Putting the right staff in place and implementing an automated process are keys to success in building a VTE prevention program, according to the experts.
Preventing venous thromboembolism, a condition that manifests itself as deep vein thrombosis and/or pulmonary embolism, has become a high-level priority for many hospitals. Aside from the fact that VTE is associated with high rates of mortality and morbidity, the Joint Commission has issued core measure requirements focusing heavily on prevention that may soon attach financial incentives to patient outcomes.
Therefore, it is critical that hospitals establish a VTE prevention program, according to Michael P. Gulseth, PharmD, program director for anticoagulation services at Sanford USD Medical Center, Sioux Falls, SD, and David Rosenberg, MD, MPH, head of hospital medicine at North Shore University Hospital, Manhasset, NY, who provide the following pieces of advice for hospitalists and other health care professionals.
Assembling a team
The first step, said Gulseth, is to assemble an interdisciplinary team that includes representatives from all key stakeholders, including the medical staff. The team should include physician and nursing personnel, pharmacy personnel, and mid-level providers as well as representatives from general, vascular cardiothoracic, and orthopedic surgery areas. It is important, he noted for both medically-oriented and surgically-oriented physicians to be represented in order to ensure that the needs of all physicians are being met.
Establishing best practices
“There are two general areas that the committees need to focus on,” said Gulseth. “One is establishing best practices.” Although there will be situations that fall outside of the recommendations, “you should have a general definition of what you think should happen for most patients with certain characteristics.”
The best way to ensure that best practices are followed is to utilized order sets to help guide physicians; organizations that utilize electronic records and computerized physician order entry can build in knowledge-based alerts to add further support.
“The other piece you have to figure out is, operationally, how are you going to do this,” said Gulseth. “Who is going to screen patients for the risk of VTE? Is it going to be a physician, nurse, or pharmacist?” This needs to be established from the start, he noted.
Automating the process
Another critical element is for hospitals to streamline the process as much as possible. Providing physicians with the information that they need (about the patient’s disease state, etc) right at their fingertips—whether in the form of an order set or a knowledge-based alert that enables them to make an evidence-based decision, “is honestly the best way to do it,” said Gulseth.
Another option is to have a nurse or pharmacist fill out a screening form and leave it for the physician; however, a paper-based system carries an added risk that the physician could miss the order set, he noted. “That’s concerning to me. I think it’s more streamlined if the physician can take ownership and do it from the very beginning. I think that ideally, those order sets should be incorporated directly in the surgical orders so that it’s just a regular part of their processes—to do that assessment and order appropriate prophylaxis.”
For organizations that haven’t adopted an EMR, Rosenberg said it is vital to create an order set that incorporates a VTE prophylaxis form into the admission process. “This allows you to risk-stratify or document the level of risk, and then from that, determine what VTE prophylaxis you’re going to order.”
Following the patient
And the same process needs to be continued throughout the patient’s hospital stay, he said, adding that as patients are transferred from one unit to another, they need to be reassessed for changes in status that could impact VTE prophylaxis. “That’s an opportunity to reassess the risk and then rewrite the prophylaxis order set based on the new assessment,” said Rosenberg, who believes that an automated system can make a big difference. “Studies have shown that when you use a paper-based set, you can probably get somewhere around 80% compliance for VTE prophylaxis. If you want to do better, usually it has to be done through a computerized order entry system that gives you reminders to make sure that this is done for every patient across the hospital.”
Covering all the bases
However, even an electronic system isn’t immune to errors, making it all the more critical that a solid plan is in place that accounts for every possible situation. “Another big issue that you have to think about from the systematic standpoint too is, what are you going to do if an order was missed? What if nothing has been ordered? What if nobody has assessed it? Who is going to be responsible for going back to the physician and making sure they know that this hasn’t been done for this patient? And then, taking it a step further, what are you going to do for general education that has to go out to all of the different medical staff groups and pharmacy and nursing groups? These are all things that need to be discussed.”
For more information on VTE prevention, check out the cover story of the next issue of MDNG: Hospitalist, which will be available soon in print and online.