California hospital team takes aim on VTE

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Effort nearly eliminates incidence of hospital-acquired VTE

Patients with venous thromboembolism, which includes deep vein thrombosis and pulmonary embolism, account for 600,000 hospitalizations and 200,000 fatalities each year, the National Quality Forum estimates. A three-year study led by Greg Maynard, MD, MS, a clinical professor of medicine and division chief of hospital medicine at the University of California San Diego Medical Center, has made waves in an effort to reduce this number.

Not only did Maynard and his team analyze years of data about deep vein thrombosis (DVT) and pulmonary embolism (PE), but they also developed a mentor program and toolkit to help other facilities combat venous thromboembolism (VTE).

“It really started out of recognition that DVT is a national problem, and it’s been shown that there are proven pharmacological measures that are underutilized,” says Maynard. The National Quality Forum (NQF) estimates that less than 50% of patients diagnosed with DVT receive appropriate prophylaxis. The University of California San Diego (UCSD) Medical Center had a similar prophylaxis rate when it applied to be a part of a grant from the Agency for Healthcare Research and Quality (AHRQ) in 2005.

Part of the goal of applying to the AHRQ was to create a toolkit that other hospitals could use. To achieve this, Maynard had to first fashion a risk assessment system that was different from the existing point-based systems requiring addition. Instead, Maynard and his colleagues created a “bucket” model that separated all inpatients into three categories: low, medium, and high. Each bucket was linked to a certain level of prophylaxis, and every inpatient was given a risk assessment at admission. This model was built into the computerized physician order entry system, allowing caregivers to see what the appropriate level of prophylaxis was for each risk level.

“Our model had a high level of reliability and agreement,” Maynard says. “It also monitored effectiveness of how often patients are getting appropriate prophylaxis.”

Gathering the data

Maynard’s team started collecting data on every case of DVT and PE at UCSD Hillcrest, a 300-bed hospital, between 2005 and 2006 using the risk assessment model. Two main methods were employed: digital scans and random sampling. Inpatient digital reports were scanned each day for DVT. Any positive outcomes were followed up to see whether any clots present were community- or hospital-acquired. Those who had hospital-acquired VTE and had followed the suggested prophylaxis regimen were considered “preventable” cases. Additionally, each day, patients were chosen at random to monitor for 48 hours to see whether they were on appropriate VTE prophylaxis and had been adequately assessed.

During the early stages of the program, UCSD Medical Center’s rate of adequate prophylaxis hovered around 55%. Maynard says it took another year to get that number up to 70%. The first year was spent educating staff members about the initiative.

Next, the risk assessment model was incorporated into an order set so that every patient admitted got evaluated. That helped raise the adequate prophylaxis rate to 90%.

“But what about that 10% not on adequate prophylaxis?” Maynard says. “After we started getting reports of who was not on prophylaxis that should be and had a smaller pool, we asked the nurses to help us.” The nurses prompted doctors to evaluate the remaining patients for DVT and PE and give the correct prophylaxis. Since mid-2007, the adequate prophylaxis rate has been approximately 98%.

The NQF recently endorsed a new set of consensus standards for hospitals, which include 48 new standards, six of which deal with VTE. This is the second set of standards that have been endorsed—the first set from 2006 had two VTE performance measures.

“NQF is suggesting that all patients should be evaluated, based on the number of risk factors there are and the fact that most patients who come into the hospital will have one or more of those risk factors,” says Melinda Murphy, RN, MS, CNA, a consultant at the NQF who has been working on the VTE project since 2005.

A toolkit and a mentoring program

One of the outcomes of UCSD Medical Center’s VTE project is direction for other facilities that need help setting up their own program. As the first recipient of the Society of Hospital Medicine’s (SHM) Team Approaches in Quality Improvement Award, Maynard’s team has worked with the SHM to publish a toolkit and mentoring program on the SHM Web site.

To date, the VTE Prevention Collaborative (the mentoring program) has 30 sites with longitudinal interaction. Hospitals that sign up for the program are provided mentors to reinforce via phone the concepts posted to the SHM Web site, and they receive instructions on successful implementation for more than one year from Maynard and his team.

“We’re excited,” Maynard says. “We’re finding out we think we can spread across whole [hospital] systems.”

Editor’s note: Go to to visit the SHM’s VTE Prevention Collaborative Web site.