Charles Levenback MD Professor and Deputy Chair for Patient Care Gynecologic Oncology Center Medical Director Lisa Kidin RN MSN MHA Sr Business Systems Analyst Deep vein thrombosis DVT ID: 268088
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1
Reducing the Incidence of VTE Among Gynecologic Oncology Patients
Charles
Levenback
, MD
Professor and Deputy Chair for Patient Care
Gynecologic Oncology Center Medical Director
Lisa Kidin, RN, MSN, MHA
Sr. Business Systems AnalystSlide2
Deep vein thrombosis (DVT):
Formation of a blood clot in the deep veins, usually the legs and pelvis
Pulmonary embolism (PE):Blood clot dislodges and travels to the lungs
2
Venous Thromboembolism (VTE)Slide3
> 2 million Americans suffer from VTE each year
> 50% develop in the hospital or within 30 daysVTE increases cost $10-16K2PE is the most common preventable cause of hospital death in the US
Gynecologic oncology patients at high riskGynecologic oncology combined med-surg
service
3
Background
Agency
for Healthcare Research and Quality, 2010
2Goldhaber,S. (2006).
Sequellae
and cost of venous
thromboembolism
. Retrieved from http://www.surgeongeneral.gov/topics/deepvein/workshop/presentations/goldhaber_seq_text.htmlSlide4
4
Case for Pharmacologic Prophylaxis
AHRQ - Agency for Healthcare Research and Quality -
www.
ahrq
.gov
NCCN - National Comprehensive Cancer Network -
www.
nccn
.org
ASCO – American Society of Clinical Oncologists -
www.
asco
.org
Prophylaxis reduces VTE in hospitalized patients by 50 -65%
VTE prophylaxis is safe and cost effective
All guidelines recommend
starting prophylactic anticoagulation within 24h of surgery
consideration of extended-duration use (up to 28 days after surgery) in high-risk patients
VTE pharmacologic prophylaxis is widely under-utilizedSlide5
We have a VTE problem…
Reach consensus to follow guidelinesExclude medical admissionsFormed multidisciplinary team to work out details
5
VTE Practice Guideline Implementation 2009
VTE Interventions 2009 in gynecologic oncologySlide6
6
VTE Practice Guideline Implementation 2009
Aim was to decrease VTE incidence by 10% by July
2010
Implement the following practice guideline in October 2009:
Initiation of low molecular weight heparin (LMWH) prophylaxis within 24h of surgery in all patients undergoing exploratory laparotomy for gynecologic malignancy
Continuation of LMWH prophylaxis for a total of 28 days following surgery
Patient
education plan developed
Communication and education to trainees, outpatient and inpatient nursing staffSlide7
7
Results of 2009 Interventions
115 patients underwent exploratory laparotomy for a gynecologic malignancy
72% started LMWH prophylaxis within 24h of surgery
100% of patients were discharged home with extended duration pharmacological prophylaxis
Decreased VTE rate from 5.9% to 3.8% reaching our aim by July 2010
Cost avoidance of $90,000/year
Project was presented at CS&E conference in Austin 2010Slide8
8
Lessons Learned
Only 72% of patients started pharmacologic prophylaxis within 24 hours of surgery
In all patients who developed a VTE, LMWH was NOT started within 24 hours of surgical end time
No data on patient compliance with continuation of VTE prophylaxis following dischargeSlide9
9
Aim Statement 2010
Demonstrate sustainability of previous
improvements and further reduce the
incidence of VTE by 10% in gynecologic
oncology patients undergoing exploratory
l
aparotomy by February 2011Slide10
10
Measures of Success
Population
:
Gynecologic Oncology Exploratory Laparotomy Patients
Timeframe
:
2009 Intervention: October 2009-July 2010
2010 Intervention: October 2010- February 2011
Process Metrics
:
Starting pharmacologic prophylaxis within 24 hours of surgery
Continuation of pharmacologic prophylaxis for a total of 28 days after surgery
Patient compliance with 28 day pharmacologic prophylaxis
Outcomes Metric:
The incidence rate of VTE within six months of surgery Slide11
11
Intervention to increase compliance
Refined post-operative order sets to include:
Scheduled initiation within 24 hours of surgery (unless contraindicated)
Hold parameters for hemoglobin and platelet countSlide12
12Slide13
13
Results-Process Metrics
Metric
2009 Project
2010 Project
Starting pharmacologic prophylaxis
(LMWH) within 24 hours of surgical end time
83/115 (72%)
132/147(90%)
Continuation of LMWH prophylaxis
for a total of 28 days after surgery
114/115 (99%)
140/147(95%)
Patient compliance with 28 day LMWH prophylaxis post discharge
Not measured
102/137 (79%)
.Slide14
14
Results-Outcomes
We are confident that a change is made and concordance with guidelines, however, more data is needed to quantify the magnitude of the improvement.
16.3
24.8
21.8
2010 InterventionSlide15
15
Results-Outcomes
VTE incidence was defined as a VTE occurrence within 6 months of surgery
Metric
Baseline
2009 + 2010 Project
VTE Incidence
Rate in the Exploratory Laparotomy Population within 6 months
13/224
(5.8%)
14/304 (4.6%)Slide16
16
Summary
Incidence rate of VTE decreased from
5.8%-4.6%
since late 2009
No statistically significant difference in hospital-acquired VTE rate
Pharmacological prophylaxis (LMWH) rate within 24 hours of surgery end time increased from
72%-90%
Continuation of LMWH prophylaxis for a total of 28 days after surgery was 99%-95%.
79% Patient compliance with 28 day home regimenSlide17
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Next Steps
Continue to revise embedded VTE module in order sets to further increase prophylaxis rates
Continue to survey patients to ensure 28 day regiment compliance
Expand to non-surgical gynecologic oncology admissions
Share findings with other departments to improve VTE prophylaxis
throughout the institution and also other institutionsSlide18
Thank YouSlide19
Aim Statement
American Society of Hospital System Pharmacists (ASHP) mentorship visit – April 2011
VTE prophylaxis highly under-utilized at MD AndersonIdentified opportunities for improvement At MDACC, approximately 400 patients per year develop a potentially hospital-acquired VTE
“A clot a day at MDA…”19
Identification of Problem at MD AndersonSlide20
20
Increase VTE pharmacologic prophylaxis among all Gynecologic Oncology admissions (surgical and medical) by
15% by 8/15/2011
Aim StatementSlide21
21
Measures of Success
Population
:
Gynecologic Oncology Admissions (medical & surgical)
Timeframe
:
Baseline: January 1 – February 28,2011
Post Intervention: June 15 – August 15,2011
Process Metrics
:
Admissions with VTE pharmacologic prophylaxis
ordered
within 24 hours
Admissions with VTE pharmacologic prophylaxis
dispensed
within 24 hours
Number of VTE pharmacologic prophylaxis interventions
identified
using the measure-vention pilot tool between July 15 - August 15, 2011
Outcomes Metric:
Number of potentially preventable hospital-acquired VTEsSlide22
22
Exclusion Criteria
Patients were considered
NOT
eligible for VTE pharmacologic
prophylaxis if any of the following were present on admission
:
Existing VTE and/or on therapeutic dose of anticoagulation for any cause
Patient considered low-risk
Contraindication to pharmacologic prophylaxis was documented on admission (i.e. active bleeding, anticipated procedure, etc.)
Patient is less than 18 years of ageSlide23
23
Implementation PlanSlide24
24
Baseline VTE Order setSlide25
25
Phase I – Order set with embedded VTE module
Contraindications:
-Active bleeding
-Thrombocytopenia (platelets
<50,000
mm3
)
-Heparin-induced thrombocytopenia (HIT)
-Patient already on anticoagulants
-Recent major surgery at high risk of bleeding
-IR procedure scheduled within 24 hours
-Recent CNS bleed
-Recent GI
bleed
-Intracranial
or spinal lesion at high risk of bleed
-Underlying
coagulopathy
-Clinical trial with contraindication
-End of life care
Pharmacologic Options:
-Enoxaparin
30 mg every 12 hours
-Enoxaparin
30 mg every 24 hours
-Enoxaparin
40 mg every 24 hours
-Unfractionated
Heparin 5,000 units every 8 hours
-Dalteparin
5,000
hoursSlide26
Pre-Intervention
Non-Eligible
26Slide27
Pre-Intervention
Eligible
27Slide28
Post-Intervention
Non-Eligible
28Slide29
Post-Intervention
Eligible
29Slide30
30
Results
Medical
Eligible
Population
Patients
who received prophylaxis within 24 h
Baseline
46/101 (45.5%)
11 (23.9%)
Post-interventions
81/136 (59.5%)
75 ( 92.6%)
Surgical
Eligible
Population
Patients
who received prophylaxis within 24 h
Baseline
54/79 (68.3%)
52 (96.3%)
Post-interventions
35/50 (70%)
34 ( 97.1%)
Statistically different at the 99% confidence level
No statistically significant difference
30.9% overall increase in eligible patients receiving VTE prophylaxis within 24 h Slide31
31
Phase II - Measure-vention
Tool to identify patients not currently receiving pharmacologic prophylaxis
A total of 6 patients received measure-
vention
STATIT web-based tool updated daily and available at any computer workstation
Limitations:
Does not interface with lab data
Both eligible and ineligible patients are on the list
Requires further review by clinician
No way to report mechanical prophylaxisSlide32
Hospital-acquired VTE was defined as a new VTE diagnosed during hospitalization or within 30 days of discharge
Additional Findings
Occurrences of VTE
Number
of Patients without existing VTE on admission
Number
of Occurrences
Baseline
148
3 (2.0%)
Post-interventions
158
9 (5.7%)
32
No significant differences were found at the 90% confidence interval (p Value = 0.09)Slide33
Additional Findings
33
Patients diagnosed with VTE during present
hospitalization
Reason
documented
2
Inadequate
chemical prophylaxis
5
Held for
pending procedures
2
Missed doses-reason
not documented
*All patients in this group were medical patientsSlide34
34
Summary
30.9%
increase in overall VTE prophylaxis rates
Medical admissions
:
23.9% to 92.5%
(
68.6%
increase)
Surgical admissions
:
96.3%
to 97.1% (
0.8%
increase)
No significant difference in hospital-acquired VTE rate
Many patients not eligible due to pre-existing VTE
Medical = 23% (54/237 admissions)
Surgical = 5% (6/129 admissions)
Continuation of prophylaxis throughout hospitalization was not assessed
Most patients with a hospital
acquired
VTE had an interruption in prophylaxis for proceduresSlide35
35
Next Steps/Recommendations
Share findings with other departments to improve VTE prophylaxis throughout the institution
Reassess current policies and practices for holding pharmacologic VTE prophylaxis prior to Surgical and Interventional Radiology procedures
Research opportunities – Do existing guidelines provide adequate prophylaxis for high risk cancer populations?Slide36
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Acknowledgements
Gynecologic Oncology Faculty and Fellows
Dr. Charles
Levenback
& Elizabeth Garcia (CAD)
Pharmacy Informatics
Katie Cain,
PharmD
Diane
Schaub
, OPI
G10 Nurses
Facilitators:
Yvette
DeJesus
, Clinical Effectiveness
Ginger Langley, Pharmacy
Dr. Doris Quinn, OPISlide37
37
Thank You