Layering Interventions
Beyond the VTE Protocol: Layering Complimentary Interventions
Consider the following hierarchy of reliability when implementing your VTE prevention initiative. To the best of our knowledge no one has achieved Level 5 yet. But, by using this resource room, and a little ingenuity, any serious institutional effort should be able to achieve the impressive performance gains of Level 4.
Level 1: State of Nature
In the “unimproved” modern hospital patients receive care that depends solely on the knowledge, skills, and memory of their physicians. There is no standardized assessment for VTE risk and there are no reminders within the real-time flow of care delivery to prompt physicians to order VTE prophylaxis. In this ‘state of nature,’ expect approximately 40% of your patients to be on appropriate VTE prophylaxis at any given moment.
Level 2: Average
Many hospitals that have tried to improve VTE prophylaxis find themselves at Level 2, with only partially effective forays into the following two elements of a VTE protocol:
- A standardized VTE risk assessment to guide choice of VTE prophylaxis, but it is not well integrated into admission and transfer order sets (i.e. it may exist as a stand-alone form or pocket card, etc), or
- A prompt to order VTE prophylaxis is nested within admission and transfer order sets, but no VTE risk assessment to guide choice of VTE prophylaxis
Level 3: VTE Protocol
Level 3 is the entry point for most serious QI efforts – a complete VTE protocol. All 3 elements of a complete VTE protocol are combined within a paper order set or CPOE. The more effective VTE protocols also have a visual aide that links the VTE risk level to the option(s) for appropriate prophylaxis; this visual link enables providers to make a rapid decision about an appropriate prophylaxis choice.
In other words, in a Level 3 VTE prevention program not only are providers prompted to order VTE prophylaxis when completing admission or transfer orders, they also have a standardized VTE risk assessment immediately available to support medical decision-making. Level 3 makes it possible for providers to have what they need, when and where they need it (i.e. at the point of care) to make an appropriate prophylaxis choice.
Expect 60-70% of your patients to be on appropriate VTE prophylaxis with the Level 3 VTE protocol.
Remember that providers should always retain the freedom to deviate from the protocol when meeting the needs of a given patient. The protocol, with successive refinements, eventually should drive management choices in the great majority of patients.
Level 4: Layers of QI Strategies that Leverage the VTE Protocol
All of the conditions of Level 3 exist, but the use of the VTE protocol at admission and transfer is enhanced by additional QI strategies. At Level 4, you are using high reliability mechanisms to make it a rare event for a patient to enter the hospital without going through your VTE protocol.
Also at Level 4, any variations from the protocol or adverse effects while on the protocol are studied in depth. The protocol and its integration are continually refined and its use continually increased based on these events, using the collective intelligence, experience, and investigation of the institution.
Use the table “Armamentarium of QI Strategies” as a trigger for additional Level 4 ideas. Most of these other strategies leverage the fact that you now have a VTE protocol in the workflow. Providers, nurses, pharmacists, even patients can refer back to the VTE protocol for clarity, confidence, or advocacy. Remember, any additional, layered interventions should include at least one high reliability mechanism in the design. Expect 80-90% of your patients to be on appropriate VTE prophylaxis with Level 4, an extremely impressive level of performance that places you among elite performers.
Level 5: Oversights “Identified-and-Mitigated”§
Level 5 represents a profound leap in quality. Here you will improve care by a whole order of magnitude, a rare achievement in health care. All of the conditions of Level 4 exist, plus there is now a strategy to identify and address the prophylaxis oversights that inevitably occur. Back at Level 4, at least one in 10 patients still fail to receive appropriate prophylaxis. Will your team be satisfied with that considerable gain? It depends on whether you are merely pursuing excellence (relative to ‘industry standards’), or actually pursuing perfection. Instances will always occur where VTE prophylaxis is not ordered on admission or transfer, or not replaced with alternatives when contraindications arise, or not resumed when suspected contraindications fail to materialize, or not administered properly when ordered (i.e. mechanical prophylaxis). Strategies that “identify-and-mitigate” these oversights are critical for achieving prophylaxis prevalence over 90%. Level 5 may be impractical or unsustainable without an electronic reporting mechanism.
A mature Level 5 will also judge the efficacy of mitigation itself and its own failures will be immediately remedied. Failure modes of mitigation are systematically catalogued, analyzed, and then eliminated. If your team achieves this level of reliability you will be pioneers. If your solutions can be adopted readily by other institutions, you may have done something transformative for
hospital care.
Armamentarium of QI Strategies
QI Strategy Categories Specific Ideas for VTE Prevention
Provider education |
• Didactic sessions on VTE prevention (e.g. noon conference, grand rounds, etc)
• Distributed educational materials (e.g. pocket cards with VTE risk factors, etc) |
Provider reminder systems |
• Prompts nested within paper admission/transfer/post-op order sets supported by VTE risk assessment as decision support (VTE protocol)
• Prompts using CPOE with risk assessment as decision support (VTE protocol)
• Stickers on charts or posters in order-writing areas |
Facilitated relay of clinical data to providers |
• Alerts to physicians by means other than medical record, e.g., page, electronic alert, phone call, email to provider regarding VTE prophylaxis oversights. |
Audit and feedback of performance to providers |
• Feedback of VTE prophylaxis performance to individual providers or groups of providers (with or without benchmarking to top performers) |
Patient education |
• Discrete disclosure to patients of increased risk for VTE (e.g. pamphlets, physician or nurse teaching of patient or caregiver, closed circuit TV program in patient rooms, etc.) |
Organizational or operational change |
• Administrative support personnel dedicated to ensure constant stocking of VTE protocol order set in needed areas
• Clinical support personnel dedicated to ensure and document that mechanical prophylaxis is worn by patients
• Hospital-wide (or unit-specific) teams or individuals with regular responsibility to ensure each patient is receiving appropriate VTE prophylaxis (e.g. physician, nurse, pharmacist, etc), a.k.a. “VTE Hit Squad” |
Incentives, regulation, and policy |
Provider-Directed:
• Honor recognition of highest performers each month or quarter
• Financial incentives based on achievement of VTE prophylaxis performance goals
• Punitive actions for failures to meet minimum performance (suspension of privileges, stockade in town square, etc.)
Health System-Directed:
• Enforced policy mandating use of VTE protocol (e.g. “hard stops” in processing of admission/transfer/post-op orders that fail to prescribe VTE prophylaxis) |
Stein J. The Language of Quality Improvement: Therapy Classes. J Hosp Med. 2006 Nov;1(6):327-30.
§ Nolan T, Resar R, Haraaden C, Griffin F. White Paper: Improving the Reliability of Health Care. Institute for Healthcare Improvement. Innovation Series 2004. http://www.ihi.org/IHI/Results/WhitePapers/ImprovingtheReliabilityofHealthCare.htm
Accessed December 1, 2006.
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