DESPITE THE FACT that venous thromboembolism (VTE) is the most preventable cause of death in hospitalized patients, and that evidence-based guidelines for mechanical and pharmacological prophylaxis are widely available, VTE is still a significant cause of morbidity and mortality among patients at risk. Studies have shown that the incidence of VTE is about one in 1,000, with more than 250,000 patients hospitalized annually with the condition.1
Recognizing the great need for VTE interventions, ASHP Advantage recently developed the Institutional Impact VTE Mentored Quality Initiative.2 Through the program, physician-pharmacist faculty teams provide on-site evaluations of health systems’ VTE preventions practices and offer site-specific recommendations to help each system meet its quality-improvement goals.
Mentorship and Support
True to the initiative’s name, faculty members go beyond a consulting role and instead mentor each facility’s staff members, said Stuart T. Haines, Pharm.D., BCPS, BC-ADM, professor and pharmacotherapy specialist, University of Maryland School of Pharmacy, Baltimore, and clinical specialist, West Palm Beach VA Medical Center, West Palm Beach, Fla. “VTE prophylaxis is one of the bread-and-butter things pharmacists do, but this particular project is far more intensive for the selected sites,” he said. “We have regular contact with them, and although we analyze what they are doing and offer suggestions for how it can be better, we also support them as colleagues and help them communicate their efforts to peers.”
Indeed, faculty members for the initiative were chosen because of their collegial efforts and reputations, according to Kristi N. Hofer, Pharm.D., ASHP Advantage’s director of scientific projects. “In choosing mentors, we focused on their expertise,” she said. “These faculty have either been involved in VTE prophylaxis at their own hospitals, have experience with similar programs, or are known for sharing their knowledge.”
Each participating hospital has different needs, and the recommendations they receive vary as much as the hospitals themselves. At the suggestion of initiative faculty, the focus at Baylor Medical Center in Waxahachie, Tex., is shifting from a “two-bucket” system, in which a patient is considered either low or high risk, to a “three-bucket” system that includes moderate risk, said Donna Drain, Pharm.D., clinical pharmacist.
Initiative faculty also prompted Waxahachie’s staff to revisit its risk- assessment procedures.
“The mentors were intuitive about that,” said Drain. “For years, we concentrated risk assessment within a few hours of admission, but the mentors asked us how we reassess when a patient changes level of care, like from surgery to ICU. It was an ‘aha’ moment.”
A third suggestion was to home in on the quality of VTE prophylaxis, as opposed to the quantity.
“That hit home with me,” Drain said. “As clinical pharmacists, we can get caught up on numbers. We’ll say that we are providing prophylaxis 72, 80, or 90 percent of the time, but we aren’t stepping back and saying, ‘Are we caring for Mr. Green? Are we there for Mrs. Jones?’”
At West Virginia University Hospitals, mentor recommendations swung in the other direction.
“We’d been sharing our VTE efforts with nursing units, but trying to attribute outcomes back to different units was difficult,” said Frank Briggs, Pharm.D., CACP, director, Center for Quality Outcomes. “Now, rather than look at which unit did what, we look instead at the percentage of patients who receive pharmacological prophylaxis.”
The focus changed as a result of mentor review, Briggs added. “We saw that we were overrelying on mechanical prophylaxis,” he said. “[The mentors] really drilled down into that and got us to look at ways of improving pharmacologic prophylaxis. We found that if you want to drive pharmacologic prophylaxis, then you have to report its use.”
Identifying Communication Gaps
The team at Sharp Grossmont Hospital in La Mesa, Calif., is incorporating suggestions from initiative faculty members Gregory A. Maynard, M.D., M.S., FHM, chief, Division of Hospital Medicine, University of California, San Diego, and Zachary A. Stacy, Pharm.D., BCPS, associate professor of pharmacy practice, St. Louis College of Pharmacy, into efforts to revamp its ordering system.
“After meeting with Dr. Maynard and Dr. Stacy, we found that we may have undermined our efforts at VTE prevention by utilizing a complicated point-based system,” said Electa Stern, Pharm.D., pharmacy clinical supervisor. “We also failed to associate the list of risk factors with the preferred pharmacological options.”
Maynard also shared a real-time measurement tool that utilizes a color-coded dashboard: Patients who have no VTE prophylaxis are in the red zone, those with only mechanical prophylaxis are in the yellow zone, and those who have pharmacological prophylaxis are in the green zone.Stern said that the first priority is to minimize the number of patients in the red zone. A standardized nursing procedure will allow nurses to start mechanical prophylaxis in at-risk patients found to be without any prophylaxis. The new tool consolidates risk into two pools, low versus moderate/high, as well as defines risk factors to help prescribers choose appropriate therapy.
Stern notes the practicality of the advice her team has received. “These are simple ideas” she said, “but that’s why they are so exciting: They should be easy
1. Goldhaber SZ. Pulmonary embolism.N Engl J Med. 1998;339:93–104.
2. An educational grant from Ortho-McNeil, Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc., administered by Ortho-McNeil Janssen Scientific Affairs, LLC., allows hospitals to participate in the program for free.