# Presentation: 922509

## Venous Thromboembolism Safety Tool Kit 

*Brenda K. Zierler, PhD, RN, RVT*
*University of Washington*
**Medication Safety: Tools for Diverse Settings**
**September 10, 2008**
**8:00 AM – 9:30 AM**

## VTE Safety Toolkit

- Partnership in Patient Safety Grant
- AHRQ (Agency for Healthcare Research and Policy)
- 2-year grant to improve care for patients at risk for or diagnosed with VTE
- PI: Brenda Zierler, PhD
- Co-PI: Gene Peterson, MD

## VTE Safety Toolkit- What is It?

- Evidence-based algorithms, guidelines, recommendations, and order sets for preventing, diagnosing, treating and educating patients and providers about VTE
- Educational intervention and compliance training
- Medications – heparin, warfarin

## Interdisciplinary Clinical Team

-  Name					Expertise
- *Ann Wittkowsky, PharmD		Toolkit/Cases/anticoagulation
- Robb Glenny, MD			Toolkit/Cases/Pulmonary ICU
- Paul Hendrie, MD			Toolkit/Hematologist
- Karen McDonough, MD			Toolkit/Medicine Consult
- Kim Cantwell-Gab, BSN			Toolkit/Patient Education
- Gene Peterson, MD			Co-PI/Cases/Administration
- Brenda Zierler, PhD			Toolkit/Cases/Research Design
- David Flum, MD			Consult/Prevention/Surgeon
- *Mark Meissner, MD			Consult/DVT Diagnosis/Surgeon
- Sylvia McKenzie, RN			QI/Mechanical Prophylaxis
- Seth Wolpin, PhD			Dashboard/Web Team

**VTE Safety Toolkit; AHRQ Patient Safety Grant**

## Why Study VTE? Epidemiology of VTE

- VTE encompasses deep vein thrombosis (DVT) and pulmonary embolism (PE)
***Most common preventable cause of hospital death***
- 900,000 Americans suffer VTE each year
- 400,000 DVT
- 500,000 PE

## Epidemiology of VTE

- In 300,000 patients, PE proves fatal
- 3rd most common cause of hospital-related deaths in the United States
- Post-thrombotic syndrome will be seen in 800,000 pts.
- 7% of these individuals will have a severe form of the problem and will become disabled
- Survivors are at risk for recurrence of PE
- Pulmonary hypertension develops in approximately 30,000 patients who survive their PE

## Epidemiology of VTE

- 1 of 20 hospitalized medical patients will suffer a fatal PE if they have not received appropriate thrombosis prophylaxis
- 50% of the 2 million cases of DVT yearly are “silent”

## Risk Factors for VTE

- Determine who should receive prophylaxis
- Every patient at UWMC should be assessed for risk of developing VTE
- Understand contraindications to pharmacologic prophylaxis (heparin, warfarin)
- Offer mechanical prophylaxis when pharmacologic prophylaxis is not safe

##  VTE Prophylaxis (focus of today’s talk)
 Risk Assessment Tool
 DVT Diagnostic Algorithm
 PE Diagnostic Algorithm
 HIT Assessment
 Heparin nomograms (dosing)
 VTE Treatment Pathway
 DVT Treatment Order Set 
 Vascular Lab Requisition
 Neural-axial anesthesia guidelines
 Patient Education (prevention & treatment)

-  Risk Assessment Tool
-  DVT Diagnostic Algorithm
-  PE Diagnostic Algorithm
-  HIT Assessment
-  Heparin nomograms (dosing)
-  VTE Treatment Pathway
-  DVT Treatment Order Set
-  Vascular Lab Requisition
-  Neural-axial anesthesia guidelines
-  Patient Education (prevention & treatment)

- VTE Safety Toolkit- Components

## VTE as a Clinical and System Problem

- System Barriers
- Providers are not employees of 450-bed academic medical center
- No standards of practice
- Multiple disciplines treating small numbers of patients (without experience or expertise)
- Prophylaxis is underutilized

## PAST EXPERIENCE

- Implementation of DVT pathways
- Reasons for failure
- Trying to change individual physician behavior
- No culture of safety
- Lack of systems supports
- No integrated information system
- Ownership/turf issues

## VTE Prophylaxis 

- Every patient should be assessed for risk of developing VTE
- Determine who should receive prophylaxis
- Understand dosing and contraindications to pharmacologic prophylaxis (heparin, warfarin)
- Offer mechanical prophylaxis when pharmacologic prophylaxis is not safe
- Document assessment and prophylaxis plan

## Steps in Implementation

-  Dedicated Web Site
-  Training Modules – pilot in winter 2007
-  Test interactive cases as educational intervention
-  Gather feedback about training (effectiveness, clarity, timeliness, relevance)

## Slide 14

**Notes:**
This is the front page of the VTE Safety Toolkit Website. A brief description of the toolkit components are described.

## Slide 15

**Notes:**
The Toolkit tab is selected and a drop down list of possible guidelines is shown.

## Slide 16

**Notes:**
A Disclaimer and terms of use document appears when a guideline is chosen. The viewer has to click on a download button, which also confirms that the viewer agrees to the terms of use.

## Slide 17

**Notes:**
This screenshot of the VTE Website demonstrates the two guidelines available under the tab screening and assessment

## Slide 18

## Slide 19

## Slide 20

## Slide 21

## Slide 22

**Notes:**
This screenshot demonstrates the various links to other websites and tools. The links are updated periodically.

## Slide 23

**Notes:**
The VTE Safety Toolkit has references for each toolkit component and they are available under the “reference” tab.

## Slide 24

**Notes:**
This screenshot highlights the members of the VTE Team who contributed to the development of the toolkit.

## Randomized Controlled Trial

- Test knowledge acquisition about VTE prevention using interactive case studies
- Control Group (passive didactic)
- Experimental Group (interactive case studies with feedback)
- Mandatory training (similar to HIPAA)
- Tracking outcomes by provider (currently tracking pre-intervention data)

## Provider will be randomized when they log-in

**Provider will be randomized when they log-in**

**Notes:**
The next few screens are screenshots of the provider training module.

## Both groups will be pre-tested on current VTE prophylaxis knowledge

**Both groups will be pre-tested on current VTE prophylaxis knowledge**

## Passive Didactic Training on core principles

**Passive Didactic Training on core principles**

## Control Group will take Post test after passive training

**Control Group will take Post test after passive training**

## Interactive case studies with feedback

**Interactive case studies with feedback**

## Slide 31

## Slide 32

## 100% pass rate expected; certification will be granted and linked to Quality Improvement (compliance)

**100% pass rate expected; certification will be granted and linked to Quality Improvement (compliance)**

## IMPLEMENTATION of VTE TOOLKIT

-  Systems approach
-  Buy-in from Administration
-  Focus on patient safety
-  Mandatory training to meet core competencies on VTE prophylaxis
- Joint Commission and the National Quality Forum

## Conclusion

-  Improve patient safety by adopting practice standards based on evidence from the literature
-  Improve utilization of diagnostic services
-  Improve safety of medications (heparin nomograms/guidelines)
-   _[http://](http://vte.son.washington.edu/)__[vte.son.washington.edu](http://vte.son.washington.edu/)_

**VTE Safety Toolkit; AHRQ Patient Safety Grant**

## Thank You

**Notes:**
This is a slide showing 4 pictures of the University of Washington campus and the University of Washington Medical Center