Multidisciplinary Team Approach to Venous Thromboembolism Prophylaxis: A 10-Year Collaborative Journey Elliott R. Haut, MD, PhD, FACS Vice Chair of Quality, Safety, & Service Associate Professor of Surgery & ACCM & Emergency Medicine & Health Policy / Management @elliotthaut #AHPeriopIG #ARM17 June 24, 2017 AcademyHealth #ARM17 New Orleans, LA
Why focus on VTE? • VTE is common – 350,000 to 600,000 Americans suffer DVT and/or PE each year http://www.surgeongeneral.gov/topics/d eepvein/calltoaction/call-to-action-on- dvt-2008.pdf
Why focus on VTE? • VTE is Deadly – >100,000 deaths per year • More deaths than combined from – Breast Cancer – Motor Vehicle Collisions – AIDS http://www.surgeongeneral.gov/topics/d eepvein/calltoaction/call-to-action-on- dvt-2008.pdf
Johns Hopkins DVT Symposium 2009
Surveillance Bias and Public Reporting of VTE @elliotthaut #ARM17 #AHPeriopIG
How did I get interested in VTE? • Adult Trauma Performance Improvement • Paraphrased letter we received • Dear Johns Hopkins Adult Trauma • You have the highest DVT rate of all Trauma Centers in Maryland • Why? • Sincerely, Maryland Institute for Emergency Medical Services Systems (MIEMSS)
A New Research Idea is Born • Johns Hopkins screens aggressively • What do other trauma centers do? • Does this impact reported DVT rates?
Should we Screen High-Risk Trauma Patients for DVT? Conflicting Guidelines vs. Rogers, J Trauma 2002 Gould, CHEST 2012
Single Center (JHH)- Duplex & DVT rates Before v. After Screening Guideline 100 * ** 10 82 DVT/PE Rate per 1000 Trauma Duplex Rate per 1000 Trauma 7 80 8 60 6 Admissions Admissions 40 4 21 20 2 0.7 0 0 Before (1995-1997) After (1999-2005) Before Vs. After Periods p<0.0001 Haut, J Trauma 2007 p=0.0024 Duplex DVT PE
Multi-Center (NTDB)- Hospital Level Duplex & DVT rates • Trauma centers with higher rates of duplex ultrasound report higher DVT rates to the National Trauma Data Bank Pierce, J Trauma 2008
The More We Look, The More We Find 7-fold higher DVT rate at hospitals in top quartile of duplex ultrasounds Pierce, J Trauma 2008 Pierce, Haut, et al. J Trauma 2008
Faculty-Student Mentoring Program • “A Faculty-Student Mentoring Program to Enhance Collaboration in Public Health Research in Surgery” • Johns Hopkins Surgery Center for Outcomes Research (JSCOR) • http://www.jscor.org/surgery-mentoring- program Smart, JAMA Surgery 2016
Faculty-Student Mentoring Program • 5 years • 90 public health master’s -degree students • 44 surgical faculty • 212 peer reviewed papers published • 83 student 1 st author papers (incl. JAMA ) Smart, JAMA Surgery 2016
A Classic Example of Surveillance Bias • Providers who screen more aggressively by performing more duplex ultrasounds may identify more cases of DVT and appear to provide worse quality of care than those providers who order fewer tests Haut & Pronovost, JAMA 2011
Implications Variability Variability Biased in DVT in DVT DVT Rates Screening Rates Reported Haut & Pronovost, JAMA 2011
“We’ll just use the test results anyway because it’s the only data we have” http://dilbert.com/strips/comic/2010-11-07
Defining Preventable Harm The VTE Example • We suggested that “performance measures could link a process of care with adverse outcomes when defining incidences of preventable harm” Preventable Harm = VTE + No Prophylaxis Haut & Pronovost, JAMA 2011
We Talked • Centers for Medicare & Medicaid Services listened
“Meaningful Use” Quality Reporting Criteria Related to VTE •“Meaningful Use” of Electronic Health Record (EHR) Technology – VTE1 Prophylaxis within 24 hours of arrival – VTE2 ICU VTE Prophylaxis – VTE3 Anticoagulation Overlap Therapy – VTE4 Platelet Monitoring on UFH – VTE5 VTE Discharge Instructions – VTE6 Incidence of Potentially Preventable VTE https://www.cms.gov/EHRIncentivePrograms/30_Meaningful_Use.asp
“Meaningful Use” Definition of Potentially Preventable VTE • VTE-6 Incidence of Potentially Preventable VTE •“This measure assesses the number of patients diagnosed with confirmed VTE during hospitalization (not present or suspected at admission) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnostic testing order date.”
Surveillance Bias in VTE Reporting in Surgery Bilimoria, JAMA 2013
Surveillance Bias in VTE Reporting in Surgery • 2,786 hospitals • 954,526 Medicare patients >=65 years • 11 major operations – AAA, CABG, craniotomy, colectomy, cystectomy, esophagectomy, gastric bypass, lung resection, pancreatic resection, proctectomy, total knee arthroplasty Bilimoria, JAMA 2013
Surveillance Bias in VTE Reporting in Surgery Bilimoria, JAMA 2013
No Association Between Hospital-Reported Perioperative VTE Prophylaxis and Outcome Rates in Publicly Reported Data • 3040 hospitals • Median prophylaxis performance = 94.5% • The median risk- adjusted VTE rate was 4.13 per 1000 surgical discharges Process JohnBull, JAMA-Surg 2014
Can a Systems Approach Improve VTE Prevention and Outcomes @elliotthaut #ARM17 #AHPeriopIG
Improving VTE Prophylaxis at The Johns Hopkins Hospital Streiff, BMJ 2012
Improving VTE Prophylaxis at The Johns Hopkins Hospital Paper Order Sets Streiff, BMJ 2012
Improving VTE Prophylaxis at The Johns Hopkins Hospital • Mandatory VTE risk stratification tool into the computerized provider order entry (CPOE) system • Advanced computerized clinical decision support (CDS) Streiff, BMJ 2012
Parent order set Different Order Sets have Different VTE Modules. Use is Mandatory in POE workflow.
General Surgery VTE Prophylaxis Any Major VTE risk factors? Previous VTE Very high risk VTE orders Any CONTRAINDICATIONS to Cancer Creatinine clearance Heparin 5000 units sc q8h pharmacologic prophylaxis? Thrombophilia < 30 ml/min or (Give first dose 2 hrs. pre-op High risk of bleeding Prolonged procedure (> 2 hrs.) unstable renal function and then beginning Yes No Yes Active bleeding NYHA Class III/IV Heart Failure (potential for CrCl to 12-24 hours post-op) Systemic anticoagulation Respiratory failure requiring Decline below 30ml/min Plus INR ≥ 1.5 or aPTT ratio ≥ 1.3 mechanical ventilation during therapy ) TEDS/SCDs Platelet count < 50,000 Acute Stroke with paresis (< 3 mos.) Pregnancy/post-partum (up to 6 weeks) Yes No No TEDs/SCDs Use mechanical prophylaxis until contraindication no longer Any Minor VTE risk factors? present. Review patient status daily Acute Infection/Sepsis Very high risk VTE orders Bed rest Yes Yes Heparin 5000 units sc q8h Yes Any CONTRAINDICATIONS to Central venous catheter (Give first dose 2 hrs. pre-op and then pharmacologic prophylaxis? Estrogens/Selective estrogen beginning 12-24 hours post-op) No High risk of bleeding receptor modulators (e.g., Tamoxifen) Plus Age > 60? Active bleeding Inflammatory bowel disease TEDS/SCD Systemic anticoagulation Enoxaparin 40mg sc qDay No No INR ≥ 1.5 or aPTT ratio ≥ 1.3 (First dose 2 hours pre-op and then Platelet count < 50,000 12-24 hours post-op) Any CONTRAINDICATIONS to (Remove epidural catheter at nadir (20-22 hrs.) pharmacologic prophylaxis? of anticoagulant effect and wait at least 2 hours High risk of bleeding after catheter removal to redose) Active bleeding No Yes Plus High risk VTE orders Systemic anticoagulation Age ≥40 ? TEDS/SCDs INR ≥ 1.5 or aPTT ratio ≥ 1.3 Platelet count < 50,000 No Heparin 5000 units sc q8h (Give first dose 2 hrs. pre-op Moderate Risk VTE Orders and then beginning 12-24 hours Yes post-op) Heparin 5000 units sc q12h With Option to add (Give first dose 2 hrs. pre-op TEDs/SCDs TEDS/SCD and then beginning 12-24 hours Use mechanical prophylaxis post-op) until contraindication no longer With option to ADD present. Review patient status daily TEDs/SCDs
Mandatory choice from each section for risk factors and contraindications
Keys to Success • Multidisciplinary team – Physicians, Nurses, Pharmacists, Informatics • Leadership buy-in • Collaborate with service teams • Educate front-line providers • Measure baseline performance • Conduct ongoing performance evaluations Streiff, BMJ 2012
Does Improving Prophylaxis Change Outcomes? The JHH Trauma Example Haut, Arch Surg 2012
Does Improving Prophylaxis Change Outcomes? The JHH Trauma Example • Significant 84.4% increase in VTE prophylaxis 62.2% • Significant drop in preventable harm from VTE • 1.0% vs. 0.17% (p=0.04) Haut, Arch Surg 2012
VTE Prophylaxis- Computerized Decision Support www.natfonline.org 36
www.AHRQ.gov 2015
Improving VTE Prophylaxis Administration with Targeted Performance Feedback @elliotthaut #ARM17 #AHPeriopIG
96.3% November 93.3% October 87.7% Sept
Surgery Resident QI Team Project Feedback Improves Prophylaxis Lau, Ann Surg 2016
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