The document summarizes a hospital's venous thromboembolism (VTE) prophylaxis program over 7 years. It shows that the program reduced hospital-acquired deep vein thrombosis and pulmonary embolism by over two-thirds, saving over $6 million in costs. Moving forward, the hospital aims to further improve prophylaxis practices by focusing on areas like daily ambulation and administering prophylaxis in the emergency department and throughout a patient's care. The goal is continuous quality improvement to help more patients and potentially achieve outcomes like preventing all hospital-acquired infections.

1. Going from a KNOWNcomplication…. .... To KNOWN complication. NO VTE Prophylaxis Program2003 - 2010 Copyright SMB and Co.

2. St. David’s VTE Prophylaxis Program7 Year Follow-up -- since January 2003 Endorsed as significant by our leadership Physician-driven and literature-based Sustained, superior results over a 7-year period: Over two-thirds reduction in hospital-acquired: DVT and Pulmonary Embolus Substantial cost-avoidance savings (more than off-setting Rx costs)

3. St. David’s-- A Community Hospital System

4. Our Greatest Challenge in Clinical Medicine Eliminate the “DEADLY” Delay !! Copyright SMB and Co.

5. 17 Years !! The Deadly Delay…From Clinical Trials to Clinical Practice…

6. Good News.. We are Doing BetterScurvy and the British Navy 1601-- Lancaster shows that lemon juice supplement eliminates scurvy among sailors 1747-- Lind shows that citrus juice supplement eliminates scurvy 1795 -- British Navy implements citrus juice supplement 194 Years !!

7. Core Measures: Acute Myocardial Infarction Heart Failure Pneumonia Surgical Care Improvement HCAHPS

8. 1981- Beta-Blocker for Acute MI The Evidence is Published

9. Goal: 100% Compliance !! Core Measures: Acute Myocardial Infarction Heart Failure Pneumonia Surgical Care Improvement HCAHPS

10. Standard of Care ? !! Core Measures: Acute Myocardial Infarction Heart Failure Pneumonia Surgical Care Improvement HCAHPS

11. The Happy Medium:Previously “accepted” practices currentlyNot Recommended Aggressive surgery for early breast cancer Hormone replacement for post-menopausal women Vioxx for pain and inflammation Drug eluting stents in off-label indications Not too fast....

12. Gaining Physician Buy- InChanging the Mind-Set Today you are a medical student. However… ..…You will be a student of medicine the rest of you’re career. Dean of Students I hope there is no physician in this room who is…. ….too old a dog to learn a new trick!

13. Venous Thrombo-Embolic Disease DVT and Pulmonary Embolism

14. The Problem of VTE Prophylaxis is Significant “Deep Vein Thrombosis and Pulmonary Embolism represent a major public health problem, exacting a significant toll on the Nation” -- Surgeon General Call to Action, 2008 “[Thromboprophylaxis]…is the number-one strategy to improve patient safety in hospitals” – ACCP Guidelines, 2008 “…a vast number of randomized clinical trials over the past 30 years provide irrefutable evidence that primary thromboprophylaxis reduces DVT and pulmonary embolism” – ACCP Guidelines, 2008 DVT-related PE kills more Americans annually than AIDS and breast cancer combined – Gerotziafas, 2004

16. No increase in bleeding

18. VTE DemographicsMedical Opportunity Exceeds Surgical Opportunity Annual number at risk for VTE in US hospitals: 7.7 million medical service inpatients1 4.3 million surgical service inpatients 1 Medical Patients: 50%-70% of symptomatic VTEs 2 70%-80% of fatal PEs4 Anderson, Am J Hematol. 2007 Geerts, Chest. 2008

19. 38.3 x greater DVT/PE Risk 2.8 X greater 1.7 X greater LVEF >45% LVEF 20-44% The Medical Patient and VTE RiskHeart Failure LVEF <20% Howell, J Clin Epidemiol, 2001

20. The Medical Patient and VTE RiskAcute Respiratory Disease The prevalence of thromboembolic disease in patients hospitalized for respiratory disease is estimated at 8%-25% 1 COPD patients with DVT are older, more likely to be inpatients, more likely to be in the ICU and mechanically ventilated, and more often have concomitant PE 2 Shetty, J Throm Thrombolysis. , 2008 Fraisse, Am J Respir Crit Care Med., 2000

21. The Medical Patient and VTE RiskCancer Cancer patients are at increased risk for VTE Cancer increases risk 4.1-fold Chemotherapy increases risk 6.5-fold Khorana, J Thromb Haemost. 2007 Heit, Arch Intern Med. 2000

22. The Medical Patient and VTE RiskCancer Khorana, Journ Thromb Haem, 2007

23. Long Term Sequella of DVTNot just an isolated incident !! For patients with a single episode of DVT, In an 8 year follow-up: Subsequent DVT: 30% Post-Thrombotic Syndrome: 29% In a 10 year follow up: Subsequent DVT: 40% Prandoni, Ann Int Med, 1996 Prandoni, Hematologica, 2007

24. The Medical Patient and VTE RiskOther Acute Medical Illnesses Copyright SMB and Co.

25. DVT/ PE Prophylaxis Reporting Agencies Upping the Ante !! 2000 2001 2002 2003 2004 2005 2006 2007 2008 2 009 2010 2011 2000 2001 2002 2003 2004 2005 2006 2007 2008 2 009 2010 2011 2000 2001 2002 2003 2004 2005 2006 2007 2008 2 0092010 2011

26. DVT/ PE Prophylaxis Reporting

27. Why are Core Measures so Important ? 1. They are evidence-based. Implementing these practices will improveclinicaloutcomes 2. Performance is tracked publicly 3. Hospital (and perhaps physician) reimbursement is based upon performance

28. DVT and Pulmonary Embolism Surf the Legal Websites

29. Clinical Safety Regulatory The Right Thing !! Legal DVT Prophylaxis Experience Is the Problem of VTE Prophylaxis Significant ?

30. VTE Prophylaxis Program Development DVT/ PE Prophylaxis Program A. Increase the awareness of DVT/ PE B. Identify and treat patients at risk

32. Nursing

33. Patients Dissemination of ACCP treatment protocols

34. 8th ACCP Guidelines for DVT Prophylaxis (2008)

35. Conflicting Guidelines in the Role of Aspirin:8th ACCP Guidelines for DVT Prophylaxis (2008) 2006 AAOS Consensus Guidelines Evidence: Grade I A vs Grade III B

36. Guidelines for Guidelines There will be MORE guidelines in clinical medicine Guidelines wereNEVERintended to apply to all patients and do NOT take the place of individual physician judgment Expect physicians to occasionally deviate from guidelines in the daily practice of prudent medical care When so… … DOCUMENTIn the medical recordthat: The patient was seen and evaluated The options were thoughtfully considered The best clinical judgment was used Discussed with the patient

37. Adverse Outcomes Adverse Outcomes protocols Do Guidelines Help or Hurt? We keep missing the point….. Simply put… Protocols reduce adverse outcomes ! Guidelines improve patient care !

38. 100 98 96 Intervention group Freedom From DVT or PE, % 94 92 Control group 90 0 30 60 90 0 Days Education is Not Enough—The Importance of Hardwiring Kucher , NEJM, 2005

39. First: Risk Factor Assessment Tools

40. Then: Nursing Risk Factor Profiler  Physician Order Sets

41. For2010: Screening by Exclusion Criteria

42. For2010: St. David’s HealthCareExclusion CriteriaSCIP-Compliant Order Sets

43. Determine what outcomes should be tracked How have we done ?? Measure the Results a. Incidence of Hospital-Acquired: DVT Pulmonary Embolism b. Cost Avoidance

44. Incidence of Hospital-Acquired DVT and PE Total Cases and Cases Avoided Copyright SMB and Co.

45. Moment of Truth !! All we really did was reproduce the literature… ….. 20 years later !!

46. St. David’s HealthCare Cost for VTE Prophylaxis Heparin, LMWH, Fonduparinux for VTE Prophylaxis: Approximately $900,000 per year For seven years: $ 6,300,000

47. PE $12,595 DVT $9,337 $9,643 MI $6,367 Stroke 12500 0 5000 10000 2500 7500 Average Cost per Admission Cost Avoidance for DVT/ PE1.Average Cost per Admission Bick RL. Clin Appl Thrombosis/ Hemostasis 1999

48. 7 Year Cost Avoidance Savings: $ 2,980,000 PE $12,595 $ 3,651,000 $ 6,631,000 DVT $9,337 $9,643 MI $6,367 Stroke 12000 0 5000 10000 2500 7500 Average Cost per Admission Costs trended at 7% per year Cost Avoidance for DVT/ PE 1.Average Cost per Admission Bick RL. Clin Appl Thrombosis/ Hemostasis 1999

49. Cost Avoidance for DVT/ PE 2.Total IP/ OP Costs per Year MacDougall, Am J Health-System Pharm, 2006

50. 7 Year Cost Avoidance Savings: $2,903,000 $4,556,000 $7,459,000 Cost Avoidance for DVT/ PE 2.Total IP/ OP Costs per Year Costs trended at 7% per year MacDougall, Am J Health-System Pharm, 2006

51. St. David’s HealthCare Cost for VTE ProphylaxisBalance Sheet Cost of Rx:$ 6,300,000 Cost-Avoidance: $ 6,631,000 Potential Cases Avoided: 380

52. More than just the Cost of DrugsDVT Prophylaxis May Reduce the Overall Cost of Care Schumoch, Ann Pharm, 2005

53. What is the Opportunity for Your Hospital ?A Simple Predictive Model Two things to measure: Annual Med-Surg Admissions Equals Total Admissions minus OB Admissions minus Peds Admissions Baseline % pharmaco-prophylaxis in Med-Surg patients Randomly pull 50 charts and determine the percentage of patients receiving prophylaxis Avoidable DVTs: = (90- Baseline %) X (Med-Surg Admissions) / 80,000 Avoidable PEs: = (90- Baseline %) X (Med-Surg Admissions) / 145,000 Copyright SMB and Co.

54. Typical Example of a 250 Bed Hospital Copyright SMB and Co.

55. DVT PE 4. Honor the Data—Take it to the Next Level The Lessons Learned

57. Daily ambulation strategy

59. appropriateness

60. site

61. SiteRite ultrasound insertion

62. verify vein size

63. minimize insertion trauma

65. Full Course of Prophylaxis…Expanding our Horizon New 73% of patients develop DVT in the out-patient setting Of those, 60% were hospitalized in past 3 months Of those, 67% had the event the first month Spencer, Arch Int Med 2007

66. VTE Incidence After Hip and Knee ReplacementThe Risk Continues Well After the Hospital Discharge Sikorski, J Bone Joint Surg, 1981 White, Arch Int Med, 1998

67. The Duration of Prophylaxis Exceeds the Typical Length of Stay

68. From Known Complication…… To Known Complication NO ! Chemoprophylaxis does not prevent VTE; It does eliminate 2/3 of all cases New Almost all VTE’s at St. David’s Healthcare now occur in patients who are alreadyreceiving chemoprophylaxis

69. Why Wait?VTE Prophylaxis in the Emergency Department

70. Continuous Improvement CycleNext Steps for 2010 and Beyond Clinical improvement focus areas: AComprehensivePreventionProgram Daily ambulation plan for all patients Prophylaxis initiated in the ED Screening for Exclusion Criteria Prophylaxis throughout the Continuum of Care New

71. Infection Rates of Zero !Pipe Dream or Reality?National Healthcare Safety Network (NHSN) Report

72. Change Perfection is unobtainable. But if we chase it, we can catch excellence. Vince Lombardi Change Change

73. Change Change To the world you may be just one person, But to one person you may just be the world.Unknown Change Change