### Title and Summary of Initiative:

Our initiative is titled, [Reducing Deep Vein Thrombosis Incidence
amongst Hospitalized Patients]{.underline}. Approximately 260,000 cases
of venous thromboembolic events (VTE) (inclusive of deep vein
thrombosis, DVT) are diagnosed per year in the U.S. amongst acute
hospitalized patients, and many cases of the disease can be asymptomatic
or undiagnosed. Additionally, the in-hospital mortality rate for VTE is
12%. Pharmacological prophylaxis has been shown to reduce the incidence
of DVT. Consequently, a review of the use of FDA approved
pharmacological prophylaxis treatments (Enoxaparin and Heparin) was
conducted. The data reflected that 67% of Enoxaparin and only 2% of
Heparin prescriptions were written in a manner reflective of the
appropriate clinical guidelines. The goal of our initiative was to
collaboratively reduce the incidence of inpatients who develop DVT. We
sought to achieve this by increasing provider adherence to the use of
proper prophylaxis treatment by developing an evidence-based protocol
for treatment of at-risk patients, and applying this to the electronic
medical record (EMR) through the use of an automated clinical reminder
for patients at risk of DVT. Following the development and
implementation of the protocol and reminder, appropriate Enoxaparin
prescriptions increased to 74% and Heparin to 32%. Additionally, the
percent of DVT related admissions decreased 21%.

**[Date of Implementation: December 2001 & continues ongoing to the
current time (June 2005).]{.underline}**

***[Evaluation of Published Opinion in Professional Literature &
Evaluation of Scientific Evidence; Research Based:]{.underline}***

The goal of our initiative was to reduce the incidence of inpatients who
develop deep vein thrombosis (DVT). We sought to achieve this by
collaboratively increasing provider adherence to the use of proper
prophylaxis treatment by developing an evidence-based protocol for
treatment of at-risk patients, and applying this to the electronic
medical record (EMR) through the use of an automated clinical reminder
for patients at risk of DVT.

Venous thromboembolic events (VTE), which include DVT, are a
demonstrated area of concern in medicine. Approximately 260,000 cases
are diagnosed per year in the U.S. amongst acute hospitalized patients,
and many cases of the disease can be asymptomatic or undiagnosed.[^1]
Additionally, the Worcester DVT Study concluded that the in-hospital
mortality rate for VTE is 12%.[^2] DVT has been recognized nationally as
an area for health care enhancement. In fact, the Agency for Healthcare
Research and Quality (AHRQ) has identified appropriate use of
prophylaxis to prevent VTE in at-risk patients as a well-evidenced
opportunity for safety improvement.[^3]

As part of the veterans health system's approach of continuous quality
improvement, the intervention was pursued based on an analysis of
internal data with support from research based literature.
Pharmacological prophylaxis has been shown to reduce the incidence of
DVT. Consequently, the data of initial interest related to the process
surrounding prophylaxis use. Specifically, the prescription patterns of
providers in relation to prophylaxis were studied. Two pharmaceuticals
were identified as indicative of pharmacological prophylaxis treatment,
Enoxaparin and Heparin. In regards to Enoxaparin, the data reflect that,
between 12/12/01 and 12/02/02, 67% of these prescriptions were written
as Q12H or daily, following the appropriate clinical guidelines.
However, 33% of these prescriptions were written as "one time, once, or
give now." The patients treated using this form of prescription could
not be assumed to be receiving appropriate dosing for prophylaxis.
During the same time period, only 2% of Heparin prescriptions were
written correctly (TID or 8H). 21% were written as PRN, IV, once, or now
(one time order), and 77% were written as QD, BID, or Q12H. Similar to
the expectations with Enoxaparin, it could not be assumed that the
patients whose prescriptions were incorrectly formulated were in receipt
of proper prophylaxis treatment.

To assist in determining the potential impact of these variations in
treatment, a literature review was conducted. The research findings
indicate the importance of proper prophylaxis treatment for hospitalized
patients to reduce the risk of DVT. For example, the incidence of DVT is
25% for general surgery patients not treated with prophylaxis, and
(specific to the leg) approximately 24% among myocardial infarction
patients.[^4]

***[Evaluation of Current Practices:]{.underline}***

Motivated by the internal data and research findings, a consideration of
the causation of provider variation in prescribing was completed. It was
determined that the process in relation to DVT prophylaxis was not
automated. In fact, the use of prophylaxis and dosage decisions were
reliant on provider memory. To improve quality of care for the target
population, inpatient veterans at risk for developing DVT, the surgical
nurse practitioner, & MVAC Co-Careline Leader/General Surgery Attending
Surgeon concluded that the non-standardized and human-dependent
processes in place increased the risk of outcomes other than those
desired and chose to pursue a process change with the intent to improve
patient safety in the veteran population.

***[Nursing and Physician Participation in Development and
Implementation of Initiative; Nursing and Physician
Co-Leaders/Co-Managers of Initiative :]{.underline}***

## Key Activities

The clinical and literature findings provided the basis for the
following proactive initiative components performed by the surgical
nurse practitioner, & MVAC Co-Careline Leader/General Surgery Attending
Surgeon:

-   Utilized the Sixth American College of Chest Physicians (ACCP)
    Guidelines for Antithrombotic Therapy for Prevention and Treatment
    of Thrombosis (published in 2001) to develop standardized and
    evidence-based protocol for DVT prophylaxis.

-   Developed automated, EMR (CPRS) based clinical reminder based upon
    the DVT prophylaxis protocol.

-   Implemented a pilot study of the new clinical reminder initiated at
    one tertiary medical center within VISN 2 (Albany VAMC), with
    concurrent training and marketing campaign.

-   Rolled out the clinical reminder to the other two tertiary medical
    centers in VISN 2 (including training and marketing).

-   Ongoing education for physicians (in tandem with changes in house
    staff) and other healthcare providers.

-   Performance monitoring.

***[Nursing and Physician Co-Leaders Demonstrate Interdisciplinary
Collaboration in Leading Initiative; Chief of Staff co-lead
dissemination of findings via clinical presentations:]{.underline}***

The following healthcare team members were integrally involved with the
successful execution of the initiative:

Surgical Nurse Practitioner (pilot site: Albany New York and VISN 2)

MVAC Co-Careline Leader/General Surgery Attending Surgeon (pilot site
Albany New York and VISN 2)

Clinical Applications Coordinators (at the three tertiary facilities)

In addition to these individuals, the support and commitment of medical
center and system leadership was essential for project achievement. The
initiative leaders presented their data and recommendations to the local
leadership council at the pilot facility and at the system level
executive leadership council for discussion and strategic concurrence.
The commitment from senior management at both levels provided the
momentum for implementation, and encouraged the dissemination of the
project to the other tertiary facilities by Chief of Staff via
presentations VISN wide, where senior leadership also pledged support.

## 

## **[Evaluation of staff perception; Initiative Impacts VISN2/VHA Wide and Recognized as a Best Practice:]{.underline}**

## 

## **[Timeline]{.underline}**

The initiative's components were executed in the following timeline:

**[2001]{.underline}**

December: Data collection began VISN 2 wide (including tertiary
hospitals) by surgical nurse practitioner, & MVAC Co-Careline
Leader/General Surgery Attending Surgeon.

**[2002]{.underline}**

Developed electronic DVT protocol.

Created clinical reminder based on protocol.

Obtained approval for implementation from local leadership council at
the pilot facility after presenting survey data obtained from clinical
staff as to their opinion regarding the concept. The purpose of this was
to elicit key "clinical staff stakeholder" buy in.

Facility wide training and marketing presentation.

Completion of initial data collection.

December 5, clinical reminder implemented for use by providers at the
pilot facility (Albany New York).

**[2003-2004]{.underline}**

Roll out of clinical reminder to remaining tertiary medical centers VISN
wide.

Ongoing education/surveying of physicians, and nursing staff VISN wide.

Progress monitoring.

**[2005]{.underline}**

Update of the protocol VISN wide (VISN 2), revisions based on the
Seventh American College of Chest Physicians (ACCP) Guidelines for
Antithrombotic Therapy for Prevention and Treatment of Thrombosis
(published in 2004).

Revision of the clinical reminder in accordance with changes to the
protocol.

Provider survey regarding clinical reminder VISN wide (VISN 2).

Most recently this initiative was recognized as a VISN 2 wide ***best
practice*** via a "Distinguished Clinician Award" by the VSIN 2 Network
Director and local leadership awarded to the surgical nurse
practitioner. Since the award, this initiative in VISN 2 has been
recognized nationally as a VA benchmark in patient safety practice for
example the chief medical officer of VISN 20 has ranked this "the top
patient care safety initiative" and the surgical nurse practitioner is
working with VISN 20 to replicate this benchmark initiative there.

In this and all areas of clinical care, the system is committed to
performance leadership in healthcare. The organization pursues an active
approach to excellence focused on the theory of continuous quality
improvement. Data is the invaluable center of the performance
improvement strategy. Targets and benchmarks from the state, the nation,
and others are used for comparative purposes. Internal data and medical
research findings provide the impetus for action, and data collection
and information systems enable progress and measurement. Process changes
are implemented using the "Plan-Do-Study-Act" (PDSA) model, including
utilizing a pilot program when modifications are predicted to affect
multiple departments and/or facilities. Clinically related changes may
involve the development and implementation of clinical guidelines or
protocols and automated clinical reminders integrated into the EMR.
These reminders function to motivate the provider to provide clinically
indicated care. In many ways, this initiative reflects the
organizational process for performance improvement. Internally and
externally produced data were the basis for action. A team led
collaboratively by the surgical nurse practitioner and the MVAC
Co-Careline Leader/General Surgery Attending Surgeon and endorsed by
leadership implemented the PDSA model, using data to develop an action
plan, implementing it at a pilot site, implementing the process change
throughout the system and conducting performance evaluation. It further
represents a commitment to continuous quality improvement through the
expansion and adaptation of a proven effective application of
evidence-based medicine in the form of a protocol and clinical reminder.

# *[Impact on Workforce Challenges/Patient Outcomes: Outcomes related to demonstration of decreased errors AND Outcomes related to demonstration of patient safety (i.e. decreased adverse events):]{.underline}* 

As is practice, the organization sought to utilize demonstrated best
practices in the development of a clinical protocol for DVT prophylaxis.
Consequently, the protocol and clinical reminder developed by the
surgical nurse practitioner, & MVAC Co-Careline Leader/General Surgery
Attending Surgeon (both located at the pilot site Albany New York) were
based upon the Sixth American College of Chest Physicians (ACCP)
Guidelines for Antithrombotic Therapy for Prevention and Treatment of
Thrombosis (published in 2001). The ACCP guidelines are created and
revised on the basis of the ACCP analysis of clinical research.

Clinical reminders are commonly used by the organization in conjunction
with the EMR as a means to enable high quality healthcare through
immediate access to patient information. A clinical reminder has the
appearance of an electronic message that appears in the EMR of a patient
in need of a particular form of care. Within this framework, clinical
reminders function to provide guidance to physicians and other
clinicians in proactively addressing healthcare needs using
evidence-based protocols. While physicians are familiar with the
clinical reminder tool, they were provided additional training to
increase their understanding of and the proper response to the new
reminder, and its value to patients. The surgical nurse practitioner, &
MVAC Co-Careline Leader/General Surgery Attending Surgeon have
collaboratively provided ongoing education to clinicians and staff
across the tertiary facilities. Training and educational activities have
included lectures on the theory and evidence supporting the program, as
well as computer-based training. Additionally, expectations were
disseminated from organizational leadership at the facility and system
level that affected physicians were responsible for addressing the
clinical reminder as it appeared in the patient's medical record. The
use of the clinical reminder and provider adherence allows the
organization to increase the use of standardized, clinically appropriate
care to patients who could potentially be affected by DVT. This
effectively reduces variability in treatment and should reduce the risk
of adverse outcomes.

#  

A pre-post study design was chosen for evaluating the initiative. For
the study, the selected performance measurement tool was automated
record review. Using system information system capabilities, the
patients' EMR at the system's facilities were reviewed to evaluate if
providers were utilizing the two FDA approved pharmacological
prophylaxis treatments available, Enoxaparin and Heparin. The data
collection periods for this analysis were from 12/1/01 to 12/2/02 and
12/4/02 to 11/13/03. Data was also extracted from the EMR to determine
which inpatients had an admitting diagnosis of DVT during the time
period from 12/12/01 to 11/30/02 and from 12/13/02 to 11/05/03. The
source of the data for the reviews was the EMR. Patient data is entered
and stored in the EMR, and, for the purpose of this study, was extracted
from this source in an automated fashion using the organization's
information system capabilities. This ability to extract data directly
from the place that it is stored helped to ensure that that the chosen
performance measurement tool provided an accurate measurement.
Similarly, the use of an electronic, automated data source and data
collection method assisted in ensuring that the most accurate and
complete data available would be utilized.

To measure the effectiveness of the intervention, provider prophylaxis
prescription patterns were measured at the system level, and DVT related
admissions were measured at the system and medical center levels across
VISN 2. Prescription data was reviewed for the periods 12/1/01 to
12/2/02 and 12/4/02 to 11/13/03 (pre and post-implementation).
Admissions data was reviewed for two similar time periods 12/12/01 --
11/30/02 and 12/13/02 -- 11/5/03. Examples of how the data were
organized can be found in Figures 1-5. Internal comparison data was used
to evaluate provider prescription patterns at the pre and post
implementation periods. The data findings indicate that the percentage
of appropriate Enoxaparin and Heparin prescriptions were higher than in
the first period of study, the increase in appropriate Heparin
prescriptions particularly noticeable (as displayed in Figures 1 and 2
in the Appendix). Based on the type of study and the data collected, the
initiative leaders chose not to use statistical process control tools in
the study.

The main measure of interest in the study was the number of admissions.
Internal data was also used for the purpose of comparison. The number of
admissions in the first period was 84, compared to 64 in the second, a
difference of 21%. At the facility level, 2 out of 3 tertiary sites and
1 non-tertiary medical center experienced a decrease in admissions (the
other non-tertiary site had an increase from 0 admissions to 1
admission). Details are provided in the Appendix in Figures 3-5 (The
tertiary sites are labeled as A -- C, A being the pilot site). Based on
the system level and a majority of the evidence at the facility level,
the following conclusions were made. First, the use of a clinical
reminder affects clinician performance of providing prophylaxis
treatment. Second, the use of a clinical protocol and reminder has the
potential to decrease the incidence of DVT in the target population. The
findings from the initiative have been shared with internal leaders and
groups, as well as to external parties. Because of their role as leaders
and in creating and sustaining change, presentations of findings have
been made to the executive leadership council and to the local
leadership councils at the three tertiary medical centers. The initial
presentations took place in 2002, and combined numerical data,
literature findings, and visual representations. For the rollout phase,
the presentations to local leadership at the other tertiary sites were
held in 2003. Additionally, to reinforce the value of the clinical
reminder tool, similar presentations were made to physicians and staff
at the medical centers during this time period.

The initiative and findings have also been presented to external
parties. For example, to provide a demonstration of a quality
improvement project within the system, the surgical nurse practitioner,
& MVAC Co-Careline Leader/General Surgery Attending Surgeon made a
presentation to reviewers from JCAHO during the system's accreditation
survey in the fall of 2003. Additionally, the Surgical Nurse
Practitioner has created a poster and performed a live presentation of
the study's findings at the Seventh National Conference on Anticoagulant
Therapy in May of 2003 and presented the findings at The American
Academy of Nurse Practitioners National Conference in June of 2004.
Furthermore, the surgical nurse practitioner is an invited speaker to
present this initiative at the 2005 19^th^ Annual Association of
Vascular Access National Conference in September 2005.

A review of prescribing patterns by physicians treating patients at risk
for DVT revealed variations in treatment. In consideration of the
influence of prophylaxis on the incidence of DVT in hospitalized
patients, as demonstrated in evidence and supported by the AHRQ, a
decision was made to proactively address the issue in order to reduce
the risk of adverse outcomes. The implementation of the protocol and the
clinical reminder was first tested using a pilot study at one tertiary
medical center before dissemination to the other tertiary sites. The
chosen initiative was expected to affect the incidence of DVT in the
health system. The clinical protocol and reminder are based upon
guidelines developed by a physician professional organization using an
analysis of sound and reputable research evidence. The initiative also
utilizes system-wide information systems in a demonstrated way,
integrating an evidence-based and visible reminder into the EMR. The
chosen measurement tool of automated record review enabled us to extract
the measurement data directly from the source, the EMR, which assisted
us in evaluating the changes in prescription patterns and admissions.
Furthermore, as part of the automated nature of the intervention, the
clinical reminder appears specifically for patients at risk of
developing DVT, the target population of the study. The admission data
results (displayed in Figures 3-5), combined with the use of
evidence-based medicine and successful automated interventions indicate
a potential relationship between the initiative and the improved
outcomes.

To determine potential changes in behavior as a result of the clinical
protocol and reminder, the percentage of correctly composed Enoxaparin
and Heparin prescriptions was studied. The initial data collection
period was 12/1/02 -- 12/2/02 and the second was 12/4/02 -- 11/13/03.
Appropriate Enoxaparin prescriptions were 67% in the first period,
compared to 74% in the second. Appropriate Heparin prescriptions had a
greater increase, from 2% to 32% (see Figures 1 and 2 in the Appendix).
The findings indicate success in achieving the objective of increasing
appropriate provider prescriptions for prophylaxis. This is important
because clinical research indicates that patients receiving medically
indicated, evidence-based, treatment are less likely to develop DVT, the
prime objective of the initiative.

Data was also collected regarding DVT related admissions (found in
Figures 3-5 in the Appendix). The initial data collection took place in
the period between 12/12/01 -- 11/30/02 (prior to implementation), and
the second data collection in the period between 12/13/02 -- 11/5/03
(post-implementation). In the time period following implementation of
the clinical reminder at the tertiary sites, there was a reduction in
DVT admissions in the system of 21% compared to the initial period of
data collection. At the facility level, 2 of 3 tertiary medical centers
and 1 of 2 non-tertiary medical centers experienced a decrease in
admissions between the two time periods. Site A, the pilot facility, had
a decrease of 63.16% (19 admissions in period 1, and 7 in period 2).
Site B (a tertiary center) experienced a reduction of 21.21% (33
admissions in period 1, and 26 in period 2). Site D (a non-tertiary
site) had a decrease of 83.33% (12 admissions in period 1 and 2 in
period 2). Site E (also a non-tertiary site) experienced a small
increase in admissions, from 0 in period 1 to 1 case in period 2. Site C
(a tertiary center) was the only site with a noticeable increase in
admissions, from 20 in period 1 to 28 in periods 2 (an increase of 40%).
These findings indicate that the improvements in prophylaxis treatment
at the tertiary sites may have resulted in the decrease in the incidence
of DVT in the target population.

An abstract of the system's findings were also published in the Journal
of Thrombosis and Thrombolysis.[^5]

Clagett, et al. Prevention of venous thromboembolism. *Chest*, 1995; 108
(4): 312 - 334.

^2^ Anderson, et al. A population based perspective of the hospital
incidence and case-fatality rates of deep vein thrombosis and pulmonary
embolism. *Archives of Internal Medicine,*1991; 151 (5): 933-938.

^3^ *Making Health Care Safer: A Critical Analysis of Patient Safety
Practices*. Summary. July 2001. AHRQ Publication No. 01-E057. Agency for
Healthcare Research and Quality, Rockville, MD.

^4^ Clagett, et al. Prevention of venous thromboembolism. *Chest*, 1995;
108 (4): 312 - 334.

^5^ The use of computerized clinical reminders for DVT prophylaxis using
clinical decision support in all patient admission and transfer orders.
*Journal of Thrombosis and Thrombolysis*, 2003; 16 (1-2): 106.

APPENDIX Figures 1 and 2

![](media/image1.wmf)![](media/image2.wmf)

# Figures 3-5

![](media/image3.wmf)![](media/image4.wmf)![](media/image5.wmf)![](media/image6.wmf)

[^1]: Clagett, et al. Prevention of venous thromboembolism. *Chest*,
    1995; 108 (4): 312 - 334.

[^2]: Anderson, et al. A population based perspective of the hospital
    incidence and case-fatality rates of deep vein thrombosis and
    pulmonary embolism. *Archives of Internal Medicine,*1991; 151 (5):
    933-938.

[^3]: *Making Health Care Safer: A Critical Analysis of Patient Safety
    Practices*. Summary. July 2001. AHRQ Publication No. 01-E057. Agency
    for Healthcare Research and Quality, Rockville, MD.

[^4]: Clagett, et al. Prevention of venous thromboembolism. *Chest*,
    1995; 108 (4): 312 - 334.

[^5]: