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Service Delivery Innovation Profile

Algorithm Enhances Provision of Preventive Treatment to At-Risk Inpatients, Reducing Incidence of Venous Thromboembolism


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Summary

To reduce hospital-acquired venous thromboembolism, a multidisciplinary team developed a computer program to guide health care providers in assessing individual patient risk for venous thromboembolism and ordering risk-appropriate preventive treatment (prophylaxis) in a timely manner to at-risk patients. Providers use a computerized algorithm to classify patients as low, moderate, or high risk on admission, and then prescribe anticoagulant (blood thinner) medication and/or mechanical devices as appropriate, based on risk level. Patients receive periodic reassessments during their stay, while monthly performance reports are shared with hospital leaders and frontline staff to stimulate ongoing quality improvement. The program significantly increased the use of risk assessments and prophylaxis, leading to reduced incidence of venous thromboembolism.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key process and outcomes measures, including the percentage of patients assessed for venous thromboembolism risk, the percentage of eligible patients administered appropriate prophylaxis, and overall venous thromboembolism incidence in discharged patients.
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Developing Organizations

Johns Hopkins Hospital
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Date First Implemented

2005

Problem Addressed

A common and costly condition, venous thromboembolism (VTE) often leads to morbidity and mortality, particularly in patients during or following hospitalization.1,2 VTE can be largely prevented through the use of appropriate prophylaxis (usually medication or mechanical devices); however, use of VTE prophylaxis remains suboptimal.
  • A common, devastating condition: VTE affects up to 900,000 patients each year. VTE includes two conditions: deep vein thrombosis (DVT), when one or more blood clots form in one of the body's large veins, commonly in the lower limbs, and pulmonary embolism (PE), which occurs when the clot breaks free and travels through the bloodstream to the lungs. VTE is the most common cause of preventable hospital-related death,2 killing more people each year than acquired immunodeficiency syndrome, breast cancer, and highway fatalities combined.2,3
  • Highly preventable with prophylaxis: VTE can often be prevented through risk-based screening and provision of appropriate preventive treatment.3 Standard prophylactic treatment (e.g., anticoagulant medications to thin the blood and prevent clots, elastic stockings to prevent the pooling of blood) for high-risk hospitalized patients has been proven highly effective in reducing the incidence of VTE. Based on this evidence, the Agency for Healthcare Research and Quality (AHRQ) ranked prevention of DVT and PE as the number-one patient safety practice out of 79 ranked practices.1
  • Failure to provide prophylaxis: Despite the evidence supporting preventive treatment, between 50 and 72 percent of hospitalized patients in the United States and other developed nations do not receive appropriate VTE prophylaxis.2 Although use could improve with the development of systems that automatically prompt risk assessment–based prophylaxis administration, very few hospitals have such systems in place.

What They Did

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Description of the Innovative Activity

The VTE prevention program consists of a computerized, evidence-based, algorithm-driven assessment to identify at-risk patients on admission, followed by administration of risk-appropriate prophylactic treatment based on the algorithm and the physician's judgment. Patients receive periodic reassessments during their inpatient stay, while monthly performance reports are shared with hospital leaders and frontline staff to stimulate quality improvement. Key elements of the program include the following:
  • Mandatory risk assessment on admission: The clinician (e.g., physician, nurse practitioner, physician assistant) who enters orders for newly admitted patients into the computerized system completes a mandatory VTE prophylaxis module that includes a checklist of specialty-specific risk factors and contraindications to prophylaxis. Previously entered patient data that relate to VTE risk (e.g., age, weight, renal function) automatically populate the system, which includes more than 15 customized VTE risk modules tailored to different patient populations/specialties. Modules cover general medicine, general surgery, trauma, orthopedic surgery (four modules), neurosurgery, neurology, cardiac surgery, obstetrics/gynecology (four modules), medical oncology, and head/neck surgery. Using the American College of Chest Physician guidelines, the computer assigns the patient to the correct level of risk (i.e., low, moderate, or high) and suggests the appropriate combination of pharmacologic and/or mechanical prophylaxis measures.
  • Prophylaxis order: Physicians review the risk level and the associated recommended prophylactic therapy. Based on their clinical judgment, physicians can then check a box on the screen to approve the order for the recommended therapy, choose an alternative prophylaxis option, or choose not to order any prophylaxis.
  • Periodic reassessment during hospitalization and transfer to different level of care: Clinicians are encouraged to reassess the patient's VTE risk and need for continued prophylaxis during the regular course of clinical care as part of their ongoing review of patient status, medications, and contraindications to therapy. Reassessment of VTE risk status and contraindications to anticoagulant prophylaxis is required when a patient's clinical status results in a transfer to a different level of care.
  • Performance reports to stimulate improvement: Each month, individual unit and hospital leaders receive a report tracking performance related to use of risk assessment and appropriate prophylaxis. These reports help to identify problem areas and stimulate quality improvement. Individual provider VTE performance reports are currently under development.

Context of the Innovation

A 1,015-bed urban tertiary care facility with 150 critical care beds, The Johns Hopkins Hospital treats roughly 268,000 inpatients annually, with patients coming from across the United States and 126 nations. The hospital treats many high-acuity patients at risk of VTE. In 2003, only about one-fourth (25 to 30 percent) of eligible patients received appropriate VTE prophylaxis, a rate close to the national average but deemed unacceptably low by hospital leadership. In response, these leaders decided to make VTE prophylaxis a quality improvement priority and authorized formation of a multidisciplinary team to study and address the issue.

Did It Work?

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Results

The program significantly increased the use of risk assessments and appropriate prophylaxis, leading to reduced incidence of VTE.
  • Increase use of risk assessments: In 2005, before implementation of the program, only approximately 25 to 30 percent of patients received screening for VTE risk on admission. By February 2010, nearly 100 percent of all inpatients received such screening and had an assigned risk level within 24 hours of admission.
  • Increased provision of prophylaxis: The provision of correct, evidence-based prophylaxis in appropriate patients increased from approximately 25 percent before program implementation to 68 percent after introduction of paper order sets (a precursor to the computerized algorithms). Prophylaxis rates have improved dramatically since the implementation of the computerized algorithm to more than 75 percent on most services and approaching 100 percent in some patient groups.
  • Lower VTE incidence: VTE incidence has decreased significantly since the program's implementation, from an estimated 2.4 percent of discharges in 2004 to approximately 1.3 percent in 2009. (Although these data are somewhat imprecise due to the use of administrative discharge billing data and changes in coding definitions for DVT and PE, program leaders remain confident that this initiative has contributed significantly to the downward trend.) Anecdotally, physicians also report a meaningful reduction in VTE; for example, according to the head of performance improvement for the trauma center (Dr. Haut), no trauma center inpatient has died in the last 2 years due to a PE.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key process and outcomes measures, including the percentage of patients assessed for venous thromboembolism risk, the percentage of eligible patients administered appropriate prophylaxis, and overall venous thromboembolism incidence in discharged patients.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Multidisciplinary team review: In 2005, the Johns Hopkins Center for Innovation in Quality Patient Care created a multidisciplinary "VTE Collaborative" team charged with designing a systematic solution to reducing VTE incidence. The team included a hematologist, pharmacist, trauma surgeon, and nurse.
  • Development of paper-based algorithm/order form: Using the American College of Chest Physician guidelines and the existing published peer-reviewed literature, the team developed a paper-based VTE prophylaxis algorithm/order form based on medical diagnoses or surgical procedures/specialties.
  • Hospital-wide rollout: The team introduced the paper algorithm to clinicians on each unit, with the rollout process varying by unit. For example, the rehabilitation service (a small unit on a single floor with a limited number of clinicians) mandated use of the algorithm by every clinician admitting a patient. In contrast, the orthopedic surgery service assigned the job of completing the algorithm/order form to a single nurse practitioner.
  • Development of computer algorithm: The team refined the algorithms and built specialty- and procedure-specific VTE prophylaxis modules for the hospital’s computerized provider order entry system, which allowed for automated risk stratification, assessment of contraindications to prophylaxis, and ordering of risk-appropriate VTE prophylaxis.
  • Computer algorithm testing and rollout: In July 2007, the orthopedic spine surgery unit pilot tested a specialty-specific VTE prophylaxis computerized decision support module, with unit staff receiving training from a member of the VTE Collaborative. After this successful test, other VTE prophylaxis modules were developed for other hospital units.

Resources Used and Skills Needed

  • Staffing: Initial development and ongoing operations have required no new staff, as existing staff incorporate program-related activities into their daily routines. However, the program did require significant time for the clinicians involved in its development and for the information technology (IT) staff who programmed the algorithms into the order entry system.
  • Costs: Program development and operations have not required any financial outlay.
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Funding Sources

Johns Hopkins Hospital
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Tools and Other Resources

Johns Hopkins Hospital's VTE symposium videos and related articles are available at
http://www.hopkinsmedicine.org/innovation_quality_patient_care/areas_expertise/infections_complications
/dvt/preventing/videos.html
.

Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 Suppl):381S-453S. [PubMed] Available at: http://www.guideline.gov
/content.aspx?id=25639&search=thromboembolism+and+prevention+of+thromboembolism


Hirsh J, Guyatt GH, Albers GW, et al. Antithrombotic and thrombolytic therapy: American College of Chest Physicians Evidence-Based Practice Guidelines (8th Edition). Chest. 2008;133(6 suppl):67s-968s. Available at: http://journal.publications.chestnet.org/article.aspx?articleid=1085921

Interactive Venous Thromboembolism Safety Toolkit for Providers and Patients. This interactive safety toolkit contains multiple evidence-based tools for providers and patients to improve the safety of the process for diagnosing and treating VTE. Tools include patient education materials, prevention guidelines, screening and assessment materials, and treatment pathways. Available at: http://www.ncbi.nlm.nih.gov/books/NBK43659/

Adoption Considerations

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Getting Started with This Innovation

  • Ensure buy-in from hospital leadership: Hospital leaders must support the program, especially because clinicians and IT staff will need to devote upfront time to the effort. Typically, leaders will support the program once they see data documenting the clinical, financial, and human costs of high VTE incidence. In addition, at Johns Hopkins Hospital, the sharing of stories about individual patients who died from PE proved to be particularly effective in gaining leaders' support.
  • Make algorithm use mandatory: Busy clinicians often will not follow the algorithm unless required to do so. Unit policies mandating such use, along with automatic contingencies programmed into the computer, help to ensure that everyone routinely uses the algorithm. For example, at Johns Hopkins Hospital, the VTE decision support module must be completed to allow any other computer orders to be placed.
  • Allow units to decide how to adopt paper-based approach: Organizations using a paper-based algorithm should let leaders and staff on individual units decide how to adopt it, based on their unique work processes and staffing considerations.
  • Adopt computerized algorithms whenever possible: Although paper-based algorithms and order sets can improve the use of VTE prophylaxis, computer-based algorithms tied to order sets likely work better, as they save clinician's time and can be more easily integrated into the existing workflow. Computer-based algorithms also greatly facilitate the collection of unit and individual provider performance data, allowing for targeted real-time performance improvement.
  • Set appropriate expectations: The speed at which both paper-based and computerized algorithms can be developed and implemented depends on the amount of time staff can devote to the project.
  • Conduct pilot test before broader rollout: Consider piloting the program in one department before implementing it across the hospital. This approach helps developers evaluate the program's impact on clinician workflow, gather user feedback, and refine the program accordingly before introducing it throughout the organization.

Sustaining This Innovation

  • Incorporate VTE prevention into general training: At Johns Hopkins Hospital, training on the VTE prevention module occurs as a part of general training for all new residents.

Additional Considerations

  • In April 2010, the Johns Hopkins Hospital received the North American Thrombosis Forum's DVTeamCare™ Award for hospitals with more than 200 beds. More information on this award can be found at www.natfonline.org.

More Information

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Contact the Innovator

Michael B. Streiff, MD, FACP
Associate Professor of Medicine and Pathology
Medical Director, Johns Hopkins Anticoagulation Service and Outpatient Clinics
Johns Hopkins Medical Institutions
1830 E Monument Street, Suite 7300
Baltimore, MD 21205
(410) 502-8642
E-mail: mstreif1@jhmi.edu

Elliott Haut, MD, FACS
Associate Professor of Surgery, Anesthesiology/ Critical Care Medicine (ACCM) and Emergency Medicine
Division of Acute Care Surgery, Department of Surgery
Sheikh Zayed 6107C
1800 Orleans St. 
Baltimore, MD 21287
(410) 502-3122
E-mail: Ehaut1@jhmi.edu
http://www.meddium.com/ehaut

Deborah Hobson, BSN
Patient Safety Clinical Specialist
Armstrong Institute for Patient Safety and Quality
The Johns Hopkins Hospital
1800 Orleans Street
Carnegie Building, Suite 667
Baltimore, Maryland 21287
(443) 287-7354
E-mail: dhobson1@jhmi.edu

Peggy S. Kraus, PharmD, CACP
Pharmacy Clinical Specialist in Anticoagulation
The Johns Hopkins Hospital
600 North Wolfe Street, Carnegie 180
Baltimore, MD 21287-6180
(410) 502-0464
E-mail: pkraus2@jhmi.edu

Innovator Disclosures

Dr. Streiff, Dr. Haut, Ms. Hobson and Ms. Kraus have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Further information about VTE and anticoagulation management is available at the Johns Hopkins Anticoagulation Clinic Web site at http://www.hopkinsmedicine.org/hematology/anticoagulation.

Footnotes

1 Kleinbart J, Williams MV, Rask K. Prevention of venous thromboembolism. In: Making health care safer: a critical analysis of patient safety practices. Evidence Report/Technology Assessment: Number 43. AHRQ Publication No. 01-E058, July 2001. Agency for Healthcare Research and Quality, Rockville, MD. Available at: http://archive.ahrq.gov/clinic/ptsafety/chap31a.htm
2 Venous Thromboembolism Prevention Bundle. Johns Hopkins Medicine. Innovation in Quality Patient Care.
3 American Public Health Association. Deep-vein thrombosis: advancing awareness to protect patient lives. White Paper. Public Health Leadership Conference on Deep-Vein Thrombosis. 2003 Feb 26. Washington, DC. Available at: http://www.apha.org/NR/rdonlyres/A209F84A-7C0E-4761-9ECF-61D22E1E11F7/0/DVT_White_Paper.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: March 16, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 18, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: April 08, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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