A 10-Year Collaborative Journey Elliott R. Haut, MD, PhD, FACS Vice - - PowerPoint PPT Presentation

Multidisciplinary Team Approach to Venous Thromboembolism Prophylaxis: A 10-Year Collaborative Journey

Elliott R. Haut, MD, PhD, FACS

Vice Chair of Quality, Safety, & Service Associate Professor of Surgery & ACCM & Emergency Medicine & Health Policy / Management

June 24, 2017 AcademyHealth #ARM17 New Orleans, LA

@elliotthaut #AHPeriopIG #ARM17

Why focus on VTE?

• VTE is common

–350,000 to 600,000 Americans suffer DVT and/or PE each year

http://www.surgeongeneral.gov/topics/d eepvein/calltoaction/call-to-action-on- dvt-2008.pdf

Why focus on VTE?

• VTE is Deadly

– >100,000 deaths per year

• More deaths than

combined from

– Breast Cancer – Motor Vehicle Collisions – AIDS

http://www.surgeongeneral.gov/topics/d eepvein/calltoaction/call-to-action-on- dvt-2008.pdf

Johns Hopkins DVT Symposium 2009

Surveillance Bias and Public Reporting of VTE

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How did I get interested in VTE?

• Adult Trauma Performance Improvement
• Paraphrased letter we received
• Dear Johns Hopkins Adult Trauma
• You have the highest DVT rate of all

Trauma Centers in Maryland

• Why?
• Sincerely, Maryland Institute for

Emergency Medical Services Systems (MIEMSS)

A New Research Idea is Born

• Johns Hopkins screens aggressively
• What do other trauma centers do?
• Does this impact reported DVT rates?

Should we Screen High-Risk Trauma Patients for DVT?

Conflicting Guidelines

vs.

Rogers, J Trauma 2002 Gould, CHEST 2012

2 4 6 8 10 20 40 60 80 100 Before (1995-1997) After (1999-2005)

DVT/PE Rate per 1000 Trauma Admissions Duplex Rate per 1000 Trauma Admissions

Before Vs. After Periods

Duplex DVT PE

Single Center (JHH)- Duplex & DVT rates Before v. After Screening Guideline

82 0.7 21

* **

7 p<0.0001 p=0.0024 Haut, J Trauma 2007

Multi-Center (NTDB)- Hospital Level Duplex & DVT rates

• Trauma centers with higher rates of

duplex ultrasound report higher DVT rates to the National Trauma Data Bank

Pierce, J Trauma 2008

The More We Look, The More We Find

Pierce, Haut, et al. J Trauma 2008

7-fold higher DVT rate at hospitals in top quartile

• f duplex ultrasounds

Pierce, J Trauma 2008

Faculty-Student Mentoring Program

• “A Faculty-Student Mentoring Program

to Enhance Collaboration in Public Health Research in Surgery”

• Johns Hopkins Surgery Center for

Outcomes Research (JSCOR)

• http://www.jscor.org/surgery-mentoring-

program

Smart, JAMA Surgery 2016

Faculty-Student Mentoring Program

• 5 years
• 90 public health master’s-degree students
• 44 surgical faculty
• 212 peer reviewed papers published
• 83 student 1st author papers (incl. JAMA)

Smart, JAMA Surgery 2016

A Classic Example of Surveillance Bias

• Providers who screen more

aggressively by performing more duplex ultrasounds may identify more cases of DVT and appear to provide worse quality of care than those providers who

• rder fewer tests

Haut & Pronovost, JAMA 2011

Implications

Variability in DVT Screening Variability in DVT Rates Reported Biased DVT Rates

Haut & Pronovost, JAMA 2011

“We’ll just use the test results anyway because it’s the only data we have”

http://dilbert.com/strips/comic/2010-11-07

Defining Preventable Harm

The VTE Example

• We suggested that “performance

measures could link a process of care with adverse outcomes when defining incidences of preventable harm”

Haut & Pronovost, JAMA 2011

Preventable Harm = VTE + No Prophylaxis

We Talked

• Centers for Medicare & Medicaid

Services listened

“Meaningful Use” Quality Reporting Criteria Related to VTE

• “Meaningful Use” of Electronic Health

Record (EHR) Technology

–VTE1 Prophylaxis within 24 hours of arrival –VTE2 ICU VTE Prophylaxis –VTE3 Anticoagulation Overlap Therapy –VTE4 Platelet Monitoring on UFH –VTE5 VTE Discharge Instructions –VTE6 Incidence of Potentially Preventable VTE

https://www.cms.gov/EHRIncentivePrograms/30_Meaningful_Use.asp

“Meaningful Use” Definition of Potentially Preventable VTE

• VTE-6 Incidence of Potentially

Preventable VTE

• “This measure assesses the number of

patients diagnosed with confirmed VTE during hospitalization (not present or suspected at admission) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnostic testing order date.”

Surveillance Bias in VTE Reporting in Surgery

Bilimoria, JAMA 2013

Surveillance Bias in VTE Reporting in Surgery

• 2,786 hospitals
• 954,526 Medicare patients >=65 years
• 11 major operations

– AAA, CABG, craniotomy, colectomy, cystectomy, esophagectomy, gastric bypass, lung resection, pancreatic resection, proctectomy, total knee arthroplasty

Bilimoria, JAMA 2013

Surveillance Bias in VTE Reporting in Surgery

Bilimoria, JAMA 2013

No Association Between Hospital-Reported Perioperative VTE Prophylaxis and Outcome Rates in Publicly Reported Data JohnBull, JAMA-Surg 2014

• 3040 hospitals
• Median prophylaxis

performance = 94.5%

• The median risk-

adjusted VTE rate was 4.13 per 1000 surgical discharges Process

Can a Systems Approach Improve VTE Prevention and Outcomes

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Improving VTE Prophylaxis at The Johns Hopkins Hospital

Streiff, BMJ 2012

Streiff, BMJ 2012

Improving VTE Prophylaxis at The Johns Hopkins Hospital

Paper Order Sets

Improving VTE Prophylaxis at The Johns Hopkins Hospital

• Mandatory VTE risk stratification tool

into the computerized provider order entry (CPOE) system

• Advanced computerized clinical

decision support (CDS)

Streiff, BMJ 2012

Parent order set Different Order Sets have Different VTE

• Modules. Use is Mandatory in POE workflow.

General Surgery VTE Prophylaxis

Any CONTRAINDICATIONS to pharmacologic prophylaxis?  High risk of bleeding  Active bleeding  Systemic anticoagulation  INR ≥ 1.5 or aPTT ratio ≥ 1.3  Platelet count < 50,000 Yes TEDs/SCDs Use mechanical prophylaxis until contraindication no longer

• present. Review patient status daily

Any Minor VTE risk factors?  Acute Infection/Sepsis Bed rest  Central venous catheter Estrogens/Selective estrogen receptor modulators (e.g., Tamoxifen) Inflammatory bowel disease Moderate Risk VTE Orders  Heparin 5000 units sc q12h (Give first dose 2 hrs. pre-op and then beginning 12-24 hours post-op) With option to ADD  TEDs/SCDs Very high risk VTE orders Heparin 5000 units sc q8h (Give first dose 2 hrs. pre-op and then beginning 12-24 hours post-op) Plus TEDS/SCDs Yes No Very high risk VTE orders Heparin 5000 units sc q8h (Give first dose 2 hrs. pre-op and then beginning 12-24 hours post-op) Plus TEDS/SCD  Enoxaparin 40mg sc qDay (First dose 2 hours pre-op and then 12-24 hours post-op) (Remove epidural catheter at nadir (20-22 hrs.)

• f anticoagulant effect and wait at least 2 hours

after catheter removal to redose) Plus TEDS/SCDs No Yes Creatinine clearance < 30 ml/min or unstable renal function (potential for CrCl to Decline below 30ml/min during therapy) Any Major VTE risk factors?  Previous VTE Cancer  Thrombophilia  Prolonged procedure (> 2 hrs.) NYHA Class III/IV Heart Failure Respiratory failure requiring mechanical ventilation Acute Stroke with paresis (< 3 mos.) Pregnancy/post-partum (up to 6 weeks) No Age > 60?

Yes Age ≥40?

No High risk VTE orders Heparin 5000 units sc q8h (Give first dose 2 hrs. pre-op and then beginning 12-24 hours post-op) With Option to add  TEDS/SCD No Yes No Yes

Any CONTRAINDICATIONS to pharmacologic prophylaxis?  High risk of bleeding  Active bleeding  Systemic anticoagulation  INR ≥ 1.5 or aPTT ratio ≥ 1.3  Platelet count < 50,000

No TEDs/SCDs Use mechanical prophylaxis until contraindication no longer

• present. Review patient status daily

Yes

Any CONTRAINDICATIONS to pharmacologic prophylaxis?  High risk of bleeding  Active bleeding  Systemic anticoagulation  INR ≥ 1.5 or aPTT ratio ≥ 1.3  Platelet count < 50,000 Yes No

Mandatory choice from each section for risk factors and contraindications

Keys to Success

• Multidisciplinary team

– Physicians, Nurses, Pharmacists, Informatics

• Leadership buy-in
• Collaborate with service teams
• Educate front-line providers
• Measure baseline performance
• Conduct ongoing performance evaluations

Streiff, BMJ 2012

Does Improving Prophylaxis Change Outcomes? The JHH Trauma Example

Haut, Arch Surg 2012

• Significant

increase in VTE prophylaxis

• Significant drop

in preventable harm from VTE

• 1.0% vs. 0.17%

(p=0.04)

Haut, Arch Surg 2012

62.2% 84.4%

Does Improving Prophylaxis Change Outcomes? The JHH Trauma Example

VTE Prophylaxis- Computerized Decision Support

36

www.natfonline.org

www.AHRQ.gov 2015

Improving VTE Prophylaxis Administration with Targeted Performance Feedback

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87.7% Sept 93.3% October 96.3% November

Lau, Ann Surg 2016

Surgery Resident QI Team Project Feedback Improves Prophylaxis

Quality Improvement can Lead to Fundable Research

• 5-year R01 grant
• AHRQ
• “Individualized

Performance Feedback on Venous Thromboembolism Prevention Practice”

Missed Doses of VTE Prophylaxis

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A Big Assumption

• As physicians, we assume that medication
• rders we place are consistently delivered
• But is that truly the case?
• Does prescription = administration?

Steps to Optimal Pharmacologic VTE Prophylaxis

Provider Prescription Nurse Administration Patient Acceptance

Missed Doses of VTE Prophylaxis Medications at Johns Hopkins

• December 1, 2007 to June 30, 2008

–>100,000 doses –12% of doses not administered

• Patient refusal most frequent (~60%)

documented reason

Shermock, PlosOne 2013

What’s the Real Story Behind Missed Doses?

• “Hidden Barriers to Delivery of Pharmacologic

Venous Thromboembolism Prophylaxis”

• Mixed methods study (quantitative/qualitative)

– Quantitative Nursing survey – Qualitative observations of nurse/patient interaction – Focus groups with nurses

Elder, Journal of Patient Safety epub 2014

What’s the Real Story Behind Missed Doses? - Quantitative

• “I have the clinical knowledge and experience to

determine if it is necessary to administer DVT/PE prophylaxis injections to patients.” – AGREE 87%/79% medicine/surgery

Elder, Journal of Patient Safety epub 2014

Our PCORI Project

• Preventing Venous Thromboembolism:

Empowering Patients and Enabling Patient- Centered Care via Health Information Technology

http://www.pcori.org/research-in-action/improving-patient- nurse-communication-prevent-life-threatening-complication

Our PCORI Collaborators / Key Stakeholders

Patient and Family Advisory Council http://www.pcori.org/research-in-action/improving-patient- nurse-communication-prevent-life-threatening-complication

PCORI Website “Research in Action”

http://on.wsj.com/1M18Aqu

What VTE Education Do Patients Really Want? Results from a Delphi Survey

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Modified Delphi Method

• Iterative process involving surveys,

feedback and revisions

• Engaged patients and family members
• Recruited via email and/or social media

(websites, Facebook, Twitter) through respective organizations

• > 400 respondents

Popoola, PLOS One 2016

What Do Patients Want?

Popoola, PLOS One 2016

What Do Patients Want?

Patient VTE Education Bundle

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http://bit.ly/bloodclots Video

Changing Practice is a Team Effort

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CDC Healthcare-Associated VTE Prevention Challenge Champions

Research Collaborators

• Johns Hopkins VTE Collaborative
• Streiff, Hobson, Kraus, Lau, Shermock,

Shaffer, Shihab, Carolan, Zeidan, Popoola, Aboyage

• Armstrong Institute
• Pronovost, Berenholtz, Demski, Holzmueller,

Michtalik,

Collaborators from Surgery

• Division of Acute Care Surgery
• Efron, Haider, Stevens, Chi, Rushing, Velopulos,

Cornwell, Schneider, Jones

• Other Surgical Divisions/Departments
• Colorectal, Surg Onc, Vascular, Pediatrics,

Transplant, Urology, Ortho, Neurosurgery

• Other Surgical Faculty
• Gearhart, Wick, Efron, Safar, Lidor, Pawlik, Weiss,

Wolfgang, Freischlag, Black, Abdullah, Stewart, Colombani, Segev

Streiff, J Hosp Med 2016

VTE and Trainee Mentoring

• 10 MPH student capstone projects
• 3 full-time post-doctoral research fellows
• 5 pharmacy residents
• 6 clinical trauma surgery fellows
• 3 clinical hematology fellows
• 1 med student full-time research year

Trainees

• Surgery Residents
• Weiss, Hayanga, VanArendonk, Howley,

Kodadek, Arnaoutakis, Poruk, Beaulieu, Ellison

• Trauma/Acute Care Surgery Fellows
• Garcia, Velopulos, Koenig, Kieninger, Leeper,

Feinman, Yanagawa, Dultz, Kent

• Medical Students
• Dat, Boelig, JohnBull, Farrow, Ray-Mazumder
• Pharmacy Residents
• Elder, Newman, Wong, Piechowski

Junior Faculty Mentoring

• Brandyn Lau

– Started as research assistant – Now Assistant Professor – 33 Pub-Med citations w/ me on VTE – NIH/NHLBI funded as PI of R21

Bloomberg JHSPH Trainees / Collaborators

• JHSPH students
• Pierce, Kardooni, Kraenzlin, Rosenberg,

Aboagye, Shrestha, Lucas, Nastasi, etc.

• JHSPH faculty
• MacKenzie, Yenokyan, Sugar, Diener-West
• Evidence Based Practice Center
• Segal, Singh, Brotman, Kebede

Acknowledgements

@elliotthaut (Twitter) ehaut1@jhmi.edu (email)

• Hopkins VTE Collaboratiev Website

– http://www.Hopkinsmedicine.org/Armstrong/bloodclots

• Patient Education Video

– http://bit.ly/bloodclots

• PCORI Research in Action

– http://www.pcori.org/research-in-action/improving- patient-nurse-communication-prevent-life-threatening- complication