RHQN Best Practice Call:
Partnership for Patients (PfP)
focus:
VTE
Tuesday, April 10, 2012
Partnership for Patients includes 10 focus areas:
(With Current RHQN Strategies for helping CAHs)
1.
2.
PfP: Cultural Transformation
Leadership Engagement
CEO and Trustee Summit May 2nd or 3rd.
Current activities:
Hospital Survey of Patient Safety Culture (HSOPS)Second group of 7 CAHs now taking the Survey.
Just Culture, Executive WalkRounds and TeamSTEPPS
Communication tool training (currently Flex funded)
RHQN Root Cause Analysis and Taste of Lean classes
3. PfP:
Preventable Readmissions within 30
days
Goal:
Reduce preventable readmission from
2010 benchmark by 20% to end of
2013.
See RHQN Best Practice calls with
Whitman in the past on RHQN website.
Also focus of future Best Practice calls.
4. PfP:
Reduce
Hospital Acquired Infections (HAI)
and
Hospital Acquired Conditions (HAC)
by 40% from 2010 to end of 2013.
3. PfP: Infection Prevention Measures (HAI)
Safe Table on April 11th.
Encourage all to come to the Safe Tables. Sometimes works best for two
to come because you have support when you go home and want to
implement something
1) CAUTI- On Survey, 20 CAHs indicated they have a CAUTI Bundle. 3
asked for support.
February Best Practice Call Fran Petersen, Lourdes : Nurse Initiated
Foley Catheter removal-on RHQN Website.
2) Surgical Site Infections- RHQN will follow WSHA lead with CAH Best
Practice discussions
3) VAP-Not applicable in many facilities. Others indicated on the RHQN
Survey that they had Ventilator Bundle and QI monitoring.
4) CLABSI- 15 CAHs indicated on the Survey that you have CLABSI
Bundles. 4 CAHs indicated it is not applicable. 4 asked for support.
PfP: Hospital Acquired Conditions (HAC)
1) VTE- On Survey, 15 indicated they had a VTE Prevention and
Treatment Protocol. Only 7 CAHs had QI projects to monitor and improve
VTE rates. 5 did not and 7 asked for support.
2) Obstetrical Adverse Events-Working with CAHs who have
challenges implementing the ACOG Guidelines for 39 weeks. Best
Practice Sharing on-going.
3) Pressure Ulcers-April 25th-WSHA Web-conference and RHQN to
follow
4) Falls-10 CAHs report on QBS. 6=less than 5%. See 4/25 WSHA Webconference.
5) Adverse Drug Events….27 CAHs indicated they track Adverse
Events with 22 having a QI project in this area. We will work especially
with the 7 who did not indicate they have a program in place. Also, we will
bring Best Practices to you in the future.
RHQN Best Practice Call:
Partnership for Patients (PfP)
focus:
VTE
April 10, 2012
Facilitated by
Bev McCullough, RN, MBA, CPHQ
VTE: DVT& PE: Alphabet Soup

Venous Thromboembolism (VTE):
Deep Vein Thrombosis of the lower
leg (DVT)
 Clot dislodges from DVT, travels to the
lungs and becomes a Pulmonary
Embolism (PE)

Implementing a VTE Protocol

The “QI Basics”: “8 Steps for Effective Change”

Explain the Urgency
Leadership buy-in, Physician Champion, engaged
team
Have a shared vision
Communicate to others: The “elevator speech”
Remove barriers: empower to create change
Choose well: Implement in one area, do “small tests of
change” and then Celebrate
Keep improving: PDSAs, Measure, Monitor, SPREAD
Sustain



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VTE: The Urgency


“Pulmonary Embolism is the third
most common cause of hospitalrelated death and it is the most
common preventable cause of
hospital-related death.”*
*http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/cardiology/venous-thromboembolism/
VTE: CMS Measures
SCIP-VTE-1 Surgery Patients with
Recommended Venous
Thromboembolism Prophylaxis
ordered
 SCIP-VTE-2 Surgery Patients Who
Received Appropriate Venous
Thromboembolism Prophylaxis Within
24 Hours Prior to Surgery to 24 Hours
After Surgery

VTE: Making the Case

Meaningful Use:

2012 –Eligible CAHs seeking to
demonstrate Meaningful Use are
required to electronically submit
aggregate CQM numerator,
denominator, and exclusion data to
CMS or the States.
VTE: Making the Case

Meaningful Use for Hospitals:
VTE prophylaxis w/in 24 hrs. of arrival
 Intensive Care Unit VTE prophylaxis
 Anticoagulation overlap therapy
 Platelet monitoring on unfractionated
heparin
 VTE discharge instructions
 Incidence of potentially preventable
VTE

VTE: Making the Case:
TJC measures: CMS 2013






VTE-1* Venous Thromboembolism Prophylaxis
VTE-2 Intensive Care Unit Venous Thromboembolism
Prophylaxis
VTE-3* Venous Thromboembolism Patients with
Anticoagulation Overlap Therapy
VTE-4 Venous Thromboembolism Patients Receiving
Unfractionated Heparin with Dosages/Platelet Count
Monitoring by Protocol
VTE-5 Venous Thromboembolism Discharge
Instructions
VTE-6* Incidence of Potentially-Preventable Venous
Thromboembolism
VTE: Making the Case:
The CAH National Measures Brief

VTE prophylaxis

VTE patients with anti-coagulation
overlap therapy

Incidence of potentially preventable
VTE
VTE Implementation

The “QI Basics”: “8 Steps for Effective Change”

Explain the Urgency
Leadership buy-in, Physician Champion, engaged
team
Have a shared vision
Communicate to others: The “elevator speech”
Remove barriers: empower to create change
Choose well: Implement in one area, do “small tests of
change” and then Celebrate
Keep improving: PDSAs, Measure, Monitor, SPREAD
Sustain







Choose a VTE Protocol

Standardized processes



The key to reliability
All patients, Every time
Example:
1. Wells Risk Assessment Tool
2. D-Dimmer blood test
3. Menu of appropriate prophylaxis options
4. Screening for pharmacological
contraindications
Scoring:
Which Risk Tool do you use?

Wells?

Cabrini?

Other:
Wells with D-Dimer test ?
Wells Score

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1-Active Cancer
1=Paralysis, paresis, or recent plaster immobilization of lower
extremities
1=Recently bedridden > 3 days or major surgery within 4 weeks
1=Localized tenderness along the deep venous system
1=Entire leg swollen
1=Calf swelling > 3 cm vs asymptomatic leg*
1=Pitting edema greater in symptomatic leg
1=Collateral superficial veins (not varicose)
-2=Alternative dx as likely or greater than deep-vein thrombosis
Wells Scoring
High >=3
 Moderate 1 or 2
 Low 0
Modify by adding one point if there is a
previously documented DVT
 Likely=>2
 Unlikely=<1

Wells Scoring
High >=3
 Moderate 1 or 2
 Low 0
Modify by adding one point if there is a
previously documented DVT
 Likely=>2
 Unlikely=<1

D-Dimer Test
A blood test of a fibrin degradation
product, present in the blood after a
blood clot is degraded by fibrinolyis.
 Combined with the Wells clinical
decision rule it has @ 99% predictive
value for VTE.

Choose a VTE Protocol

Standardized processes



Are the key to reliability
All patients, Every time
Example:
 1.

Wells Risk Assessment Tool
2. D-Dimmer blood test
3. Menu of appropriate prophylaxis options
4. Screening for pharmacological
contraindications
Menu of Treatment Options

Pharmacological prophylaxis reduces
the incidence of asymptomatic and
symptomatic DVT and PE by 50-65%*

Resources:

Society of Hospital Medicine

http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_VTE
/VTE_Home.cfm

http://www.hospitalmedicine.org/ResourceRoomRedesign/R
R_VTE/PDFs/SAMPLEVTEPROTOCOLS.pdf
VTE Order Sets

AHRQ Suggests the Society of
Hospital Medicine site for CAHs
Getting to 100%
Situational Awareness and "Measure-intervention"—
Identify patients on no anticoagulation-Put on the daily checklist.
Empower nurses to place mechanical prophylaxis.
Contact MD if no anticoagulant in place and no obvious contraindication:
Template note, text page, etc.
Back up these interventions:
Physicians can not "shoot the messenger."
Create Highly Reliable Strategies

Desired Action is the Default (You have to Opt-Out if you don’t do it)

Desired Action is Prompted by a reminder or decision aide

Desired Action is Standardized into a process (a deviation feels
weird)

Desired Action is Scheduled to occur at known intervals

Responsibility for the Desired Action is Redundant
(Example: The clerk or pharmacist is empowered to halt processing of
an admission order set that has not prophylaxis selected)
Implementing a VTE Protocol

The “QI Basics”: “8 Steps for Effective Change”

Explain the Urgency
Leadership buy-in, Physician Champion, engaged
team
Have a shared vision
Communicate to others: The “elevator speech”
Remove barriers: empower to create change
Choose well: Implement in one area, do “small tests of
change” and then Celebrate
Keep improving: PDSAs, Measure, Monitor, SPREAD
Sustain
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RHQN Website:
http://www.rhqn.org/
Select “Resources”:
User Name: RHQN
Password: Quality1
Or contact:
Bev McCullough, RN, MBA,CPHQ
bevm@wsha.org
206-216-2862