Venous Thromboembolism (VTE)

Prevention in the Hospital

Greg Maynard MD, MSc

Clinical Professor of Medicine and Chief,
Division of Hospital Medicine
University of California, San Diego

VTE: A Major Source of

Mortality and Morbidity

350,000 to 650,000 with VTE per year

100,000 to > 200,000 deaths per year
Most are hospital related.
VTE is primary cause of fatality in half More than HIV, MVAs, Breast CA combined
Equals 1 jumbo jet crash / day
10% of hospital deaths
May be the #1 preventable cause
Huge costs and morbidity (recurrence, postthrombotic syndrome, chronic PAH)
Surgeon Generals Call to Action to Prevent DVT and PE 2008 DHHS

Risk Factors for VTE

Stasis

Hypercoagulability

Age > 40
Immobility
CHF
Stroke
Paralysis
Spinal Cord injury
Hyperviscosity
Polycythemia
Severe COPD
Anesthesia
Obesity
Varicose Veins

Cancer
High estrogen states
Inflammatory Bowel
Nephrotic Syndrome
Sepsis
Smoking
Pregnancy
Thrombophilia

Endothelial
Damage
Surgery
Prior VTE
Central lines
Trauma

Anderson FA Jr. & Wheeler HB. Clin Chest Med 1995;16:235.

Risk Factors for VTE

e
v
a
h
ts Endothelial
E
Stasis
Hypercoagulability
n
T
e
V
i
t
Age > 40
Cancer
r
Damage
a
o
p
f
Immobility
High estrogen states
r
d
Surgery
o
e
t
CHF
Inflammatory
Bowel c
z
i
Prior VTE
l
a
f
Stroke
a
Nephrotic
Syndrome
t
i
k
Central lines
p
s
Paralysis
i
s
Sepsis
r
Trauma
e
Spinal Cord injury ho
Smoking
n
t
o
s
Hyperviscosity
Pregnancy
t
o
s
M leaThrombophilia
Polycythemia
Severe COPD t
a
Anesthesia
Obesity
Varicose Veins

Anderson FA Jr. & Wheeler HB. Clin Chest Med 1995;16:235.

Bick RL & Kaplan H. Med Clin North Am 1998;82:409.

Failure to Do Simple Things

Well

Wash Hands

60% Reliable

Patients Understand Meds / Problems

40% Reliable

Central Lines Placed w/ Proper Technique

60% Reliable

Basal Insulin for Inpt Uncontrolled DM

40% Reliable

VTE Prophylaxis
50% Reliable

Registry Data
Highlight the Underuse of
Thromboprophylaxis
DVT-FREE

RIETE

IMPROVE

BAD NEWS!
Only a minority of hospitalized
patients receive
thromboprophylaxis
Goldhaber SZ, Tapson VF. Am J Cardiol 2004;93:259-62.
Monreal M, et al. J Thromb Haemost 2004;2:1892-8.
Tapson V, et al. Blood 2004;104:11. Abstract #1762.

Endorse Results
Out of ~70,000 patients in 358 hospitals,
appropriate prophylaxis was administered
in:
58.5% of surgical patients
39.5% of medical patients

Cohen, Tapson, Bergmann, et al. Venous thromboembolism

risk and prophylaxis in the acute hospital care setting
(ENDORSE study): a multinational cross-sectional study.
Lancet 2008; 371: 38794.

The Stick is coming.

NQF endorses measures already
Public reporting and TJC measures coming soon:
- Prophylaxis in place within 24 hours of admit or risk
assessment / contraindication justifying its absence
- Same for critical care unit admit / transfers
- Track preventable VTE

CMS DVT or PE with knee or hip replacement

reimbursed as though complication had not
occurred.

Why dont we do better?

Lack of awareness or buy in of guidelines
Underestimation of clot risk,
overestimation of bleeding risk
Lack of validated risk assessment model
Translating complicated guidelines into
everyday practice is difficult

E-Alerts Can Increase

Prophylaxis
2506 hospitalized patients
VTE risk score 4
Randomized to intervention or control

Intervention

Treatment Received
Mechanical, %

Pharmacologic, %

E-Alert

10

23.6

Control

1.5

13

P-value

0.001

0.001

Kucher N, et al. N Engl J Med. 2005;352:969-977.

E-Alerts Decrease VTE

% Freedom from DVT/ PE

100
98

Intervention

96
94
92

41%
P = 0.001

Control

90
0

30

60

90

Time (days)

Number at risk
Intervention

1255

977

900

853

Control

1251

976

893

839

Kucher N, et al. N Engl J Med. 2005;352:969-977.

Effectiveness can wane over time

*P < 0.05

Lecumberri R, et al. Thromb Haemost. 2008;100:699-704.

Human Alerts Increase

Prophylaxis
2493 hospitalized patients
VTE risk score 4
Randomized to intervention or control
Intervention

Treatment Received
Mechanical, %

Pharmacologic, %

Hu-Alert

21

28

Control

14

95% CI

10.6-16.0

10.5-16.8

Piazza G, et al. Circulation. 2009;119:2196-2201.

% Freedom from DVT/ PE

Human Alerts Decrease VTE

P = 0.31

Time After Initial Enrollment (days)

Piazza G, et al. Circulation. 2009;119:2196-2201.

Bottom Line - Alerts

A Useful Strategy
E Alerts and Human Alerts can work
Not a panacea
Alert fatigue can be a problem

Need a multifaceted approach

Medical Admission Order Sets Can

Improve DVT Prophylaxis
Baseline- Only 11% of inpatients on any VTE
prophylaxis
Intervention
A simple prompt for UFH or Mechanical
Prophylaxis placed into voluntary admission
order sets.
Post intervention:
44% on any prophylaxis
26% pharmacologic prophylaxis
O'Connor C, Adhikari N, DeCaire K, Friedrich Jan. Medical Admission Order Sets to Improve Deep Vein
Thrombosis Prophylaxis Rates and Other Outcomes. J Hosp Med 2009

but not enough by themselves, and

design of the order set matters
Best practice prophylaxis not defined
Prompt Protocol

No protocol = No guidance at the point of

care
in order set, heparin, mechanical devices, and no
prophylaxis presented as equal choices

Implementation / Reliability
At 15 months, only about half of inpatient
admissions utilized standardized order set.

Other methods needed to enhance

performance!

Education alone is not

sufficient
.but it is essential to optimize other strategies
that are effective

Standardized order sets

Computerized decision support
E-alerts
Human alerts
Raising situational awareness
Audit and feedback

Percent of Randomly Sampled Inpatients with

Adequate VTE Prophylaxis
UCSD experience

N = 2,944

mean 82 audits / month

100%
90%
80%
70%

Order Set Implementation

& Adjustment

Real time ID &

intervention

60%
50%
40%

Baseline

Consensus
building

30%
20%
19

UCSD
VTE Protocol Validated
Easy to use, on direct observation a few seconds
Inter-observer agreement
150 patients, 5 observers- Kappa 0.8 and 0.9

Predictive of VTE
Implementation = high levels of VTE prophylaxis
From 50% to sustained 98% adequate prophylaxis
Rates determined by over 2,900 random sample audits

Safe no discernible increase in HIT or bleeding

Effective 40% reduction in HA VTE
86% reduction in risk of preventable VTE

Level 5

Oversights identified and addressed in real time

95+%

21

Hospital Acquired VTE by Year

2005
2006

2007

2008

9,720

9,923

11,207

Cases w/ any VTE

Risk for HA VTE
Unadjusted RR
(95% CI)

131
1 in 76
1.0

138
1 in 73
1.03
(0.81-1.31)

92
1 in 122
0.61#
(0.47- 0.79)

Cases with PE
Risk for PE
Unadjusted RR
(95% CI)

21
1 in 463
1.0

22
1 in 451
1.02
(0.54-1.86)

15
1 in 747
0.62
(0.32-1.20)

116
1 in 85
1.03
(0.80-1.33)

77
1 in 146
0.61*
(0.45-0.81)

68

21
1 in 473
0.47#
(0.28-0.79)

7
1 in 1,601
0.14*
(0.06-0.31)

Cases with DVT (and no PE)

Risk for DVT
Unadjusted RR
(95% CI)

110
1 in 88
1.0

Cases w/ Preventable VTE

Risk for Preventable VTE
Unadjusted RR
(95% CI)

44
1 in 221
1.0

Dr. Maynard, the CIs are different here and

in the proof. Which are correct?

Patients at Risk

# p < 0.01 *p < 0.001

Maynard GA, et al. J Hosp Med. 2009;

80

12

VTE Prevention Guides Modeling a

Multifaceted Approach

http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_VTE/VTE_Home.cfm
http://ahrq.hhs.gov/qual/vtguide/

VTE QI Resource Room

www.hospitalmedicine.org

Collaborative Efforts

SHM VTE Prevention Collaborative I - 25 sites

SHM / VA Pilot Group - 6 sites
SHM / Cerner Pilot Group 6 sites
AHRQ / QIO (NY, IL, IA) - 60 sites
IHI Expedition for VTE Prevention 60 sites

Effective across wide variety of settings

Paper and Computerized / Electronic
Small and large institutions
Academic and community

Basic Ingredients for

Success
Institutional support, will to standardize the
process
Designated multidisciplinary team with
physician leadership
Specific goals and metrics
VTE Protocol guidance built into order sets
Education / consensus
Alerts / feedback to clinicians in real time

Enlist Key Groups / Leaders

Section Heads
Hospitalists
(most groups receive some direct support
from the hospital)

Other high volume providers

Find some more physician champions

Educational Detailing - PR
Quote ACCP 8 Guidelines
Dont use aspirin alone for DVT prophylaxis
Mechanical prophylaxis is not first line
prophylaxis in the absence of
contraindications to pharmacologic
prophylaxis
Geerts WH et al. Chest. 2008;133(6 Suppl):381S-453S

Use the powerful anecdote and

data
Look for VTE case that could have been
prevented
Personalize the story
Enlist a patient / family to help you tell the
story
Get data on VTE in your medical center
(it occurs more often than the doctors think it
does)

Q and A
Q. What is the best VTE risk assessment model?
A. Simple, text based model with only 2-3 layers of
VTE Risk
Q. Who should do the VTE risk assessment?
A. Doctors (via admit transfer order sets), with back
up risk assessment by front line nurses or
pharmacists, focusing on those without
prophylaxis.

Hierarchy of ReliabilityPredicted
Level
1
No protocol* (State of Nature)
2

3
4
5

Decision support exists but not linked to

order writing, or prompts within orders
but no decision support
Protocol well-integrated
(into orders at point-of-care)
Protocol enhanced
(by other QI / high reliability strategies)
Oversights identified and addressed in
real time

Prophylaxis
rate

40%
50%

65-85%
90%
95+%

* Protocol = standardized decision support, nested within an order set, i.e. what/when

The Essential First Intervention

VTE Protocol
1) a standardized VTE risk assessment, linked to
2) a menu of appropriate prophylaxis options, plus
3) a list of contraindications to pharmacologic VTE
prophylaxis
Challenges:
Make it easy to use (automatic)
Make sure it captures almost all patients
Trade-off between guidance and ease of use /
efficiency

32

Map to Reach Level 3

Implementing an Effective VTE Prevention

Protocol
Examine existing admit, transfer, periop order
sets with reference to VTE prophylaxis.
Design a protocol-driven DVT prophylaxis order
set (w/ integrated risk assessment model [RAM])
Vette / Pilot PDSA
Educate / consensus building
Place new standardized DVT order set module
into all pertinent admit, transfer, periop order
sets.
Monitor, tweak - PDSA

Is your order set in a

competition?

34

Too Little Guidance

Prompt Protocol
DVT PROPHYLAXIS ORDERS
Anti thromboembolism Stockings

Sequential Compression Devices

UFH 5000 units SubQ q 12 hours
UFH 5000 units SubQ q 8 hours
LMWH (Enoxaparin) 40 mg SubQ q day
LMWH (Enoxaparin) 30 mg SubQ q 12 hours
No Prophylaxis, Ambulate

No Math!
Critiques of VTE Risk Assessment
Model using point scoring techniques
Point based systems low inter-observer agreement in real use
users stop adding up points
too large to be modular (collects dust)
point scoring is arbitrary
never validated

Example from UCSD

Keep it Simple A 3 bucket model

Low

Medium

High

Ambulatory
with no other
risk factors.
Same day or
minor surgery

CHF
COPD / Pneumonia
Most Medical Patients
Most Gen Surg
Patients
Everybody Else

Elective LE arthroplasty
Hip/pelvic fx
Acute SCI w/ paresis
Multiple major trauma
Abd / pelvic CA surgery

Early
ambulation

UFH 5000 units q 8 h

Enox 30 mg q 12 h or
Enox 40 q day
or
Other LMWH
or

(5000 units q 12 h if > 75

or weight <50 kg)

LMWH
Enox 40 mg q day
Other LMWH
CONSIDER add IPC

Fondaparinux 2.5 mg q day

or
Warfarin INR 2-3
AND MUST HAVE
IPC
37

IPC needed if contraindication to AC exists

Paper Version 3 Bucket

RAM DVT Prophylaxis Order Set
Module

See separate paper version demonstrating 3 bucket model

Integrate order set as a

module
Make order set even more portable
Incorporate module into current heavily
used order sets
Or
Strip out VTE orders from popular order sets
and refer to the standardized orders
Clip orders to all admit / transfer orders

Most Common Mistakes in

VTE Prevention Orders
Point based risk assessment model
Improper Balance of guidance / ease of use
Too little guidance - prompt protocol
Too much guidance- collects dust, too long

Failure to revise old order sets

Too many categories of risk
Allowing non-pharm prophy too much
Failure to pilot, revise, monitor
Linkage between risk level and prophy choices are
separated in time or space

Hierarchy of ReliabilityPredicted
Level
1
No protocol* (State of Nature)
2

3
4
5

Decision support exists but not linked to

order writing, or prompts within orders
but no decision support
Protocol well-integrated
(into orders at point-of-care)
Protocol enhanced
(by other QI / high reliability strategies)
Oversights identified and addressed in
real time

Prophylaxis
rate

40%
50%

65-85%
90%
95+%

* Protocol = standardized decision support, nested within an order set, i.e. what/when

Measure-vention
Daily measurement drives concurrent intervention
(i.e. same as Level 5 in Hierarchy of Reliability)

Identify patients not receiving VTE prophylaxis in

real time
1) Suitable for ongoing assessment, reporting to
governing body
Archive-able data (!)

2) Can be used for real time intervention

Actionable data (!)
42

Map to Reach Level 5

95+ % prophylaxis
Use MAR or Automated Reports to Classify
all patients on the Unit as being in one of
three zones:
GREEN ZONE - on anticoagulation
YELLOW ZONE - on mechanical
prophylaxis only
RED ZONE on no prophylaxis
Act to move patients out of the RED!

Situational Awareness and

Measure-vention: Getting to
Level 5

Identify patients on no anticoagulation

Empower nurses to place SCDs in
patients on no prophylaxis as standing
order (if no contraindications)
Contact MD if no anticoagulant in place
and no obvious contraindication
Templated note, text page, etc

Need Administration to back up these

interventions and make it clear that docs
can not shoot the messenger

Effect of Situational Awareness on

Prevalence of VTE Prophylaxis by
Nursing Unit

Hospital A, 1st Nursing Unit

Interventio
n

UCL:

Mean:
LCL:

Baseline
93%

73%
53%

Post-Intervention
104%
99% (p < 0.01)
93%

Hospital
Days

Hospital A, 2nd Nursing Unit

UCL:

Mean:
LCL:

Interventio
n

Baseline
90%

68%
46%

Post-Intervention
102%
87% (p < 0.01)
72%

Hospital B, 1st Nursing Unit

UCL:

Mean:
Interventio
n

LCL:

Baseline
89%

71%
53%

Post-Intervention
108%
98% (p < 0.01)
88%

_______________________
UCL = Upper Control Limit45
LCL = Lower Control Limit

Most Common Mistakes in

Measurement of DVT
Prophylaxis
Not doing it at all
Not doing it concurrently
Failure to make measured poor
performance actionable

Key Points - Recommendations

QI building blocks should be used

Multifaceted approach is needed
VTE protocols embedded in order sets
Simple risk stratification schema, based on VTErisk groups (3 levels of risk should do it)
Institution-wide if possible (a few carve outs ok)
Local modification is OK
Details in gray areas not that important

Use measure-vention to accelerate improvement

47

Maynard G, Morris T, Jenkins I, Stone S, Lee J, Renvall M, Fink E, Schoenhaus

R (2009) Optimizing prevention of hospital acquired venous
thromboembolism: prospective validation of a VTE risk assessment model. J
Hosp Med 4(7). doi:10.1002/jhm.562
Maynard G, Stein J. Preventing Hospital-Acquired Venous Thromboembolism: A
Guide for Effective Quality Improvement. Prepared by the Society of Hospital
Medicine. AHRQ Publication No. 08-0075. Rockville, MD: Agency for
Healthcare Research and Quality. August 2008, last accessed September
15, 2008 at http://www.ahrq.gov/qual/vtguide/.
Maynard G, Stein J. Preventing Hospital-Acquired Venous Thromboembolism: A
Guide for Effective Quality Improvement, version 3.3. Society of Hospital
Medicine supplement The Hospitalist August 2008, Vol 12 (8) 1-40.
Maynard G, Stein J. Designing and Implementing Effective VTE Prevention
Protocols: Lessons from Collaboratives. J Thromb Thrombolysis DOI
10.1007/s11239-009-0405-4 published online Nov 10, 2009