QI efforts lead to success in VTE prophylaxis

Online education, computer alerts used

While Brigham and Women's Hospital in Boston has been successful in reducing the incidents of venous thromboembolism (VTE), it has taken an ongoing effort and a combination of successful interventions, says Sylvia McKean, MD, SFHM, FACP, a senior hospitalist. "National and international registries have shown that prophylaxis is still underutilized," she says.

Actually, she says, prophylaxis is not complicated (although, as the data on hand-washing compliance have shown, complexity and compliance rates may not always be linked). "The key thing to remember is that you basically need to do a risk assessment on all adult patients," she says, "because about 90% of patients who are hospitalized on a medical service should get pharmacologic prophylaxis; only about 10% may be low risk or have a contraindication to heparin."

That number is so high, she explains, because there are many major risk factors — including acute medical illness; cancer (active or occult); inherited or acquired hypercoagulable states; prior VTE; acute infection; congestive heart failure; COPD exacerbation; acute ischemic stroke; acute neurologic disease; inflammatory bowel disease; obesity; pregnancy or postpartum state; immobilization; central lines; certain medications; and increasing age (patients over 40). "Basically, that covers everybody, unless they are admitted for observation to rule out conditions like myocardial infarction," says McKean.

The regimen for prophylaxis is also relatively straightforward: Therapy for moderate and high-risk patients is the same, unless the risk of bleeding is greater than the risk of clotting (since heparin is used). So, for example, heparin is contraindicated with a "GI" bleed, serious bleeding in the past couple of weeks, or a low platelet count (less than 50,000). Otherwise, McKean says, "Low-molecular-weight heparin is used in Europe and unfractionated heparin or low-molecular-weight heparin is used here." It also is important to remember to prescribe mechanical prophylaxis for patients at increased risk who have a contraindication to heparin and to reassess the risk of bleeding as the hospitalization proceeds.

CPOE yields results

The system at Brigham and Women's has evolved, thanks to the work of Samuel Z. Goldhaber, MD, in the cardiovascular division. "He's an international expert in blood clots," notes McKean, "and he developed a computer alert system." The entire hospital, she notes, is on computerized physician order entry.

"Normally, patient order entry involves a blue computer screen," she recalls. "But when Goldhaber developed the alert system, the screen would turn red to remind people to order appropriate prophylaxis."

Use of the alert resulted in a 40% reduction in incidents of hospital-acquired VTE. "So, he didn't just improve the process, he improved outcomes," notes McKean.

The hospitalists at Brigham and Women's also have developed their own VTE prophylaxis standards for their service. "We all agreed on what the standard should be regarding risk assessment and prophylaxis," says McKean. There is an internal website for members of the hospitalist service containing this and other important information.

But for hospitalists who do not have access to CPOE and are asked by their institution to try to improve VTE prevention, resources from the Society of Hospital Medicine (SHM) could prove beneficial.

"Across the country now, a huge percentage of facilities utilize hospitalists, and this helps them approach VTE in a uniform way," McKean explains. "They can get the workbook and work with their QI person without having to attend a course. They can just download the entire workbook." They can also enroll in the SHM VTE mentoring project.

[For additional information, contact:

Sylvia McKean, MD, SFHM, FACP, Senior Hospitalist, Brigham and Women's Hospital. Phone: (617) 732-6794.]