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.
By using this tool, instead of other strategies which take a lot longer and often involve complex mathematical calculations or require following pages, Maynard and colleagues at UCSD found amazing results.
When they categorized their patients in this way, the number of patients in the hospital who were given blood-thinning medication went from 40% to 70%. "The rest were either low-risk or were contraindicated," he says. Detailed audits on randomly selected inpatients revealed improvement from 50% having adequate prophylaxis, as defined by the above protocol at the onset of the improvement effort to over 98% having adequate prophylaxis currently.
"High rates of adherence to the VTE protocol resulted in a 40% decline in the incidence of hospital acquired VTE in our institution," he wrote in a summary of the experiment in the January issue of the Journal of Hospital Medicine.
"This is really pretty low-hanging fruit," Maynard says.
In 2008, Lancet published the ENDORSE report by British researchers, who looked at 70,000 patients in 358 U.S. hospitals, and found only 39.5% of medical patients and 58.5% of surgical patients received drugs such as heparin or enoxaparin or have sequential mechanical compression devices applied. The study was called the Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting.
Maynard says hospitals aren't doing what they need to do for a number of reasons.
In the November issue of the Journal of Thrombosis and Thrombolysis, he and co-author Jason Stein wrote that physicians lack familiarity with prevention guidelines or disagree with them. Some underestimate their patients VTE risk, or have concerns that any medication they give the patients will cause them to bleed. Most believe that protocols to assess risk are "resource intensive or difficult to implement in a practical fashion."
Many hospitals and doctors have just gotten into the habit of accepting VTE as unavoidable part of hospital care.
They absolutely should not, says Maynard.
He says that hospital officials need to get more concerned about preventing VTE because "the Stick" is coming. Not only does the National Quality Forum endorse these and other measures, but the Centers for Medicare and Medicaid Services will not reimburse for care of a patient with a hospital-acquired DVT or PE that occurs with a knee or hip replacement. Instead, reimbursement is paid "as though the complication had not occurred." CMS may soon extend that non-reimbursement rule for the care of any patient who gets a preventable VTE.
Also, public reporting of hospitals' incidence of VTE is likely to come soon, and the Joint Commission now offers hospitals the option of using VTE as one of their core measures for evaluation on certain services, a measure that may soon become mandatory, and hospital-wide rather than just confined to the orthopedic service, Maynard says.
Today, Maynard explains, several hundred hospitals are using the tool and getting experience through collaborative efforts organized by the Society of Hospital Medicine, the Institute for Healthcare Improvement Expedition to Prevent VTE, AHRQ, and other entities.
"We thought we were on to something several years ago and started telling people how to do this even before we had great data," Maynard says. Even before they had a chance to publish, he says they "had enough data to know that it was working."
Maynard says that the Three Bucket approach gets hospitals a long way toward reducing VTE mortality and morbidity rates, but it's not the only thing that's needed.
"You also have to have the right infrastructure, the right institutional support and the ability and will to standardize the prevention process," he says. That requires an interdisciplinary team, " a lot of medical leaders, the nurses and pharmacists, all onboard with this process to get this done." Other strategies, such as pharmacist review of all orders for patients who are not on prophylaxis, would reduce the VTE death rate even more.
With so many lives at stake, that sounds like something every hospital would want to do.
Note: You can sign up to receive HealthLeaders Media Community and Rural Hospital Weekly, a free weekly e-newsletter that provides news and information tailored to the specific needs of community hospitals.