nullThe Surgical Care Improvement Project: VTE MeasuresThe Surgical Care Improvement Project: VTE MeasuresMasspro
June 21, 2007This material was prepared by Masspro, the Medicare Quality Improvement Organization for Massachusetts, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily represent CMS policy. 8sow-ma-hosp-07-76 SCIP-VTEMeasures-juneObjectivesObjectivesReview the science / medicine
Share improvement strategies and tools
Discuss the performance measures and key data elements
Review frequently asked questions
Respond to new and unanswered questionsVTE ReferencesVTE ReferencesAnderson Frederick, PhD
University of Massachusetts
Bratzler Dale, DO, MPH
HI QIOSC Medical Director
Dalton Vanessa MD
American College of Obstetricians and Gynecologists
DePalma Ralph, MD
National Director of Surgery, Acute Care Strategic Healthcare Group, Dept of Veterans Affairs
Flum David, MD
University of Washington
Geerts William, MD
Canada: chairs the ACCP Consensus committee on VTE prevention Heit John, MD
Mayo Clinic, Rochester
Hyman Neil, MD
American Society of Colon and Rectal Surgeons
Kresowik Timothy, MD
Society for Vascular Surgery
Lieberman Jay R, MD
American Academy of Orthopedic Surgeons
Padberg Frank, MD
Chief, Vascular Surgery, Dept of Veterans Affairs
Raskob Gary, PhD
University of Oklahoma, Dean of College for Public Health
Sidawy Anton, MD
Chief, Vascular Surgery, Dept of Veterans Affairs VTE ReferencesVTE ReferencesPrevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.
Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, Ray JG.
Chest. 2004 Sep;126(3 Suppl):338S-400S.
From the Seventh American College of Chest Physicians Conference, this article provides guidelines for the prevention of venous thromboembolism in hospitalized patients and represents an update of the guideline published in 2001.
VTE 101VTE 101A venous thromboembolism (VTE) is a formation, development, or existence of a blood clot or thrombus within the venous system.
Virchow’s Triad:
Vascular wall abnormality
Venous stasis
Activation of coagulation
Symptoms include:
None
Calf / Thigh pain
Leg swelling
Dyspnea, chest pain, hemoptysisRisk Factors for VTERisk Factors for VTESurgery
Trauma (major or lower extremity)
Immobility, paresis
Malignancy
Cancer therapy
Previous DVT
Increasing age
Pregnancy and the postpartum period
Estrogen-containing oral contraceptives or hormone replacement therapySelective estrogen receptor modulators
Acute medical illness
Heart or respiratory failure
Inflammatory bowel disease
Nephrotic syndrome
Myeloproliferative disorders
Parxysmal nocturnal hemoglobinuria
Obesity
Smoking
Varicose veins
Central venous catheterization
Inherited or acquired thrombophiliaVTE and the Hospitalized PatientVTE and the Hospitalized PatientVenous thromboembolism (VTE) includes deep vein thrombosis (DVT) and pulmonary embolism (PE)
VTE is one of the most common complications of the hospitalized patient
Thromboemboloic complications
Excess length of stay
Excess mortality
Excess hospital charges
PE is the most common preventable cause of hospital deathAbsolute Risk of DVTAbsolute Risk of DVTPatient Group
Medical patients
General surgery
Major gynecologic surgery
Major urologic surgery
Neurosurgery
Stroke
Hip or knee arthroplasty, hip fracture surgery
Major trauma
Spinal cord injury
Critical care patientsDVT Prevalence, %
10 – 20
15 – 40
15 – 40
15 – 40
15 – 40
20 – 50
40 – 60
40 – 80
60 – 80
10 – 80
Clinical Evidence for VTE ProphylaxisClinical Evidence for VTE ProphylaxisHundreds of randomized trials
Over 20 published evidence-based guidelines showing clear evidence of benefits and safety
Reductions in:
Incidence of DVT
Incidence of PE
All-cause mortality
CostsVTE Prophylaxis: Grade 1 RecommendationsVTE Prophylaxis: Grade 1 RecommendationsVTE Prophylaxis: Grade 1 RecommendationsVTE Prophylaxis: Grade 1 RecommendationsVTE Prophylaxis: Grade 1 RecommendationsVTE Prophylaxis: Grade 1 RecommendationsVTE Prophylaxis: Grade 1 RecommendationsVTE Prophylaxis: Grade 1 RecommendationsRational for ThromboprophylaxisRational for ThromboprophylaxisHigh prevalence of VTE
Adverse consequences of unprevented VTE
Efficacy and Effectiveness of thromboprophylaxis
Without prophylaxis, deep vein thrombosis occurs in 25% and pulmonary embolism occurs in 7% of all major surgical procedures. Despite the well-established efficacy and safety of preventive measures, studies show that prophylaxis is often underused or inappropriately used.
Improvement Strategies and ToolsImprovement Strategies and ToolsIncorporate into routine patient care
Develop a written policy on VTE prophylaxis
Recognize the role of nursing staff
Pre-printed orders – sensible prophylaxis
Computer reminders with CPOE (Computerized Physician Order Entry)
Audit and feedback
VTE MeasuresVTE MeasuresVTE 1 - Surgery patients with recommended venous thromboembolism prophylaxis ordered
VTE 2 - Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery
VTE 3 - Intra- or postoperative pulmonary embolism (PE) diagnosed during index hospitalization and within 30 days of surgery
VTE 4 - Intra- or postoperative deep vein thrombosis (DVT) diagnosed during index hospitalization and within 30 days of surgery.Version 2.2b ExclusionsVersion 2.2b ExclusionsPatients who are less than 18 years of age
Procedures performed entirely by laparoscope
Procedures where total surgery time is < 30 minutes
Length of stay < 24 hours postop
Burn patients
Patients on Warfarin prior to admission
Patients with contraindication to both mechanical and pharmacological prophylaxis
Principal procedure occurred prior to the date of admissionKey Data Elements: VTE ProphylaxisKey Data Elements: VTE ProphylaxisDocumentation of venous thromboembolism (VTE) prophylaxis ordered anytime during this admission.
1 Low dose unfractionated heparin (LDUH)
2 Low molecular weight heparin (LMWH)
3 Intermittent pneumatic compression devices (IPC)
4 Graduated compression stockings (GCS)
5 Factor Xa Inhibitor
6 Warfarin
A None of the above / not documented / UTDKey Data Elements: VTE ProphylaxisKey Data Elements: VTE ProphylaxisIPCs include:
AE pumps
DVT boots
EPC cuffs / stockings
Flotron / Flotron DVT system
Impulse pump
Plexipluse
Sequential compression device
Sequential TEDS
Venodyne boots
GCS include:
Anti-embolism stockings
Anti-thrombosis stockings
Elastic support hose
Graduated compression elastic stockings
Jobst stockings
Surgical hose
Ted hose (TEDS)
Thrombo-guard
White hose
Thrombosis stockingsKey Data Elements: VTE TimelyKey Data Elements: VTE TimelyDocumentation of venous thromboembolism (VTE) prophylaxis received within 24 hours prior to Surgical Incision Time to 24 hours after Surgery End Time.
If VTE prophylaxis was ordered and administered within the defined time frame, select “Yes”
If VTE prophylaxis was ordered and not administered, select “No”
If VTE prophylaxis was ordered and not administered within the defined time frame, select “No”Key Data Elements: ContraindicationKey Data Elements: ContraindicationDocumentation by a physician / advanced nurse practitioner / physician assistant of contraindications to both pharmacological and mechanical venous thromboembolism (VTE) prophylaxis.
In order to select “Yes”, patients must have documentation of contraindications to both mechanical and pharmacological prophylaxis
Documented Bleeding Risk is not a contraindication to all types of VTE prophylaxisKey Data Elements: Bleeding RiskKey Data Elements: Bleeding RiskDocumentation by a physician / advanced nurse practitioner / physician assistant of a risk for bleeding that contraindicates an order for pharmacological VTE prophylaxis.
If the physician / APN / PA documents that the patient is at risk for bleeding or that pharmacological prophylaxis is not being ordered “due to bleeding”, select “Yes”
If there is documentation of a bleeding risk, the patient may still be eligible for mechanical prophylaxisNewport Hospital Initiative 2004Newport Hospital Initiative 2004Absolute Contraindication
Active hemorrhage
Epidural/indwelling spinal catheter – placement or removal
Heparin or warfarin use in patients with heparin-induced thrombocytopenia (HIT)
Severe trauma to head, spinal cord, or extremities with hemorrhage within the last 4 weeks
Warfarin use in the first trimester of pregnancy Relative contraindication
Active intracranial lesions / neoplasms / monitoring devices
Coagulopathy (PT > 18 sec)
Craniotomy within 2 weeks
GI / GU hemorrhage within the last 6 months
Hx of cerebral hemorrhage
Proliferative retinopathy
Thrombocytopenia
Uncontrolled HTN (SPB>200, DBP>120, or both)
Vascular access / biopsy site inaccessible to hemostatic controlKey Data Elements: Neuraxial AnesthesiaKey Data Elements: Neuraxial AnesthesiaDocumentation that the patient received neuraxial anesthesia for the surgical procedure.
Neuraxial anesthesia is medication administered into the epidural space (“epidural”) or spinal canal (“spinal”) to block sensations of pain
An epidural catheter whether for anesthesia or pain management is consistent with neuraxial anesthesia and this data element should be answered “Yes”Key Data Elements: Preadmission WarfarinKey Data Elements: Preadmission WarfarinDocumentation that the patient was on Warfarin prior to admission.
If there is documentation that warfarin was a “home” or “current” medication, select “Yes”
If warfarin was listed as a “home” or “current” medication, but placed on hold prior to surgery, select “Yes”
If there is no documentation that the patient was on warfarin prior to admission, select “No”
Key Data Elements: LaparoscopeKey Data Elements: LaparoscopeDocumentation that the surgical procedure was performed entirely with a laparoscope.
If there is documentation the surgical procedure was performed entirely by laparoscope, select “Yes”
If there is documentation the surgical procedure was not performed entirely by laparoscope, select “No”
If unable to determine, select “UTD”
If the only incision that is made is to introduce the laparoscope or thorascope, the operation is laparoscopic onlySCIP: VTE MeasuresSCIP: VTE MeasuresFrequently Asked QuestionsSCIP: VTE MeasuresSCIP: VTE MeasuresNew and Unanswered Questions