not as mobile as they might be, and they're still at risk for VTE. But we don't know if or how long continued doses of anticoagulation medicines really provide protection."

That's an area that needs more work.

The nation's VTE experts, including those at the CDC, say that hospitals are only in the earliest stages of understanding how much VTE death and illness they can prevent with better stewardship in the care process, not just from admission, but to weeks or months after discharge.

Maynard says that the proof is evident when protocols are implemented. "When we did it, we got fewer VTE and no increase in bleeding or HIT. I fear the clot more than I fear the risk of bleeding from anticoagulants."

"Hospitals' chance of success, if they follow certain principles, is high," says Maynard. "It just needs leadership's support, for standardization and measurement, to follow the right road map."


This article appears in the November 2012 issue of HealthLeaders magazine.

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