Optimizing Local Clinical Decision Support to Address National Hospital Improvement Imperatives; Early Efforts Toward a Scalable Collaborative HIMSS Virtual Conference and Exhibition 11/19/08 Session #107B Jerry Osheroff John Chuo Anwar Sirajuddin Donna Currie
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Optimizing Local Clinical Decision Support to Address National Hospital Improvement Imperatives; Early Efforts Toward a Scalable Collaborative HIMSS Virtual.
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Optimizing Local Clinical Decision Support to Address National Hospital Improvement Imperatives; Early Efforts Toward a Scalable Collaborative
• Goal: Develop scalable, validated guidance for provider organizations to optimize CDS to drive measurable local performance improvement on specific targets of high local and national priority. (Initial focus=VTE)
• Formed CDS Task Force within HIMSS 8/08
• 6 clinical sites: Advocate, CHOP, HealthEast, Memorial Hermann, Orlando, Texas Health Resources
• Other thought leader participants (CDS, performance measurement, benefits realization) and Scottsdale Institute
So What? Implications for You and Your Organization
• This work is manifestation of evolution toward “mass collaboration” in society (see Tapscott’s Wikinomics)
• Such best practice syntheses and collaborations can accelerate local efforts; consider jumping into the HIMSS fray and/or beginning your own collaborative
• Engaging in HIMSS CDS efforts– Review CDS guides and keep an eye on the CDS parts of
HIMSS website (e.g. www.himss.org/cdsguides)
– Send an email to David Collins ([email protected]) if you’re interested in exploring participation in the VTE collaborative when it scales later next year
• Memorial Hermann-TMC was recognized as one of 100 U.S. hospitals to make the greatest progress in improving hospital-wide performance over five consecutive years (2001-2005).
• For the 18th consecutive year, Memorial Hermann TIRR ranks among America’s Best Hospitals in the U.S. News & World Report magazine’s annual survey.
• Memorial Hermann Named A "Most Wired" Healthcare System for Fourth Consecutive Year in 2008
• Hospital acquired VTE is potentially life-threatening and may; -Prolong length of hospital stay -Require invasive treatment -Result in chronic disability, the need for follow-up care and long-term anticoagulation
• Overall risk of VTE in children is much lower than in adults, but children often have multiple risk factors
• Cases of hospital acquired VTE have occurred at CHOP
Why is VTE prevention Important?Why is VTE prevention Important?
The Children's Hospital of Philadelphia
Improvement AimImprovement Aim
•To reduce the potential for harm through the use of mechanical and chemoprophylaxis by increasing the compliance with the clinical practice guidelines to > 90% by February 2009.
The Children's Hospital of Philadelphia
1. Are we assessing everyone who is at risk?
2. Are we treating everyone who is at risk?
3. Has treatment reduced the incidence of VTE?
Key QuestionsKey Questions
The Children's Hospital of Philadelphia
MINIMIZEthese groups
MAXIMIZEthese groups
+ VTE - VTE
- VTE
+ VTE - VTE+ VTE - VTE
ALL ADMISSIONS
Assessed with Risk score tool Not assessed with Risk score tool
After the newborn period, an increase is seen at approx. 14 yrs
Age Distribution of Patients with Venous Age Distribution of Patients with Venous Thrombosis at CHOPThrombosis at CHOP
The Children's Hospital of Philadelphia
Infection
Surgery
Cancer
Cardiac
Renal
DiabetesSickle Cell Disease
Prematurity
Cystic Fibrosis
Trauma
Other
None
Dehydration
This does not include the presence of a central venous catheter, which is the single greatest risk factor for thrombosis - found in ~40% of children over age 1 with a DVT
Underlying Medical Conditions in Children with Underlying Medical Conditions in Children with ThrombosisThrombosis
The Children's Hospital of Philadelphia
• Immobility
• Orthopedic surgery
• Spinal cord injury
• Major trauma or trauma to the lower extremities
• Previous history of thrombosis / VTE
• Pregnancy
• Taking estrogen containing medications
• Acute infection
• Burns
• Obesity
• Disorder associated with thrombosis including but not limited to; Inflammatory Bowel Disease, Nephrotic Syndrome, Sickle Cell Disease, Lupus and Diabetic Keto-Acidosis
• Central venous catheter in the lower extremity
• Acquired or inherited thrombophilia
• Family history of thrombosis in a first degree relative < 40 years of age
At RISK patients are > 14 years old and have one or more of the listed conditions
RISK assessment toolRISK assessment tool
At HIGH RISK patients are > 14 years old, immobile, and have one or more additional conditions
The Children's Hospital of Philadelphia
Defining risk
groups
Execution How well executed is
the tool?
Outcome
PAPER Retrospective chart review, consensus, adult literature
Risk assessment tool is incorporated into the nursing admission intake paperwork
Are paper forms of the tool readily available?
Do people know how to use it?
Is there accountability?
How many risk assessments are done?
TECH Work underway for: Point of care reminders in selected ordersets to remind prescribers to assess risk. i.e. preop ordersets. The tool itself will be computerized.
Assessed with Risk score tool Not assessed with Risk score tool
At risk Not at risk
Prophylaxis No Prophylaxis
+ VTE
OUTCOME MATRIXOUTCOME MATRIX
WHAT IS TREATMENT and can it be proven?
The Children's Hospital of Philadelphia
• Treatment must …1. Impact outcome (less VTE for at risk patients)
2. Safe
3. Determined by ….• Research • Published standards - from adult literature• Consensus – Anticoagulant workgroup• Randomized trials requires large numbers
- Venograms too invasive, U/S technology and MRI not good enough
The Challenge of TreatmentThe Challenge of Treatment
The Children's Hospital of Philadelphia
• A Patient who is at RISK or HIGH RISK receives one or more forms of mechanical thromboprophylaxis*
• A patient who is at HIGH RISK receives one or more forms of mechanical prophylaxis and may also receive anticoagulant thromboprophylaxis with low molecular weight heparin (Enoxaparin) or unfractionated heparin
* Mechanical prophylaxis is not used if acute VTE is suspected
Treatment GuidelineTreatment Guideline
The Children's Hospital of Philadelphia
Define treatment
Execution How well executed
is the process?
Outcome
PAPER Literature review, consensus, adult protocols
TECH - VTE prophylaxis order set containing mechanical and chemoprophylaxis - Nursing staff has the ability to initiate mech. prophylaxis
Ordersets awareness?
Ordersets usability?
How often is prophylaxis initiated?
What % of those assessed to be at risk received prophylaxis and how do their VTE rates compare with the other groups?
Treatment - executionTreatment - execution
The Children's Hospital of Philadelphia
Other key Measures for chemoprophylaxisOther key Measures for chemoprophylaxis
-Dosage adjustment algorithms and monitoring guidelines (enoxaparin, heparin, warfarin)
-Discharge Education and scheduled follow-up appointment (enoxaparin, warfarin)
The Children's Hospital of Philadelphia
The Children's Hospital of Philadelphia
ALL ADMISSIONS
Assessed with Risk score tool Not assessed with Risk score tool
+VTE -VTEAt risk Not at risk
Prophylaxis No Prophylaxis
+VTE -VTE
+VTE -VTE+VTE -VTE
= obtain from querying Hospital Information System
OUTCOME MATRIXOUTCOME MATRIX
The Children's Hospital of Philadelphia
• We share the same challenges and have common strategies for overcoming the hurdles of technology, culture, and clinical evidence.
• Risk assessment- We all stratify risk, some calculating a score.- Initial assessment - some done by nursing, some by physicians (about 50/50)- All working on electronic tool, but most using paper tools- Electronic alert triggers seems to be a good idea as reminder systems
• VTE Prophylaxis- Order sets is the most popular way to group VTE related orders- Some embed the order sets into existing ordersets associated with high risk populations- Prompts to reminder clinicians to order VTE prophylaxis is a more difficult task than dose guidelines.
• VTE prophylaxis Complication prevention and outcome measures- Compliance with guideline is a commonly measured metric among our group- Prompts for appropriate labs is doable (i.e. INR)
• Improvement is temporally related to project activities and tapers off between activities.
• To hard-code practices into daily routine, it is necessary to insert continuous prompts at the point of care
• Buy-in from and a sense of responsibility by front-line clinicians positively impacts the use of VTE prophylaxis
• Identifying stakeholders is critical for success
Lessons learned from workgroupLessons learned from workgroup
Provide a consistent process for assessing the risk of VTE in medical and/or surgical patients.
Assessment Guidelines
- Within 8 hours of admission to the hospital
- With a change in level of care
- Post operatively for inpatient surgical patients
- Pre operatively for all surgical patients
- Notify the MD of the VTE risk assessment results, suggested VTE prophylaxis and obtain orders within 12 hours of admission to the hospital.
VTE PROPHYLAXIS GUIDELINESVTE PROPHYLAXIS GUIDELINES PLEASE NOTE: These are GUIDELINES for the Prophylaxis of VTE. This
is NOT an order set. Please contact the patient’s physician for orders
VTE Prophylaxis GuidelinesGeneral • DO NOT USE ASPIRIN AS PROPHYLAXIS AGAINST VTE
• Discharge with LMWH for high risk general surgery patients; major cancer surgery• Avoid thromboprophylaxis in vascular surgery patients with no additional risk factors
Low (1) • Early & Persistent mobilization
Moderate (2) • Enoxaparin (Lovenox) 40 mg (If CrCI< 30mL/min = 30 mg) SubQ every 24 hours OR • Fondaparinux (Arixtra) 2.5 mg SubQ daily † (Do not use if CrCl< 30 mL/min or weight< 50 kg) OR • Heparin, 5,000 Units SubQ every 12 hours CONSIDER ADDING§ • GCS and/or IPC in addition to one of the above or if high risk of bleeding
High (3-4) • Enoxaparin (Lovenox) 40 mg (If CrCI< 30mL/min = 30 mg) SubQ every 24 hours OR • Fondaparinux (Arixtra) 2.5mg SubQ daily† (Do not use if CrCl< 30 mL/min or weight< 50 kg) OR • Heparin, 5,000 Units SubQ every 8 hours CONSIDER ADDING§ • GCS and/or IPC in addition to one of the above or if high risk of bleeding
Highest (> 5) • Enoxaparin (Lovenox) 30 mg Sub Q every 12 hours (If CrCl< 30 mL/min = 30 mg daily) OR • Fondaparinux (Arixtra) 2.5mg SubQ daily† (Do not use if CrCl< 30 mL/min or weight< 50 kg) OR • Heparin 5000 units Sub Q every 8 hours AND§ • GCS and/or IPC in addition to one of the above
† Approved for thromboprophylaxis in certain surgical patients§ GCS = Graduated Compression Stockings IPC = Intermittent pneumatic compression
MEASURESMEASURESOutcome Measure
◦ AHRQ measureActual post-op PE/DVT rate /expected post op PE/ DVT rate
Compliance (Process) Measures ◦ Risk assessment completion rates◦ Time from admission to VTE risk assessment ◦ Time from admission to prophylaxis orders ◦ Risk assessments by risk category
Low – 19% Moderate – 14% High – 28% Highest – 39%
DRILL DOWN AT ONE SITEDRILL DOWN AT ONE SITE
Overall 64% medical vs. 36% surgical
65% of patients scored High or Highest Risk
30% of all DVT/PE cases reviewed grouped into a circulatory MDC◦ ¼ of these were