R E V I E W S & A N A LY S E S Program* Promotes the Establishment of Hospital VTE Prevention Programs Arlene E. Fleck MNEd, RN, CCM INTRODUCTION Clinical Quality Program Consultant, Hospital Performance Management In 2008, the Surgeon General’s Office acknowledged venous thromboembolism (VTE) as a major public health problem in the United States and requested multiple Deborah J. Donovan, MLLS, RHIA, CPHQ Director, Provider and stakeholders to come together in a coordinated approach to reverse the increasing Hospital Performance Management trend projected for this health issue.1 VTE—blood clots—is an occlusion of the venous Mary Kathleen Blank, MPH, CIC, CPHQ system and includes both deep venous thrombosis (DVT) and pulmonary embolism Manager, Hospital Performance Management (PE). DVT occurs when a clot forms in a deep vein, such as in the thigh, calf, or upper Highmark Inc. extremity. A PE results when a piece of thrombus dislodges from this clot and travels to the lungs. While approximately one-third of patients with symptomatic DVT also develop a PE, only a smaller subset of cases are fatal events because of improved diag- nostic testing and effective anticoagulation therapy.2 VTE is frequently cited in the lit- ABSTRACT erature inclusive of the Agency for Healthcare Research and Quality and the National The Agency for Healthcare Research and Quality Forum as the most common preventable cause of hospital death.3-6 Much Quality (AHRQ) reports that efforts to attention has been focused on the prevention of VTE in surgical patients. In fiscal reduce the incidence of venous thrombo- year (FY) 2010, Highmark Inc., an independent licensee of the BlueCross BlueShield embolism (VTE) can result in substantial Association, created an indicator for the QualityBLUE Hospital Pay-for-Performance reductions in morbidity and mortality in Program focusing on the prevention of blood clots in the high-risk medical population addition to substantial cost savings. VTE and in intensive care units (ICUs). Unlike the Centers for Medicare and Medicaid Ser- is also a focus of the Centers for Medi- vices (CMS) Surgical Care Improvement Project requirements to report timeliness and care and Medicaid Services and the Joint appropriateness of VTE prophylaxis with select surgical populations, no such current Commission and will be a mandated requirements exist for the vulnerable medical population. quality measure in the future. Highmark’s QualityBLUE Hospital Pay-for-Perfor- PROBLEM mance Program has targeted improve- ments in averting VTE with 25 hospitals A review of the literature shows that the incidence of VTE varies widely because the in its service area. Recognizing the disease can be clinically silent and its diagnosis cannot be consistently confirmed. In scope of the problem is the first step to an incidence-based model developed by Heit et al., symptomatic VTE is estimated to confronting it. Evidence-based programs exceed 600,000 cases annually in the United States, of which approximately two-thirds are then developed to prevent VTE, and are healthcare acquired.7 Two popular cited population VTE studies, one conducted in their implementation has substantially Worcester, Massachusetts, and the other in Olmsted County, Minnesota, suggest that reduced the number of VTE events. The the annual incidence of VTE is 1 per 1,000 people.8,9 Another study using the 2003 successful application of processes that national inpatient sample from the Healthcare Cost and Utilization Project reported are unique to the individual hospitals 56% of hospital discharged patients were at moderate to very high risk for developing a and in alignment with best practices has VTE.10 In the Commonwealth of Pennsylvania, the Patient Health Care Cost Contain- resulted in an 18% decrease in the deep ment Council’s September 2010 Hospital Performance Report released data showing a venous thrombosis (DVT) rate and a 21% 53% increase in PE volumes from 2002 until 2009.11 decrease in the pulmonary embolism (PE) In 2008 the American College of Chest Physicians (ACCP) reported evidence to rec- rate in the participating hospitals. The ommend routine thromboprophylaxis for most hospitalized patient groups, including total cost savings of preventing 77 DVT surgical and medical patients.12 These evidence-based clinical practice guidelines have cases and 63 PE cases was projected at been developed to rigorously provide therapeutic interventions to prevent VTE and nearly $2 million. Lives have been saved, are specific to patient subsets within the broad category of medical surgical populations and morbidity has been avoided. This such as vascular surgery, orthopedic surgery, neurosurgery, critical care, and oncology. unique program lets hospitals be on the The ACCP guidelines provide a system of graded recommendations to balance risks forefront of incorporating activities, well such as bleeding or death with the benefits of prophylactic therapies specific to patient before regulatory agencies mandate subsets. This type of reference tool support leads to better clinician compliance with such efforts. (Pa Patient Saf Advis 2011 hospital efforts to improve rates of VTE prophylaxis. Jun;8[2]:55-62.) * QualityBLUE: A Hospital Pay-for-Performance Program, an initiative of Highmark Inc., an independent licensee of the BlueCross BlueShield Association. Vol. 8, No. 2—June 2011 Pennsylvania Patient Safety Advisory Page 55 ©2011 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S DVT prevalence varies widely and is direct medical costs is large because of not reimbursement dollars with the delivery reported for patients not receiving throm- only the index hospitalizations but also of high-quality, safe healthcare based on boprophylaxis for general surgery as 15% the high rate of readmissions and long- performance. QualityBLUE hospitals are to 40%, for medical patients 10% to 20%, term complications resulting from the required to implement evidence-based and for critical care patients as 10% to event. Readmission rates for a VTE (DVT practices designed to deliver high-quality 80%.12 Lack of VTE prophylaxis among and PE) are 5% for a principal diagnosis care. Performance is evaluated and scored medical patients is more prevalent than and 14% for a secondary diagnosis.18 The based on achievement of targeted compli- for surgical patients. The DVT FREE Reg- average cost per DVT or PE discharge ance goals, including the ability to reduce istry, a trial of 5,451 inpatients and outpa- including 12 months of follow-up was adverse events. Program requirements tients with an ultrasound-confirmed DVT $10,804 and $16,644, respectively.18 include defined performance measures, from 183 geographic sites, found that only Hospital costs incurred by patients who measurement results (process and out- 42% of the patients received prophylaxis, develop VTE complications are double comes), and facility-specific critical analysis. and nonsurgical patients were much less those for patients who do not develop Twenty-five QualityBLUE hospitals likely to have received prophylaxis than these complications.19 chose to participate in the VTE preven- were surgical patients.13 In Highmark’s FY 2010 pay-for-perfor- tion and care coordination indicator in VTE prophylaxis evidence-based guide- mance program population, 25 hospitals the FY 2010 program year to improve lines have been available for hospitals reported 2,018 VTE events (across all patient care by reducing occurrences of to review and use for nearly 20 years.14 payers), compared with the 154 Pennsyl- healthcare-acquired DVT and PE. Patients Yet despite existence of these guidelines, vania hospitals reporting 14,984 events who developed a DVT or PE during their studies have found low rates of compli- for federal FY 2009 in the September index hospitalization or 30 days post- ance with the guidelines. The ENDORSE 2010 Pennsylvania Hospital Performance discharge were included in the outcome study (Epidemiologic International Day Report.11 These volumes of adverse events assessment measurement for this indica- for Evaluation of Patients at Risk for suggest that much additional hospital tor. Hospital performance was also scored Venous Thromboembolism in the Acute focus is needed to create effective preven- on process measurements, which included Hospital Care Setting) assessed the pro- tion programs. the hospital’s compliance for administer- portion of 68,183 hospitalized at-risk ing VTE prophylaxis on medical patients patients who received appropriate pro- HOSPITAL PAY-FOR– at high risk for developing a VTE and phylaxis in 358 hospitals in 38 countries. PERFORMANCE APPROACH compliance for providing discharge Results of the study showed that appropri- instructions on anticoagulation therapy To address this growing healthcare ate prophylaxis was administered to only for all hospitalized patients discharged on quality of care concern, Highmark Inc. 59% of the surgical patients and 40% of warfarin. To achieve successful reimburse- incorporated the VTE prevention and the medical patients.15 Appropriate pro- ment, hospitals are scored by a standard- care coordination indicator as part of the phylaxis was defined as administration of ized method and must demonstrate a QualityBLUE Hospital Pay-for-Performance the correct type of prophylaxis and dose decreasing trend of VTE events and 90% Program. This indicator allows hospitals for the correct duration of time specific to or greater compliance for both administer- to assess and quantify the development of a particular patient population as defined ing appropriate VTE prophylaxis and pro- healthcare-acquired VTE and work to pre- by the ACCP guidelines. In another study viding appropriate discharge instructions vent these events, as well as to ensure that of 390,024 patients discharged from 500 to patients on warfarin. patients discharged on warfarin therapy hospitals in the United States, only 13% have appropriate education to coordinate of medical discharges and 16% of surgi- PROGRAM REQUIREMENTS their care across healthcare settings. The cal discharges received appropriate pro- QualityBLUE program is an innovative phylaxis.16 The studies report that VTE Defined Performance Measures program designed to “chase zero”—elimi- practices in hospitals are suboptimal and To participate in the indicator, hospitals nate adverse events that have been identi- it is important for hospitals to improve were required to measure hospitalwide fied nationally as areas of opportunity in current practices. patients (excluding patients under age 18, the health care environment. Highmark’s Measures to prevent VTE have been QualityBLUE program began in 2001 with those hospitalized for behavioral problems, widely studied because of the incidence, six participating hospitals and has grown and obstetrical patients) diagnosed with associated mortality and morbidity, and to 63 hospitals in Pennsylvania and West healthcare-acquired DVT and PE during annual care costs of more than $1.5 bil- Virginia. The program aligns hospital the index hospitalization or within 30 days lion.17 The economic burden of VTE in following discharge. Patients diagnosed Page 56 Pennsylvania Patient Safety Advisory Vol. 8, No. 2—June 2011 ©2011 Pennsylvania Patient Safety Authority with a VTE may or may not have been (2) compliance issues related to follow-up neurology, and oncology. Depending on readmitted to the hospital facility within appointments and taking medication as the hospital’s level of information tech- 30 days. The healthcare-acquired event instructed; (3) dietary instructions; and (4) nology support, the prevention guidelines case-finding methodology included dis- the potential for adverse drug reactions or could be pre-printed documents on the covery from hospital radiology reports, interactions. All four components had to chart or electronic decision support tools outpatient encounters, and emergency be addressed for the instructions to count such as a mandated risk assessment and department visits. This additional case- as compliant. Sampling was permitted for standardized computer-generated orders. finding methodology was more difficult this measurement for hospitals that dis- One of the most challenging steps identi- for hospitals to pursue if they did not charged more than 25 patients a month fied by hospitals was the timely medical have an electronic medical record system on warfarin. executive committee approval process for in place. the guidelines. The hospital was also required to select Critical Analysis: How to Develop A key part of the initiative was education two units that predominately housed a a VTE Prevention Program for physicians, hospital staff, and patients. high-risk medical population for VTE Each hospital was responsible for writing One facility identified education as a “core development to measure VTE prophylaxis a critical analysis for the VTE indicator, essential for the success of the program.” compliance. Hospitals that selected the summarizing key program objectives, Examples were VTE grand rounds, man- VTE indicator for the first time were implementation strategies, and results. datory continuing medical education, new required to choose an ICU that housed The critical analysis discusses the hospi- physician VTE orientation packets, an predominately medical patients as one tal’s improvement strategies, educational interactive storyboard rotated throughout of the two units. Each unit measured the efforts, lessons learned, barriers to imple- the hospital, participation in March VTE total number of patients that received mentation, and facility-specific return on prevention month with posters and news- appropriate VTE prophylaxis or had a investment. Common themes and strate- letters, one-on-one education with physi- documented reason for no VTE prophy- gies were identified in the hospital’s VTE cians, preoperative education materials for laxis being given the day of or day after critical analysis, and it provided examples patients, community lectures involving the hospital admission or transfer to the of important steps for creating a VTE pre- local library and senior residential centers, selected unit. The medical population of vention program. Hospitals described the an annual breakfast program to educate patients versus surgical population was initial step as identifying key personnel skilled nursing facilities, and screensavers chosen since the lack of VTE prophylaxis to form an interdisciplinary VTE team. for the computers. More creative strategies among medical patients is more prevalent. Examples would be physicians and nurses were developed to engage physicians to be Lastly, hospitals were required to measure from surgical and nonsurgical depart- compliant with the VTE protocols, includ- the total number of acute care hospital- ments, residents, health educators, data ing the following: ized patients discharged to home on abstractors, and personnel from phar- — Provider- and service-specific report warfarin who received comprehensive macy, dietary, laboratory, quality services, cards of VTE events and mortalities patient-specific written discharge instruc- and information systems departments. A were created and reviewed by medi- tions. This measure was developed to physician champion was identified to lead cal staff. align with the 2010 Joint Commission the team and address any barriers identi- — Unit-level and physician-level National Patient Safety Goal 3, “Improv- fied by the physician staff. In some hospi- VTE prophylaxis data compliance ing the Safety of Using Medications,” tals, pharmacists successfully assumed the was displayed on the two study and the CMS Venous Thromboembolism role of team champion. units, including names of noncom- National Hospital Inpatient Quality Mea- Teams were then tasked with reviewing pliant physicians. sures VTE-5, “Venous Thromboembolism the literature to create evidence-based — Compliance letters were sent to phy- Discharge Instructions.” The use of warfa- VTE prevention guidelines (see “Resource sicians with data comparing them to rin has been related to adverse events that List”). Gaps between the current prophy- their peers, overall hospital compli- result from complex dosing, insufficient laxis practices and the literature were iden- ance rate, and hospital goals. monitoring, and inconsistent patient tified. Guidelines were created to include — Noncompliant physicians were compliance.20 The discharge instructions development of a VTE risk assessment, contacted by nurses regarding were to include education that addressed identification of contraindications to completion of prophylaxis orders or the following components: (1) importance prophylaxis, and the development of VTE appropriate documentation related of follow-up blood work monitoring, prevention physician order sets, including to contraindications after review of including details of with whom and date; specialty order sets for orthopedics, Vol. 8, No. 2—June 2011 Pennsylvania Patient Safety Advisory Page 57 ©2011 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S a patient case by pharmacy and the RESOURCE LIST nurse manager. The following resources were used to develop an evidence-based hospital venous — An organizational quality dash- thromboembolism prevention program: board was used to communicate performance outcomes to all staff, Academy of Family Physicians and the American College of Physicians including members of the board. Current diagnosis of venous thromboembolism in primary care: a clinical practice — Electronic decision support tools guideline. Available from Internet: http://www.annals.org/content/146/6/454.full. were used that mandate VTE risk reassessment with change in patient’s Agency for Healthcare Research and Quality level of care. Preventing hospital-acquired venous thromboembolism: a guide for effective quality improvement. Available from Internet: http://www.ahrq.gov/qual/vtguide. Nursing engagement was viewed as a criti- cal component of success and included American Academy of Orthopaedic Surgeons surveys to query staff on successes and Clinical guideline on prevention of pulmonary embolism in patients undergoing total barriers of the VTE prevention program. hip or knee arthroplasty. Available from Internet: http://www.aaos.org/research/ The pharmacy manager conducted guidelines/pe_guideline.pdf. reviews of patients who were ordered sequential compression devices (SCD) for American College of Chest Physicians utilization compliance with immediate Evidence-based clinical practice guidelines, 8th edition. Available from Internet: educational follow-up for noncompli- http://www.chestnet.org/accp/guidelines/antithrombotic-and-thrombolytic- ant staff. Morning huddles were held therapy-8th-edition. to discuss a patient’s status, including American College of Obstetricians and Gynecologists (Committee on VTE prophylaxis, and decision support Practice Bulletins) software solutions were used that created ACOG Practice Bulletin No. 84: Prevention of deep vein thrombosis and pulmonary automatic hard stops to prevent nurses embolism. Available from Internet: http://www.acog.org. from advancing discharge instructions without addressing the appropriate warfa- Institute for Healthcare Improvement rin patient teaching. IHI improvement map: Venous thromboembolus (VTE) prevention & treatment. Data collection and analysis is another Available from Internet: http://www.ihi.org/imap/tool/#Process=5b9bfd5a- critical step in the VTE quality improve- 1e17-433b-a9d4-602fafef73c8. ment program. Monthly tracking of data Institute for Clinical Systems Improvement is required by the QualityBLUE program. Hospital performance on the program, Venous thromboembolism diagnosis and treatment [guideline online]. Available from Internet: http://www.icsi.org/guidelines_and_more/gl_os_prot/cardiovascular/ including analysis of the data, is presented venous_thromboembolism/venous_thromboembolism_6.html. two times, during midyear and year-end presentations to the QualityBLUE team. National Comprehensive Cancer Network In addition to the required data collec- Clinical practice guidelines in oncology: venous thromboembolic disease. Available tion tool measures, the unit prophylaxis from Internet: http://www.nccn.org/professionals/physician_gls/pdf/vte.pdf. compliance, the number of DVT and PE events, and compliance for warfarin National Institute for Health and Clinical Excellence discharge education, hospitals evalu- Venous thromboembolism: reducing the risk. Available from Internet: http://www. ated other metrics to drive performance nice.org.uk/CG92. improvement. The hospitals’ critical analy- Society of Hospital Medicine ses discussed the following: Preventing hospital-acquired venous thromboembolism: guide for effective quality — Healthcare-acquired VTE trends by improvement. Available from Internet: http://www.hospitalmedicine.org/ service lines and physicians ResourceRoomRedesign/RR_VTE/html_VTE/00_ImplementationGuide.cfm. — VTE prophylaxis ordered on dis- charge for patients readmitted with a DVT or PE Page 58 Pennsylvania Patient Safety Advisory Vol. 8, No. 2—June 2011 ©2011 Pennsylvania Patient Safety Authority — Potentially preventable VTE events, — Readmission analysis of VTE showed a significant increase for VTE pro- patients with a healthcare-acquired patients that includes review of dis- phylaxis compliance in the nine months VTE who did not receive appropri- charge anticoagulation therapy of the program year. Figure 1 represents ate (type, dose, duration, and timely — Pilot projects that determined combined prophylaxis compliance for the administration) VTE prophylaxis that pharmacists might be the best two high-risk units studied for the aggre- — Nursing documentation of an SCD patient educator for warfarin dis- gate of the 25 participating hospitals. A being used by a patient, including the charge instructions steady improvement from FY 2010 quarter time the device was not being used by A hospital’s success in decreasing the 1 to quarter 3 can be noted. The average the patient and secret shopper visual number of VTE events in their hospital first quarter compliance was 76%, which audits to compare nursing documen- is related to establishing individualized increased to 94%, representing a 24% tation with patient experience approaches that may be unique to their change from quarter 1 through quarter 3. — Patient satisfaction survey results hospital. However, common themes This is a statistically significant increase related to their experience with SCD related to lessons learned in the implemen- (p-value < 0.05). Twenty-one hospitals, or (e.g., Did patient understand rea- tation of the VTE prevention program 84%, had a 90% or greater VTE prophy- son for device? Was the equipment were noted. (See “Lessons Learned.”) laxis compliance for both units in the last uncomfortable? Did the patient keep quarter of the program year. The range of hospital compliance scores for the final device on as ordered?) Measurement Results quarter was from 87% to 100%. — Return trips to the operating room For many hospitals, this quality initiative related to bleeding for patients on was the first-ever measurement and analy- The second measurement for the VTE VTE prophylaxis sis of facility VTE events, and this analysis indicator was monitoring compliance for — Staff survey results related to the prioritized the importance of a VTE discharge instructions specific to warfarin staff’s knowledge of the VTE preven- prevention program for such hospitals. anticoagulation therapy. The focus of tion program For the first process measure, hospitals this measure was to ensure that patients or their families received instructions on safely self-administering this drug. Figure 2 shows the steady increase in appropriate LESSONS LEARNED warfarin discharge instruction compliance — Opportunities did exist for VTE prevention practice changes. over the nine months of the program year. — Real-time, day-to-day monitoring of VTE prophylaxis compliance is needed Aggregate compliance for FY 2010 quarter 1 instead of retrospective data collection. was 60%, which increased to 92% by — Application of standardized processes based on evidence-based guidelines can quarter 3. This is a statistically significant reduce healthcare-acquired VTE. increase (p-value < 0.05). — Continuous monitoring of all quality improvement processes and staff feedback The 25 QualityBLUE hospitals reported is required. a total of 1,222 DVTs and 859 PEs over a — Input by frontline staff is essential to identify opportunities and barriers. nine-month period. Figure 3 displays the — Decision support alerts embedded in care processes for the practitioner is the DVT and PE aggregate rate per quarter ideal means for sustaining change in practice. for all participating hospitals. The aggre- — Clinical pharmacists’ roles expanded in the hospital VTE prevention program gate DVT rate is reported at 0.53 per 100 to include team champion, patient educator for warfarin discharge instructions, patient admissions for the first quarter of and physician educator for ensuring patients receive appropriate prophylaxis the FY 2010 program year compared with (type, dose, duration), including weight adjustment dosing if needed. a DVT rate of 0.43 per 100 patient admis- — Real-time, face-to-face communication with physicians and nurses regarding best sions for the third quarter of the year. practices and evidence-based medicine proved vital in achieving VTE compliance. This decrease in the DVT rate between — Repeated educational sessions throughout the year will help to inform physician the quarters represents a percent reduc- and nursing staff about the VTE prevention program. tion of 18%, which is statistically signifi- cant (p-value < 0.05) and translates to a — Engaging nursing staff in fun, creative educational activities, such as hospital safety fairs, can increase awareness and compliance. potential 77 averted DVT cases. Potential cost savings of $831,908 is estimated from — Direct and transparent physician performance feedback is important. the 77 DVT averted cases, calculated Vol. 8, No. 2—June 2011 Pennsylvania Patient Safety Advisory Page 59 ©2011 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S from the estimated costs of $10,804 to 1 and quarter 3 of the program year. A change (p-value < 0.05) and represents treat one DVT case, including the costs rate of 0.38 per 100 patient admissions 63 potentially averted PE cases. Cost sav- for 12 months of follow-up care.18 Simi- was reported for the first quarter and a ings estimated for the 63 averted cases is larly, Figure 3 shows a reduction that was rate of 0.30 for the third quarter. This $1,048,572, based on $16,644 per case noted for the PE rate between quarter decrease is a 21% statistically significant and including costs for 12 months of follow-up care.18 The aggregate performance of the 25 hos- Figure 1. FY 2010 VTE Prophylaxis Compliance (Units 1 and 2) by Quarter, pitals participating in the VTE prevention All QualityBLUE Participating Hospitals—Aggregate and care coordination indicator showed 100 94% statistically significant improvements for 85% all indicator performance measurements. These improvements directly relate to bet- 76% ter patient outcomes, the ultimate goal for 80 healthcare delivery. Percentage Compliance 60 CONCLUSIONS The QualityBLUE indicator lets hospi- 40 tals be on the forefront of incorporating improvements well before they are man- dated by regulatory agencies. Currently, 20 CMS and the Joint Commission have vol- untary requirements to report the Venous MS11197 Thromboembolism National Hospital 0 Quarter 1 Quarter 2 Quarter 3 Inpatient Quality Measures. However, starting in 2012, the Medicare and Med- FY 2010 Quarters icaid Electronic Health Record Incentive Program meaningful use requirements will require participating hospitals to elec- tronically submit these six VTE clinical quality measures.21 Figure 2. FY 2010 Compliance for Appropriate Warfarin Discharge Instructions by The QualityBLUE hospital pay-for- Quarter, All QualityBLUE Participating Hospitals—Aggregate performance program could be replicated by health plans nationwide. The program 100 92% components for operation, data collection 79% tools, and program manual align with 80 national evidence-based practices. Detailed measurement definitions and result Percentage Compliance 60% expectations are developed annually and 60 keep pace with national healthcare quality agendas and changes in clinical practice. For example, with the development of 40 numerous novel oral anticoagulants such as Pradaxa® (dabigatran etexilate), which 20 has recently been FDA approved to pre- vent strokes in atrial fibrillation patients, MS11198 the use of warfarin may be replaced, and 0 monitoring warfarin patient education Quarter 1 Quarter 2 Quarter 3 will be obsolete.22 Established targets for threshold performance both in compliance FY 2010 Quarters Page 60 Pennsylvania Patient Safety Advisory Vol. 8, No. 2—June 2011 ©2011 Pennsylvania Patient Safety Authority Figure 3. FY 2010 DVT and PE Rates by Quarter, All QualityBLUE Participating with evidence-based process measures and Hospitals—Aggregate reducing adverse events are well defined. The expected payoff for widespread adop- 0.8 tion of this program would be quantified Quarter 1 through significant lives saved by avoiding medical misadventures. In addition to the Quarter 2 tremendous toll on human life, the finan- 0.6 0.53 0.53 Quarter 3 cial burden attributed to these misadven- tures is staggering. Because this program 0.43 0.38 motivates an entire organization, aligning 0.37 Rate 0.4 board, leadership, and frontline workers, 0.30 improvement occurs and “chasing zero” is no longer simply a concept but a reality 0.2 for QualityBLUE participating hospitals. MS11199 0.0 DVT Rate PE Rate Rate per 100 patient admissions. NOTES 1. U.S. Department of Health and consensus report [online]. 2006 [cited venous thromboembolism. Am J Human Services. The surgeon general’s 2011 Jan 20]. Available from Internet: Hematol 2007 Sep;82(9):777-82. call to action to prevent deep vein http://www.qualityforum.org/ 11. Pennsylvania Health Care Cost Con- thrombosis and pulmonary embolism Publications/2006/12/National_ tainment Council. Hospital perfor- [online]. 2008 [cited 2010 Sep 28]. Voluntary_Consensus_Standards_ mance report, FFY 2009 [online]. [cited Available from Internet: http://www. for_Prevention_and_Care_of_ 2010 Sep 27]. Available from Internet: surgeongeneral.gov/topics/deepvein. Venous_Thromboembolism__Policy,_ http://www.phc4.org/reports/hpr/09/ 2. White RH. The epidemiology of Preferred_Practices,_and_Initial_ docs/hpr2009keyfindings.pdf. venous thromboembolism. Circulation Performance_Measures.aspx. 12. Geerts WH, Bergqvist D, Pineo GF, 2003 Jun;107(23 Suppl 1):14-8. 7. Heit JA, Cohen AT, Anderson FA Jr. et al. Prevention of venous thrombo- 3. Heit JA, O’Fallon M, Petterson TM, Estimated annual number of incident embolism: American College of Chest et al. Relative impact of risk factors and recurrent, non-fatal and fatal Physicians evidence-based clinical prac- for deep vein thrombosis and pulmo- venous thromboembolism (VTE) events tice guidelines (8th edition). Chest 2008 nary embolism. Arch Intern Med 2002 in the US. Blood 2005;106(11):267a. Jun;133(6 Suppl):S381-453S. Jun;162(11):1245-8. 8. Anderson FA Jr, Wheeler HB, 13. Goldhaber SZ, Tapson VF; DVT Free 4. Tapson VF, Hyers TM, Waldo AL, Goldberg RJ, et al. A population-based Steering Committee. A prospective reg- et al. Antithrombotic therapy practices perspective of the hospital incidence istry of 5,451 patients with ultrasound- in US hospitals in an era of practice and case-fatality rates of deep vein confirmed deep vein thrombosis. Am J guidelines. Arch Intern Med 2005 Jul 11; thrombosis and pulmonary embolism. Cardiol 2004 Jan 15;93(2):259-62. 165(13):1458-64. Arch Intern Med 1991 May;151(5):933-8. 14. Clagett GP, Anderson Jr FA, Levine 5. Clagett GP, Anderson FA, Heit J, et al. 9. Silverstein MD, Heit JA, Mohr DN, MN, et al. Prevention of venous throm- Prevention of venous throbloembolism. et al. Trends in the incidence of deep boembolism. Chest 1992 Oct;102 Chest 1995 Oct;108(4 Suppl):312S- vein thrombosis and pulmonary embo- (4 Suppl):391S-407S. 334S. lism: a 25-year population based study. 15. Cohen AT, Tapson VF, Bergmann JF, 6. National Quality Forum. National Arch Intern Med 1998 Mar 23;158(6): et al. Venous thromboembolism risk voluntary consensus standards for pre- 585-93. and prophylaxis in the acute hospital vention and care of venous thrombo- 10. Anderson FA, Zayaruzny M, Heit JA, care setting (ENDORSE study): a mul- embolism: policy, preferred practices, et al. Estimated annual numbers of US tinational cross-sectional study. Lancet and initial performance measures—a acute-care hospital patients at risk for 2008 Feb 2;371(9610):387-94. Vol. 8, No. 2—June 2011 Pennsylvania Patient Safety Advisory Page 61 ©2011 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S 16. Amin A, Stemkowski S, Yang G, Lin J. subsequent hospital readmissions rates: 21. Centers for Medicare and Medicaid Inpatient thromboprophylaxis use in an administrative claims analysis from Services. Medicare and Medicaid EHR US hospitals: adherence to the seventh 30 managed care organizations. J Manag incentive program: meaningful use stage 1 American college of chest physician’s Care Pharm 2007 Jul-Aug;13(6):475-86. requirements overview [online]. 2010 recommendations for at-risk medical 19. Ollendorf DA, Vera Lionch M, Oster Aug 24 [cited 2010 Sep 27]. Available and surgical patients. J Hosp Med 2009 G. Cost of venous thromboembolism from Internet: http://www.cms.gov/ Oct 8;4(8):E15-21. following major orthopedic surgery in EHRIncentivePrograms/Downloads/ 17. Spyropoulos AC, Hurley JS, Ciesla GN, hospitalized patients. Am J Health Syst MU_Stage1_ReqOverview.pdf. et al. Management of acute proximal Pharm 2002 Sep;59(18):1750-4. 22. U.S. Food and Drug Administration. deep vein thrombosis: pharmacoeco- 20. The Joint Commission accreditation FDA approves Pradaxa to prevent stoke nomic evaluation of outpatient treat- program: hospital national patient in people with atrial fibrillation [press ment with enoxaparin vs inpatient safety goals effective July 1, 2010 release online]. 2010 Oct 19 [cited treatment with unfractionalted hepa- [online]. [cited 2010 Aug 19]. Available 2011 Jan 17]. Available from Internet: rin. Chest 2002 Jul;122(1):108-14. from Internet: http://www. http://www.fda.gov/NewsEvents/ 18. Spyropoulos AC, Lin J. Direct medical jointcommission.org/assets/1/6/2011_ Newsroom/PressAnnouncements/ costs of venous thromboembolism and NPSGs_HAP.pdf. ucm230241.htm. Page 62 Pennsylvania Patient Safety Advisory Vol. 8, No. 2—June 2011 ©2011 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 8, No. 2—June 2011. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2011 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s An Independent Agency of the Commonwealth of Pennsylvania website at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.