Hospital pharmacy develops DVT prophylaxis program

Each patient is assessed

Winter Haven Hospital in Winter Haven, FL, targeted deep vein thrombosis (DVT) prophylaxis as a goal, targeting this project to prevent readmissions related to DVT.

"We formed a multidisciplinary team of a pharmacist, nurse, and physician to see what we could come up with for a DVT protocol," says Jovino Hernandez, PharmD, clinical coordinator of pharmacy services at Winter Haven Hospital.

After reviewing existing DVT protocols, some with very complex scoring systems that might be impractical to use, they settled on an order form that put patients into three categories: low risk, moderate risk, or high risk.

"It's a nurse-driven system," Hernandez says. "Every adult medical or surgical patient who enters our hospital is assessed at admission by the nurse as low risk, moderate, or high risk, and the physician determines which therapy to administer."

Then the order is faxed to pharmacy, and the pharmacist enters the order, documenting that the DVT assessment was done.

The system automatically looks for patients who don't have that order documented, and reports are sent to the nursing stations with lists of patients who have not had their DVT risk assessed and treatment ordered, Hernandez says.

For patients who are not ordered DVT prophylaxis, the physician needs to document why he or she believes it is not needed.

"Nurses receive this report each morning, and the results are put on their score card which shows how well they're doing," he says. "Each month, there's a report that shows how each floor is doing as far as recording proper assessment and treatment."

This process was developed over a year and then implemented in 2006, beginning with pilot runs on a few floors, Hernandez says.

The pilot process highlighted some problems requiring additional staff education and better timing, he notes.

"The order form was by no means perfect and required more nursing input," he says. "We needed a cue to remind nurses of targeted patients, those who really needed the assessment because they hadn't had one yet."

That cue became the list sent to nursing stations each morning.

To help nurses make this process a habit, the hospital held a contest with floors competing against one another.

"We ran reports to see who was doing the best job, who had highest percentage of DVT assessment and intervention compliance," Hernandez says.

The winning floor receives a lunch-and-learn session in which a pharmaceutical company is invited to provide education about a particular medication while feeding attendees lunch.

"They call us up every month and say, 'Who won this month?'" Hernandez notes. "The nursing staff wants to win."

Prior to 2008, there were no electronic DVT data, but the problem of avoidable DVTs has largely disappeared since the program began, he adds.

Another change has been that as of January, 2010, the assessment has been shifted to physicians. The nursing stations still are responsible for making certain all of the assessments are recorded, but the nurses no longer do them.

"It's become automatic for all patients to be assessed, and a lot of our physicians are automatically upon admission doing it themselves now," he says. "They know if they don't do the assessment they'll have a nurse calling them about doing it."

The new protocol moves in the direction that each patient should be given a DVT prophylaxis unless a physician documents a reason why it's not needed, he adds.