Preventing Avoidable Venous Thromboembolism: Every Patient, Every Time

Preventing Avoidable Venous Thromboembolism: Every Patient, Every Time


My name’s Elliott Haut and I’m here with the rest of the
Johns Hopkins VTE collaborative. We are a group of physicians, nurses, pharmacists,
and researchers who are working on prevention
of venous thromboembolism. We have a jam-packed section for
you today, and each one of is gonna be
talking about different parts. We’re gonna take
questions at the end. We’ve got about 45 minutes
worth of slides, and then please send in your questions
via chat or on Twitter. So without further ado,
I’m gonna move ahead and tell you what we’re
gonna talk about, which is basic epidemiology and
public reporting about VTE. And then we’re gonna touch on
systems approaches, the impact of missed doses, the role of
nurses, and patient engagement. So to get us started
is Peggy Kraus. Peggy is a pharmacist who
works with our group.>>Thank you. So like Elliott said,
I’m the pharmacist. So I’m gonna just go over a few
things to start off before we get into the nitty
gritty of our research. So most of you
probably are aware, VTE stands venous
thromboembolism. Which essentially composes of
a DVT, or deep vein thrombosis, and a PE, or pulmonary embolism. Although, if you have a patient
with the more rare occurrences such as a splenic vein or hepatic vein, those would
count as a VTE as well. So we have been talking
about VTEs since the 1800s. As you can see, Rudolf Virchow
started discussing clots way back when and there has been this triad
that’s been developed. So any one of these three things
occur, then the patient is at risk for having a clot,
whether it be stasis, injury to the vessel wall
such as in trauma, or if somebody’s born with
a hypercoagulable state or develops a hypercoagulable
state, they can be at risk for developing a VTE. So why are we worried about VTE? In 2008, the Surgeon General
put out a call to action to prevent DVT and PE. As many as 350,000,
up to 600,000, or maybe more, in the US alone will suffer
from a VTE each and every year. We also know that VTE is deadly. We have over 100,000
deaths per year from PEs. And this is combined,
this is more than breast cancer, motor vehicle accidents,
and AIDS combined. Now, one thing that we
are trying to do here is help raise awareness, because most of you probably are
aware of breast cancer, there’s a boatload of organizations that
are helping raise awareness. The same thing with AIDS and
motor vehicle accidents, but yet you don’t hear a lot about
preventing blood clots and how deadly they can be. Hang on. Okay. There we go. So we had our first
DVT Symposium way back in 2009, it doesn’t seem like it was
that long ago, but it was. And we actually were
lucky enough to get the Surgeon General to be one of
our keynote speakers right after they had put out
the call to action. Most of you are probably aware
that there’s a plethora of risk factors for blood clots ranging
anywhere from the older you get to trauma, just being
in the hospital, being pregnant, infection, recent strokes and
such. So we also know that there’s
a cost associated with VTE. There’s been a few studies that
show each DVT can cost depending on which study from around
12,000 up to 16,000 per patient per event. And as you know, most likely some patients will
have more than one blood clot. If we look at the long-term
effects from developing a blood clot such as venous stasis and
ulcers that can occur, we’re looking at a cost of
around 250 million each year. We know that VTE is preventable,
most of the time. However, we know that not
all events are preventable, even despite getting
the absolute best prophylaxis that is out there. There have been at least
eight randomized controlled clinical trials done in the
orthopedic population between total knee replacements and
total hip replacements that show they still
develop VTE, symptomatic, not just those that are found on
scans, up to 2.5% of the time. So when CMS came out with their
ruling that they were going to make VTE a never event
after total knee and hip arthoplasty, Dr Haut and Dr Streiff put together this
commentary saying that this is an impossible measure
to meet because we cannot prevent all events [INAUDIBLE]
each type of surgery. You also will see the plethora
of guidelines out there, anywhere from the ACCP, College
American Chest Physicians, which put out their guidelines, trauma
with the East Association, ortho’s got their own
guidelines, OB-Gyn, and the American College
of Physicians. Now, despite having
all these guidelines, raising awareness, we still
have an under-utilization of DVT prophylaxis in our patients. In this study from 2004 from Dr.
Goldhaber and Dr. Tapson, they showed that
only 42% of their patients were getting prophylaxis prior
to their development of a VTE. Here’s an international study,
because the previous study was only in the US, that showed
pretty much the same thing. In 32 countries, we still have
an underutilization of VTE prophylaxis. While surgery tends to do
a little bit better job than the medicine population,
it’s still well underutilized. So this has led to [COUGH]
a call to help raise awareness, because there’s clearly a
disconnect between the evidence out there and the execution,
that can prevent DVT to the point where it’s really
become a public health crisis. Dr. Goldhaber had
this quote with the American Public Health
Association in 2003. So AHRQ also has put out
statements that DVT and PE are the most common cause
of preventable hospital death. So just a sidenote, so
if you could put us on mute, cuz I know somebody’s is having
a coughing attack like I was afraid I might do. So if you could put us on mute,
that would be terrific. Thanks a lot. We also know that DVT is one of
the ways we can really improve patient safety, and it should be one of our
number one strategies. Also, AHRQ has put
that prophylaxis for VTE should be one of your top
ten when it comes to improving patient safety practices
in your institution. Again, to kind of promote
our little group, Dr. Haut and Brandyn Lau also
wrote the chapter for AHRQ regarding
the prevention of VTE, a brief update review which is
well worth your time reading. So now Dr.
Haut is going to take over and talk about surveillance bias and
public reporting of VTE.>>Hi, so people ask me
how I got interested in DVT, and I think you’re
gonna understand after the next couple of minutes. There’s a lot of conflict out
there about screening high-risk asymptomatic patients for DVT. This is mostly in
the trauma literature, but in other groups as well. And the idea behind it is
that if you screen high-risk patients, you are gonna
find events and treat them before they become
a fatal pulmonary embolism. However, there’s another
side of the coin, which is that there is a con. It may be very expensive, not
cost effective, and you might also end up anticoagulating
patients who might not need it, and there can be harm from
that anticoagulation. So if we go to the guidelines
on the topic, there’s actually conflicting guidelines from
EAST, which is one of the trauma organizations, and the American
College of Chest Physicians. EAST suggests that this,
at least in trauma patients, this may be cost-effective and
decrease the incidence of PE. However, the American College of
Chest Physicians suggests that this should not be performed. So now we’ve got different
organizations that are giving different opinions. And what that did was
it made us wonder, should we be screening patients? We’re not. So we got a call from the state
telling us that our trauma center had the highest
DVT rate in the state. And we said, well, maybe that’s just because
we’re screening more patients, we’re getting lots
more ultrasounds. So we did this small
study at our center. We did a before and
after study and found that after we implemented
a protocol to screen a lot of trauma patients, we did four
times as many ultrasounds and got ten times as many
DVTs identified. We then went ahead and looked at
this on a national level using the National Trauma Data Bank. And this paper was entitled The
More We Look, The More We Find. If you break trauma centers
into four different groups by the number of ultrasounds
they do per patient, the group that does the most
ultrasounds has a seven fold higher DVT rate then the other
three groups of hospitals. The more you look,
the more you find, at least in trauma patients. People said well,
maybe that’s an issue of different patient populations. So we actually did a patient
level analysis, controlling for all these patient level
variables that are known to evoke DVT. And found that if you’re
a patient at a center that does a lot of ultrasounds, you are twice as likely
to have a DVT identified. I’m not gonna say you’re twice
as likely to get a DVT, but you’re twice as likely to
have it identified and put into a registry. And then when you ask trauma
surgeons what their opinion, their opinion is about
three-quarters of us think that we should be screening high
risk asymptomatic patients. The other quarter
are really not sure or disagree with that statement. So there is variation
in practice. And this is a classic
example of surveillance bias. The more you look, the more you
find, and those providers who do more testing may appear
to provide worse care, even though it’s really
just a testing phenomenon. So what are the implications
of that? The implications are that
that variability in screening leads to variability in DVT
rates that are reported, and those rates are biased. And you can’t just look at
the outcome rate of DVT alone. It’s probably not
the best outcome measure. So sometimes, we’ve talked
about this before, we all feel like Dilbert when the boss tells
us that we’ll just use the test results anyway because it’s
the only data we have. None of us were very happy
with that answer, and we hopefully came up
with a better idea. And that better idea is this
definition of preventable harm. So we suggested that the
performance measures could link the process of care with
the adverse outcomes, so this preventable harm is
a VTE in patients who got no prophylaxis or
suboptimal prophylaxis. So we spoke,
we gave that suggestion. And CMS actually listened,
and if you keep up with the literature,
that’s the new VTE-6. So VTE-6 is and the incidence
of potentially preventable VTE. And when you look
at that definition it’s patients who are diagnosed
with confirmed VTE who did not receive VTE prophylaxis
while in the hospital. That’s the idea
behind that measure. So, the papers I just mentioned
before were all on trauma patients in this difference
of opinion, mostly in trauma. So then the question becomes, does this occur in other
patient populations as well? So this is a paper in JAMA
from a few years ago now about surgical patients. This looked at 11 types of
surgical patients, wide ranging types of surgery, cardiac,
vascular, cancer surgery, orthopedic surgery, etc, almost
a million Medicare patients. And if you look at the main
graphic from this paper, it shows the exact same thing. The more imaging you
do looking for VTE, the more events you find,
whether it’s VTE or DVT or PE separately, the more you
look, the more you find. This is not just
a phenomenon in trauma, it happens in surgical
patients as well. And this is one graph from
one project, we had a Masters of Public Health student do
this, his thesis project. This, if you look at hospitals
and look at the relationship between their process measure,
SCIP VTE-2, that’s the process where they’re giving appropriate
prophylaxis versus the outcome, which is PSI-12,
there’s really no relationship. It’s a really, really flat line,
and everybody or most of the people
are clustered, the hospitals are clustered
way at the end near 100%. Most hospitals are doing very,
very well, and there’s no relationship between
the process and the outcome. And if you actually compare the
hospitals that reported being 100% perfect for VTE prophylaxis
versus the lowest end hospitals in the bottom six, basically
the same exact outcome rate. So it just goes to show
that this specific measure that was used as the initial
measure of the process is really not a good measure. It doesn’t really correlate
with the outcomes and doesn’t really help you. So the jury is still out. We’re still not sure what
we should be doing and what we should be reporting
related to VTE as far as public reporting. Is it a process? Is it an outcome? Is it the combination? We should know that VTE-1, the prophylaxis measure,
is now being retired. So that is no longer gonna
be a reportable measure, because it really was
not all that helpful. So, I’m gonna turn this over
right now to Mike Stripe who’s gonna talk to us about
kinda systems approach, improve VTE prevention and
VTE outcomes.>>Thank you very much, Elliot. So I’m Mike Stripe, a hematologist at Hopkins that’s
been working with our group for the last, I guess,
eight, nine, ten years. So can you take a systems
approach to improving the VTE prophylaxis, and we did look
at this starting back in 2005. But it’s important to note
that while education, which was part of our approach,
is not enough. That you really have to
use multiple, different, active strategies as shown
on this systematic review, including reminding
clinicians and providing them assistance in risk
stratification and selection of risk appropriate prophylaxis
to have the biggest impact. And in this paper from BMJ from
now a few years ago, we kind of go through the history of how
we used what Peter Pronovost, the TRIP model, which is translating
research into practice. We use that same model that
he applied in surgical site inspections and
applied that to VTE. And as you see, we’ve had some
success with that approach. So initially in 2005, when we
were starting this process, we did not have electronic
order sets yet. We were still using paper order
sets, and so this is a version of one of our paper order
sets that shows at the top, we have risk factors, then below
had been the risk categories. In the middle, had the different
risk appropriate prophylaxis selections, and then had contra indications
at the bottom of the sheet. And while this helps organize
clinicians’ thinking or approach to DVT prophylaxis, it was suboptimal in that we
couldn’t ensure that it was in every chart at the time of
the mission or transfer. It made it very
difficult to get data out of this system as to
see how we were doing. And so once we started
a transition to an electronic order entry system,
we got together and redesigned our approach using
a computer order entry. We made a mandatory risk
assessment tool that would then lead the clinician into risk
appropriate prophylaxis using a few questions to risk
stratified patients, VT risk, and their bleeding risk. And then gave them advanced
computerized clinical decision support to help them give
them selections that would be appropriate for their patient,
based on their risk. And this is a screenshot of
one of those VTE order stats. You see at the top,
it has patient information about weight, also gives them a
calculated chlorine clearance if in case they’re gonna use
a lightweight heparin, and then has several questions
that look at major and minor risk factors, as well
as risk factors for bleeding. And then when they’ve
answered those questions, then it gives them the
recommended prophylaxis options that would lead to optimal
prophylaxis for their patient. And so what we found with
the benefits of this approach, well one is instead of paper
order sets where they weren’t all within the charts, this put
VTE prevention in the work flow. It was part of the order sets
for admission and transfer. It helped the clinicians do
this rapidly, so it took a few seconds and guided them to
risk appropriate prophylaxis. And it allowed us also to
make any literature advances that occurred with literature, we could try to translate these
into changes in the order sets. And that made it much
more effective for performance monitoring and
reporting, which was very difficult
with our paper order sets. The keys to our success, as it
was reported in this paper, was that we had a multidisciplinary
team from the start. We had interested physicians,
nurses, pharmacists that worked
on the front lines. We had medical informatics,
professionals that helped us design and build
the system and then extract the data out of the system, so
that we had seamless reporting. We also were fortunate to
have leadership buy-in. We collaborated with all
the service teams to different specialties to make sure the
order sets we designed would fit with their practice, but
were yet evidence based and educated the providers on the
evidence bases in their area. And then the computer system
allowed us to not only measure baseline performance, but
also conduct ongoing performance assessments so that we can
track how we were doing. So did it improve our
prophylaxis and our outcomes? Well, we did two studies
that suggest it did. That this is the first study
published in 2012 looking at our trauma service. And it’s a single
center study obviously. A Pre/Post study. We had one year of data
before the order set went into effect and then three
years of post order set data. And what we found,
on the next slide, you see that there’s a dramatic
increase in prophylaxis compliance, went
from 62% almost 85%. During this time period you also
see a concombinent decrease in all thrombotic events. And more importantly you
see a significant decrease in preventable harm so
that patients who are getting prophylaxis and thus we
are doing all that we possibly could to prevent
thrombotic events. And so preventable harm went
from about 1% to about 0.17% of the population,
a dramatic change. We also saw the same thing in
department of medicine where we had an order set guiding
prophylaxis selection in that group of patience,
again it was a pre post study. About a thousand patients before
the order set introduction and almost a thousand
in the post period. What we saw was significant
increases in optimal prophylaxis. It was appropriate for
the patients’ risk level. In addition we saw dramatic
reductions in the number of patients that got no
prophylaxis from 24% to 4% And then on this table you can
see that if we only follow patients out to about 90 days,
there was a significant reduction in total VTE from
about 2.5% to less than 1%. And more importantly,
preventable harms, you see highlighted in this
red box, went from 1.1% of patients to no patients in
an opposed implementation period had preventable events
of thromboembolism. And so when in 2010, the North
American Thrombosis Forum sponsored a competition of
different approaches and strategies to decrease VTE. We submitted our intervention,
and we’re fortunate to receive one of their DVTEAM CARE
awards for our work. And it’s also been recently
highlighted by HRQ and their guide to effective
quality improvement as one of the they selected as
providing a model for how you can prevent a hospital
acquired venous thromboembolism. And so now I’m gonna turn
the program over to Brandon Lau, who is our medical informatician
to talk about other strategies to improve VTE
prophylaxis administration with performance feedback.>>Thank you very much, Ed. My name is Brandon Lau. I’m a clinical informatician by
training and I’ve been working with the VTE collaborative for
some time trying to figure out how we can empower clinicians
and nurses and patients with this data to help improve
VTE prevention practices. And that’s what I’m going to
be talking to you about now. What we saw in the last
couple of slides is that after implementation of
clinical decision support, about 85 to 90% of patients
are now being prescribed risk appropriate prophylaxis. So that’s down to the individual
patient level if patients are getting what is appropriate
for their level of risk. And what that tells me is that
somewhere between 10 and 15% of patients aren’t being prescribed
risk appropriate prophylaxis. And because we’ve been able
to move forward with this decision support tool to
collect data electronically, we thought that it might present
an opportunity to really harness the power of analytics
and electronic information. And bring performance data right
to the front line providers to try to incentivize
performance improvement. And our first thought with
this was to give feedback to attending physicians, which you’ll see highlighted
in the dark blue lines here. But, to the eye, correctly,
there isn’t really much of a difference between attending
physicians under proportion of patients who are prescribed
appropriate prophylaxis. The primary reason for this
is that attending physicians rarely, if ever,
write BT prophylaxis orders. Instead, what you can see
in the light blue lines are the proportion of residents
who write appropriate prophylaxis orders for the
proportion of their patients. And you see why
varying differences, a lot of residents do
the right thing all the time. Some residents do the right
thing none of the time and a smatery of residents do the
right thing some of the times. And because they’re quasi
randomly paired with attendings. It doesn’t really seem as though
there’s any different between attendings on risk appropriate
prophylaxis prescriptions. So we thought that residents
would be ideal target to give individualized feedback
about prescribing habits. And that’s what we did. We started by giving the
previous three months of data, which you’ll see in
the first figure. And you’ll see a lot
of red in this. And think about who it is that
we’re talking about here. Very, very competitive
residents, surgical residents, wanting to be the best, driving
to be the best, and we rank order them to tell one of them
that they are in last place. And that fact alone drove
performance on a month by month basis where we went
from the mid 80s of patients being prescribed appropriate
prophylaxis to the high 90s. And this is the highly
sustainable intervention of using electronically available
data to give performance feedback. Here we see 15 months
before giving feedback and 15 months after a dramatic
improvement with only one drop off when our
new interns began. But even with that drop, performance very rapidly
returned to the high levels that we saw before the new
interns arrived. Overcoming this July effect and
providing meaningful feedback to frontline prescribers
about their habits. But this actually brings
up the other question, are we actually targeting
the right thing at this point? As I’d mentioned 85,
90% now high 90% of patients are being prescribed
appropriate prophylaxis, but is that where we should
really be targeting? And if the classic
assumption here is that when patients are prescribed
medications in hospitals they will always
be administered. But is that actually a fact. And when you think about
optimal VTE prophylaxis, optimal VTE prevention, it
really requires risk assessment of patients prescribing
the appropriate medication, for nurses to administer
the medication as prescribed. And perhaps,
most importantly for patients to accept that
medication as it’s prescribed. A lot of work goes into
these various steps. Making sure each one is done. And what we found from a small
study published by colleagues of us looking at high risk trauma
and general surgery patients, is that missing even
a single dose matters. Missing doses of VTE Prophylaxis
is associated with developing VTE, and certainly among patients
who do develop DVT about a quarter of patients missed
one or more of their doses as opposed to 5% of patients
who missed none of their doses. So we can tell that
missing doses matters. In addition, we found very
similar findings here. That about half of patients who
developed hospital-acquired VTE received appropriate care. They were prescribed
the right medication, and they received every dose of
medication as prescribed. The other half were divided
nicely into two groups. About a quarter of whom, simply were not prescribed
the appropriate prophylaxis. There was an opportunity to
improve on the prescribing side but three quarters missed one or
more of their doses. They were prescribed the best
practice prophylaxis. But they missed one or more of their doses representing
an ideal opportunity to improve. So we did a small study on
looking at a little more than 100,000 doses all prophylaxis
at Hopkins Hospital. And we found that 12% of doses, 12% of all doses
are not administered. With the greatest
documented reason for non administration
has patient refusal. About 60% of all doses missed
due to patient refusal. Which might indicate
that there’s a problem across
the hospital uniformly. But when we look at
the individual floor levels, we see that some floors, about
5% of doses on administered, and then the extreme outliers,
we see that somewhere between 25 and 30% of doses
aren’t administered. And there’s a lot that we could
gain from understanding just the distribution
based on the data But it’s really when you take it to
the floor and talk to nurses and talk to patients to find out
what’s really driving them. And so for that I’m going to turn it over
to one of our lead nurses Deb Hopson to talk about what we
found from the frontline nurses.>>Thanks Brandon. So, hi everyone, I’m Deb Hopson. I’m the nurse who’s been
on this project with Dr. Strike from the beginning. So, how he says it eight,
nine, or ten years, however long we’ve
been doing this. And like Brandon just said,
even working from the beginning, we put a lot of focus on
making sure the patients got the appropriate prophylaxis, and
I felt really good as a nurse that we were moving in
the right direction. But then you see this data here
that Brandon just showed you, and I was shocked by
the amount of missed doses and how it was really different
on all of our floors. So we really wanted to find out
what was happening out there on our nursing unit. And so, whoops, what did I,
I hit the button, sorry. So, this is what we did. We started looking on
the nursing units and wanted to do some
research out there. And I worked with a pharmacist,
Stacy Elder. And we did some quantitative and
qualitative observations of what was going on and
I’m gonna show you those. And one of the papers we wrote,
and that’s there and it is with Stacy Elder, it’s
Hidden Barriers to Delivery of Pharmacological Venous
Thromboembolism Prophylaxis. And we did, we went out there,
we did a survey with nurses. We did observations where
the pharmacists truly observed the nurses and their interaction
with the patient when they were giving the prophylaxis dosage. And then after we did those,
we met with different groups of nurses to find out more,
we had focus group meetings. So and this is sorta what we found out from
the quantitative survey. We had one of the questions, I
have the clinical knowledge and experience to determine if it
is necessary to administer the VTE prophylaxis
injections to patients. And this is good,
I mean they felt like they did have the knowledge, but with
87% medicine and 79% surgery. Which, I think is important that
nurses have the knowledge, but not that it’s necessary to
administer because that’s a prescribed dose. And then and
also the second one, nurses use their clinical
decision-making skills to determine when to omit
unnecessary doses of prescribed VTE prophylaxis injections for
each individual patient. This, as a nurse, and
the doctors in the room and everybody will tell you, when
I found out this I was shocked as a nurse that we were making
decisions on whether or not a routine prescribed
medication for a patient should be given or
not. It’s not a PRN medication. So I was really shocked and
I wanted to know more of what was going on, so
is VTE prophylaxis optional? And these were some of the
comments when we had the focus group meeting. One nurse would say
I push harder for my patients to accept
heparin if they have sickle cell disease as
opposed to say pneumonia or something where they’re just
here for IV antibiotics. I was like mm-hm. And then another one. Sometimes if it is the middle of
the night and they are due for their heparin and the patient’s
asleep, I’m not gonna wake them up if I don’t really feel they
need that VTE prophylaxis. And one of our favorite ones
is the ambulation myth. We make the clinical
decision all the time as to whether a patient needs
VTE prophylaxis every day, based on how much
the patient is ambulating. And then another one, and
we observed this, hey Ms. R, it’s time for your heparin
dose, but as long as I see you out in the hallway high-fiving
me, we can hold off for now. Now really? So we looked at that and we knew that there is not enough
on ambulation to tell us for sure how much a patient
should be doing or not. There’s not enough
literature out there. So we really, at that point,
knew that we not only needed nursing education, but again
to go along with what Brandon showed you most of those missed
doses were patient refusal. So we also needed that we wanted
to focus on the patient’s side. So that’s when our team
together looked at the grant. And we got the grant from the Patient-Centered Outcomes
Research Institute and that’s when we started this
project, the PCORI project. And it was a three year project, which we’re ending in
July of this year. But you can see our project
is titled Presenting Venous Thromboembolism, Empowering
Patients and Enabling Patient-Centered Care via
Health Information Technology. And with that, the objectives
are to really help the patient so that they can make
informed decisions. And we wanted to focus on that
patient-nurse communication, along with empowering
the patients so that they can take an active role in
their preventive care for VTE. And then also, one of
the biggest parts to this and Doreen, our nurse researcher on
the project, will go over this, but really gets
the patients engaged. And we wanted to talk
to them as soon as possible after they
missed the dose, when they did that patient
refusal of that VTE prophylaxis. So we decided to get a lot
of major players involved, a lot of the national
organizations and key stakeholders and
those are listed here. You can see, we had ClotCare,
North American Thrombosis Forum and National Blood
Clot Alliance. We even involved our own Patient
and Family Advisory Council so that we could really get input
with them on what they wanted so that we knew how to
approach this big problem of patient refusal. And then here’s the website and
you can go to the PCORI website at any time and
it’s Research in Action and you can find everything
that we’re doing. And with that I’ll
turn it over to Doreen.>>Hi this is Doreen. I’m a nurse educator for
the Department of Surgery and have been working with the
collaborative for about two and a half, three years now. And I’m going to be talking
about how nursing education can improve VTE prophylaxis
administration. As Brandon had talked about and
Deb had talked about, we’re looking at impacting all aspects
of the VTE prophylaxis process. So when you’re looking
at education and delivering education models,
what we really seem to evaluate for the most
part historically is we’re looking more at the effective
and the cognitive domain. So we look at the reaction
of the learner to an education model. Did they like it? Did they learn? And we measure that
by surveys usually. But truly is liking it and
learning the education actually translated into
a change in behavior. And in relationship to VTE
prophylaxis, do we stop missed doses and then ultimately are we
able to impact VTE events? So we partnered with Central
Nursing Education to build an educational program to
impact all of these aspects. We looked at learner-centric and
interactive scenario-based dynamic education
module, and delivered it to a set group of bedside
nurses at this institution. It was a learner-based,
scenario-based platform. We actually looked at patient
safety events that had been reported and developed
the scenarios based on that. We used critical thinking and
worked in multi-disciplinary venues to get
the information across. The platform itself was fairly
generic, it was a storyboard. One of the negatives with this
is that some of the avatars were a little more Laura Croft as
opposed to our natural patients population that we have. But really engaging the user in
going through these scenarios. And if the user was getting
the information incorrectly, they weren’t penalized, they were able to move
throughout the scenario. But, if the user had wrong
answers to any of these scenarios then they were
remediated at that time. So where is this gonna go? Does this work? Does in those domains that
Kirkpatrick measures, are we going to change behavior? Is this effect going
to be sustained? Is there a honeymoon phase
associated with this? Do we need an injection
of education and how is that gonna look like? Are we going to be rolling
this out to more nurses, just our whole hospital or
the health system? Are we able to deliver
this to other hospitals? At this point in time,
we’re sharing these modules with the Illinois Surgical Quality
Improvement Collaborative. So seeing how this impacts. Again those last two levels
in the Kirkpatrick model will show whether we are actually
able to impact behavior and ultimately decrease VTE events. So what do patients really want? When you’re developing
the patient education, so we’ve already talked about physicians
and providers risk assessment, we’ve talked about the education
that we need from the nurses to impact the administration
of the VTE prophylaxis. And now we’re looking at what
patients really want that are gonna impact that refusal. And how did we do that? We used a modified
Delphi method. We surveyed patients,
patients and family members, the end users. We recruited them
using social media, select websites, Facebook,
Twitter, and we got more than 400 respondents from all of the
international organizations and our internal organization that
Deb had actually discussed. What do patients want? We asked. What are patients
willing to read? What is the venue? Who is to deliver
the information? How long is that information
supposed to be and what does it actually look like? When we got that information,
we not only took the information and built the educational
delivery method, but we also reviewed
those face to face. We had focus groups, we went
out into the community and reviewed this. So we weren’t the ones that were
developing the information and the education in the delivery
system, the patients were. So what did the patient
education bundle look like? What did the patient
specifically want? Well they wanted paper. It’s just showing enough in this
day and age with all of our different again social media
videos and access to a lot of online gaming, patients
really wanted a paper form. So we utilized a template that
was built on some adult learning theory, but the information
within that paper was written literally by the patient. Interestingly enough, we would ask them your
word smithing things, you know what was the comfort
level of different terminology. Patients liked information
such as shots and belly. Now when we would reviewed
this again with providers, the providers would like to
change that to injections and injections or abdomen but when
the patient spoke, we listened. We actually used what
the patients had wanted. You need to make
it easy to find. An information paper is only as
good as the ability to hand it to a patient. When you’re developing
this type of education, make sure that it’s
easily searchable. We used keywords that were
common terminology and also had it so that when you enter those
keywords, this patient education form would be at the top of the
list when you did your search. We made it in multiple
languages and a large font. Again, the information is only
as good as the patient’s ability to understand it. Truly patient centered,
if you have a patient who speaks English or understands English,
then that’s wonderful. But it doesn’t really show
the value that you have for the patient itself in truly
patient centred care, if you are able to hand that patient an
educational information packet, that’s in their language. I had an elderly gentleman
who was Russian and the look on his face
when I handed him our patient education packet
in Russian was priceless. He was engaged, this was
a patient that was going to have a discussion and we would be
able to talk about what it meant to help keep him
safe from clots. So with the video,
what did patients want? They wanted a ten minute or less
video, they wanted physicians, nurses and patients talking,
they wanted to see someone who looked like them,
who was talking about the fact that they had a clot or what
they did to help prevent a clot. We had an Oscar winning director
and we took all of that information that the patients
gave, put it into this video and then we screened it for our
patient family advisory council. More importantly, we made those changes based
on the feedback that we got. These are some of
the patients that we had. We had physicians patients. We filmed them in
their own homes. We showed them what
tests they wanted. Again, all information that we
received from the patients and what they wanted and
how they wanted to learn. So what did our intervention
actually look like? We had a real time alert of
any non-administered dose. This alert came to a pager or
an e-mail. You don’t need to go and talk to patients necessarily
that are taking the medication, you need to target the patients
that are refusing. If patients that are taking
it want to speak to someone, you’re able to do that, but
you want to do a real-time one on one discussion with
the patients that are refusing. Once the page would come in,
the nurse educator would go and then it was a bundled
approach and again patient-centred care so
what the patient wanted. Did they want the paper? Did they want to
watch the video? Did they wanna discuss
with the nurse? Did they want none of this? This intervention usually
went one of three ways. You would have the discussion,
educate the patient, and then the patient would take their
prescribed VTE prophylaxis. Sometimes we’d
have patients that wouldn’t necessarily
want the shot. They understood
the importance but the shot was not necessarily
something that for whatever reason, they were able
to deal with at that time. And at that time again, using
that patient intervention or patient-centered intervention,
we would work with them to get the best, maybe not the best
evidence prophylaxis, but the right prophylaxis for
that patient. And then other times, we would have patients
that truly would refuse. This was an informed refusal,
this was an educated refusal and again, patient centered care. This project was rolled out from
April 2015 through December 2015 and at this point in time, we’re
looking at the effects of this. Where do we go from here? We’re looking at
getting the word out. How do we get patients,
as you could see, the amount of patients
that we have aren’t aware of how important
dt prophylaxis is. So getting the word out
nationally, internationally, we need to look at
sustainability, how are we going to maintain the progress
that we’re able to achieve.>>So all in all, I think we’ve
covered quite a bit today. We’ve touched
a little bit on many, many different aspects
of VTE prophylaxis. We got a feel for our whole
entire team who had a chance to present and
we do have some acknowledgments. This is our group at a couple of
different pictures along the way and it’s important to notice
that we’ve invited many important speakers,
nationally and internationally, to our VTE symposium. On the bottom, somewhere in
that bottom left-hand picture, you’ll see Bill Gertz in there. Richard White is over
on the bottom right and it’s important to see patients. So if you look in the top left
part at the four people sitting at that table, those are
patients who present every year. We have a patient panel at our
VTE symposium where patients get up and tell their own personal stories
of what did it feel like? What did I had to when
I had my DVT or my PE? So you can get a feel for
patient perspective. And as we’re talking about
engaging with the community, that’s some of us in
a little more casual attire, attending a NBC,
National Blood Clot Alliance. A walk to help support a
community engagement in some of our group with some of
the members of the NBCA locally. And then these are our emails
and a few of us are active on Twitter and happy to answer
questions along the way there. All these slides and eventually, the audio will be put up on
the Armstrong website and then the final site I’m going
to leave up while we do our question and answer session
is some other resources. So just as a reminder,
we heard a lot about the paper forms that were
created, the education. Those are out there for free. You can go to the Armstrong
Institute website and download the version. You can download it in English. You could download it in English
in a large font version and a series of translated
into other languages to use with your patient. The patient education video
that already got mentioned, you can go there to watch it. You can see what
the video looks like. You can watch it to
learn yourself and you could show it to patients. There’s also a link to our PCORI
research in action website which really is talking about
the active project we have going on and
an article from last summer in the Wall Street Journal that
focused on the group and what we’re doing here and
really trying to highlight and improve public awareness of
how important blood clots are. So with that, I think we’re
gonna end the presentation side. I know there are lots and lots
of different questions that have come in via chat that
we’re gonna try to answer. Peggy’s been following them
along on her computer and I think what we’ll do is, Peggy, will be triaging them,
asking them to the group and then the other, or the six of us
will all get together and try to answer the question depending
on our personal expertise.>>Okay, so I know some
are chomping at the bit here, but the first question I said I
would save till the end is what VTE risk scoring tool do
you use, and is it for all patients, surgical,
medical, etc?>>Yes, as Mike Strikes said, these older sets we designed
back in 2007, 2008. So at that time period,
there was no evidence-based risk stratification model,
so we at that time, I think in conjunct you know
what you in association what you’d see in the chest
guidelines at that time was that every patient that came out of
a hospital was assumed at risk. I think this is particularly
more important for the medical patients than
the surgical patients but every patient was at risk. And so our risk
stratification model was basically based on
the MEDENOX study. High-risk patients got high-risk
prophylaxis, the enoxaparin or TID heparin, lower risk
patients got BID heparin, and patients that had
contraindications to pharmacologic prophylaxis got
sequential compression devices. And in our medicine population,
about 20% of them get SCBs as their prophylaxis,
cuz they have contraindications. Now, we’re making a migration to
EPIC where on the medical side, because there’s a realization
there are low-risk patients in the medicine patient population
that we’re gonna use in our EPIC order sets that are going
to be launched on July 1st. On the medicine side,
we’ll be using the improved risk score that Alex Spyropoulos
and group identified, and I think we figured it was the
most evidence-based risk score for medical patients, so
we’re gonna be using that. And then on the surgical side, I guess I’ll turn it
over to [INAUDIBLE]. We don’t use the same
risk stratification for medicine, surgery, trauma. In all of our original order
sets, they were all based on literature at the time,
in those different specialties. And Elliot, I don’t know if you-
>>And I would say that on surgery, we use kind of a modified
bucket approach. Our patients in surgery are very
high risk, high risk, or moderate risk. We don’t find anybody who’s
really admitted to the hospital who’s low risk. It’s very hard in this day and
age to find a surgical patient who is at low risk who’s
admitted to the hospital, all those patients
are going home. So, I would tell you that
there’s many different risks scores that are out there. You know, there’s the Caprini
score, the Roger’s score, there’s all these different
approaches that can be done, the Pagent score in medicine,
etc. There’s no data that I’ve seen
that any one is better than another. I think the most critical part
is that you use something, so you standardize it so
that everybody gets some sort of risk assessment,
whether it’s a point scoring or a bucket or whatever, so that
you’re really considering it for every patient and then giving
that patient the appropriate prophylaxis based on their
risk stratification.>>I guess there was one
question I think I saw over. Peggy that there was just
a concern about bleeding complications, have we
monitored those pre and post? And bleeding complications, major bleeding was
extraordinarily uncommon at least in the medical population. It was about 1 in 1,000 patients
had a major bleed in our pre and our post order set experience. So I think major bleeding is
very uncommon in our patients, and that’s because we ask the
providers to risk stratify their patients. If they’re a high
bleeding risk patient, we’re not using pharmacological
prophylaxis in that patient. Sorry.>>No, no.
Go ahead. I was just gonna say,
do you want ambulation, it’s been part of
many questions here. And mobility versus
DVT prophylaxis, especially in medical patients. Because some people will not
give, if they can get up and walk around, they typically
don’t give them DVT prophylaxis. So that’s been,
that’s multiple questions. Anybody want to address?>>So I think, this is Brandon,
I think that there hasn’t really been some strong evidence
that would actually show what the association is between
ambulation and VTE prevention, particularly in a hospitalized
patient population. And one of the frequent
questions that I ask the interns who come to Hopkins
Hospital when giving their orientation lecture is,
what is the amount of ambulation that equals a standard
5,000 unit shot of heparin? And I hear everything from
a nebulous two laps around the unit to three miles. And I think, that that really
underscores the fact that we don’t really know what the contribution of
ambulation is to VTE prevention. In reality,
it probably does something. I just don’t think that anyone
really has the evidence to really say that it works every
time, and this is how much.>>There’s many, many, many
different randomized trials for the pharmacological medications. There’s very little
data on ambulation. And as Brandon points out,
we don’t know the dose, we don’t know the frequency,
we don’t know any of that. So I think, when people put
together evidence-based approaches to VTE prophylaxis, I
don’t know what you can have any very strong evidence
that ambulation alone or in combination with
anything else works. It’s certainly good patient
care, and there’s lots of huge pushes at our hospital
and others for ambulation, getting patients out of bed,
and physical therapy, etc. But the data that that prevents
VTE is really pretty sparse.>>Well, and if anything,
I think, Mike and Elliot, you can talk to this too, we’re even
finding, especially in surgery, that patients going home after
surgery, because of our NSQIP database, that they’re even
developing VTEs within 30 days. So now we’re even looking at
prophylaxis at discharge and how long do we need
to do that too. So, I think, we know that
mobility in the hospital and immediately after discharge
is not the same mobility that patients were doing prior
to being hospitalized.>>Right, and this issue of
post-discharge prophylaxis is a really important question. There’ve been a few studies
on medicine, patients, and the data are conflicting. And some show that the
prophylaxis actually leads to more bleeding and doesn’t really
necessarily help with events. There are some specific surgical
patient populations where the data is relatively strong. Certainly on some orthopedics, especially joint replacement
procedures, hip fracture, as well as some abdominal
pelvic cancer surgery, the extent of prophylaxis does
have a relatively strong data.>>So, it looks like there’s
a question in here about obstetrics patients in our
preferred screening tool. So, there’s no evidence-based
screening tool in obstetrics. So when we put the order sets
together with the obstetrical positions, the OB department,
that as you indicate in your question about an older
patient or an obese patient with a C-section,
that those are risk factors. Certainly obesity, age,
C-section puts at higher risk. So patients that had surgical
deliveries tend to get pharmacologic prophylaxis
while they’re in the hospital. We’re not sending any OB
patients home with prophylaxis. But so, there’s a variety
of risk factors in the OB population, medical
disorders and such, and those patients will
get prophylaxis. Most of them don’t get
prophylaxis in the hospital, it’s only the high-risk patients
that get surgical deliveries and have serious medical problems or previous thrombotic events
that are getting prophylaxis.>>What about weight and BMI?>>So yeah, I mean, so as far as
weight and prophylaxis, I mean, our bariatric surgery group
uses, I guess, increased doses of enoxaparin for
prophylaxis in those patients. So instead of 40 once a day, they’re using 40 twice a day in
people that have BMIs over 40. And I think in BMIs over 50,
they’re using 60 twice a day based on the bariatric
surgery literature. We’re not doing that in
medicine, although there are certainly studies looking
at the medical population and showing that higher doses in
very large patients are probably appropriate to
medical patients too. But they’re not
randomized studies, these are retrospective
observational studies.>>And we did a systematic
review through AHRQ a few years ago that really
looked to answer this question in the obese patients. And really,
except in bariatic surgery, there’s a paucity of data
on what we should be doing. Lots of different people and
lots of different institutions are doing it differently, double
dosing their enoxaparin or increasing their
heparin amount per day. But there’s really not strong
evidence on what should be done.>>So, there’s also been, how much longer do we
want to go [INAUDIBLE]? Okay. So, there’s a question about
the not much discussion about sequential compression devices
or other mechanical prophylaxis.>>Where, I mean- [CROSSTALK]
>>Well, do you wanna give the-
>>I mean, in medicine, we’re using it
in about 20% of patients that are contraindicated to
pharmacologic prophylaxis. In surgery, they use a lot
of combined prophylaxis. We don’t do that in medicine,
they’re either pharmacologic or mechanical prophylaxis. But in your high risk surgery
patients, I’m sure, yeah, they’ll use both.>>We use pharmacologic and we use sequential compression
devices up until discharge. So we motivate it and engage the family members to
help the nursing staff out. All of our patient rooms
now have SCD pumps available in them, and so the patient gets connected
to the sequential compression devices as soon as they’re
done ambulating or in the bed. Whether it’s the bed or
the chair, we hook them back up. And like I said, we’ve even
started engaging family members to help with that.>>And then TEDs, I mean, what-
>>Yeah, we found out, the study a couple years ago,
we found out that, we were using both TEDs and SCDs, And
this tells my age in a way, of nursing, because years ago
what we found out when we first started using sequential
compression devices, patients were complaining because it
was sticking to their legs. It was the old type of
devices that were very, they had a lot of
plastic on them, and patients felt they were hot,
and sticking to their legs. So at that time we started
using both TEDs and SCDs, the TEDs making the SCDs
more comfortable. And then recently we found out,
especially in our surgical ICUs, that patients weren’t
measured appropriately for SCD’s prior to going
into surgery, but then they were fluid
overloaded in surgery. And when they were
out in our ICUs, we were seeing pressure
ulcers from the TED. So now, our standard is pretty
much SCDs for all our patients. If TEDs are needed, or if
they’re requested, we can still get them, but we now use SEDs
in our operating room and all our surgical units,
without the TED.>>And it looks like
there’s a question, I was just looking over Peg’s
shoulder about neurosurgery, and what we do with neurosurgery and
>>[LAUGH]>>So neurosurgery, they approach working with the
neurosurgeons here, is we use, they prefer unfractionated
heparin to low molecular weight heparin, and so, although there
are data with low molecular weight heparin,
we use unfractionated heparin. There are obviously no
preoperative dosing of anticoagulants. They use SCDs during the case,
and until the patient’s ambulatory, they use, starting
24 hours after the surgery, if hemostasis is achieved, they’ll start unfractionated
heparin prophylaxis. So that’s what the neurosurgery
group does here.>>There’s another question
that I wanna try to reply to. This one here says,
it sounds like we prophylax 96% of patients, and that’s much
higher than the ACCP guidelines recommend, cuz there’s gonna
be many low-risk patients. And I think what we need to do
is clarify, that that 96% is we gave the appropriate
prophylaxis to the patient, based on the clinical decision
support tool recommendation.>>Right, right.>>And it might be that the
clinical decision support tool recommendation suggests
heparin twice a day, and we ordered heparin twice a day,
that counts. It might be that
it suggests that the patient is contraindicated,
so they get mechanical only, and as long as we give
mechanical only, that’s the appropriate order for
that specific patient. So it’s not that we gave
prophylaxis and ordered, for example, low molecular weight
heparin to 96% of our patients. We were following the
recommendation of the decision support tool, 96% of the time,
which is a key difference. And if we do agree,
there’s gonna be patients, whether you believe that the
low-risk patients who shouldn’t be getting anything,
whether they exist or not, that’s still up for debate. But there certainly aren’t
patients who are contraindicated for reasons, and we should not
be giving them prophylaxis, cuz it’s gonna weigh,
the risk and benefit then goes in
the wrong direction.>>And it looks like there’s
another question here about hip fracture patients, and
delays in surgery. What chemoprophylaxis
is recommended? And, generally, on the orthopedic service for
many years, low molecular weight heparin
was the prophylaxis of choice. That has changed some,
I would say, in the last years, as aspirin’s become more
acceptable, although our group, I think, prefers
an anticoagulant approach. So we would recommend low
molecular weight heparin prophylaxis, until
the surgery is performed. If you’re gonna do surgery and
you give a prophylaxis preoperatively, you would start
your surgery 12 hours after your last dose of prophylactic low
molecular weight heparin. And then restart it 12
hours after the surgery, if hemostasis is appropriate. Nowadays, I think they’re using
a lot more aspirin in low-risk patients, and low molecular
weight heparin in higher-risk patients, is the approach of
our orthopedic surgeons here. And that’s reflected in our new
order sets, not our current orders sets, but the ones
that’ll be active in July.>>There’s one question here
about the pediatric population.>>Actually, more than one
question about the pediatrics.>>I’ve only seen some of them,
I apologize.>>[LAUGH]
>>But there’s at least one question
about the pediatric population, and at least the general
answer to that is, the data on that is not nearly
as good as the adult population. There’s tons of studies
in the adult populations. There are many fewer,
I don’t personally know of any randomized trials in
the pediatric population. Some have extrapolated
down to the younger, kind of teenage group,
the post-puberty patients. We’ve looked at this in trauma,
and patients in trauma seem to matchup with the adults around
the ages, somewhere between 13 and 16, they reach adult risk,
and we treat them like adults. But the data in there’s
a lot more sparse. So what we’ve done, is we do
have a risk assessment tour for pediatrics, that was put
together with our pediatricians and our pediatric hemotologist,
based on a little more expert opinion,
rather then the pure evidence. And it really guides people to
the most highest-risk patients, the older patients, the ones
with thrombophilia, etc., to consider prophylaxis in
that patient population.>>So just to add to that,
cuz I didn’t respond to one of the questions with regards, we
have a pediatric anticoagulation management service, which is
also looking at a point scoring system for risk assessing
the pediatric population. And they’re still looking at
how well this is performing.>>Yeah, I think Neil Goldenberg
and Cliff Takemoto, who are the pediatric
hematologists at Hopkins and at St. Pete Children’s, they’ve collected evidence
of a pediatric service, and are putting together a risk
offer for pediatric patients.>>And they’re using
the first version of that, in their border sets currently.>>Does not need camcorder.>>And so it looks like
there’s a question in SCDs, as far as a concern, that
the only data are in stroke and surgery patients. And I think that does point out
a limitation in the SCD data, that it’s almost all surgical
data, or from the recent CLAW trials’ stroke patients, but
I guess we’ve extrapolated from the stroke patient population to
the medicine patient population. We’ve kinda considered them as
a high-risk medicine patient. And then there’s
lots of data in this surgery literature
that it’s effective. And so, we’re constrained
by the data, but if you have felt that as
persuasive enough that that should be what we
should use in patients, that are contraindicated
to receiving prophylaxis. And have been persuaded that
the TEDs stockings, since as Deb shared, we’ve had the similar
experience to the clots trial that, TED stockings cause
skin breakdown in patients. And so I’ve deemphasized
TED stockings as a method of prophylaxis in our patients.>>Thanks so much everyone,
for joining our webinar today. We really enjoyed
the discussion. We’ll be sending out the slides,
as we mentioned, by March 15th. And you have our
contact information, so please feel free to
reach out to us. Thanks again for joining us.>>Thanks for joining.>>Yeah, thanks everybody.

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