Hospital-Acquired VTE: What We Have Learned

Martha J. Radford, MDChief Quality Officer

NYU Langone Medical CenterSeptember 2009

VTE Prevention in the USA

2005 2006 2007 2008 2009 2010

SCIP Measures

SCIP on Intranet POA HAC

Chest Guidelines

Ortho GuidelinesAHRQ PSIs

VTE Prevention in the USA

2005 2006 2007 2008 2009 2010

SCIP Measures

SCIP on Intranet POA HAC

Chest Guidelines

Ortho GuidelinesAHRQ PSIs

AHRQ Validation

VTE Prevention at NYULMC

2005 2006 2007 2008 2009 2010

SCIP Measures

SCIP on Intranet POA HAC

Chest Guidelines

Ortho GuidelinesAHRQ PSIs

InternalSCIP

SCIP VTE in P4P

2010 Goal: NoPreventable VTE

VTE Prophyin CPOE

Dept VTE Standards

HAC Review

We Learned from AHRQ Validation: Our Coding Needs Improvement

• Of the 17 2006 VTE PSI cases we reviewed for the AHRQ validation study, our coding was incorrect for 5 (29%).

• This began a focus on VTE coding quality that continues today.

• The appearance of VTE following ortho procedures as a HAC has solidified the need for accurate VTE coding.

NYULMC VTE Coding Accuracy

Coding Errors at NYULMC

• One fourth to one third: no evidence for VTE

• Two thirds to three fourths: VTE was present on admission– If date of study demonstrating VTE was after the

date of admission, VTE not coded as “present on admission”.

Coding Interventions at NYULMC

• Outreach to coders about impact of their coding on quality and safety assessment.

• Ongoing feedback to coders about coding errors

• Organizational focus on clinical documentation, clinical documentation specialists interact frequently with coders.

Actual Hospital-Acquired VTE

VTE Prevention at NYULMC

2005 2006 2007 2008 2009 2010

SCIP Measures

SCIP on Intranet POA HAC

Chest Guidelines

Ortho GuidelinesAHRQ PSIs

InternalSCIP

SCIP VTE in P4P

2010 Goal: NoPreventable VTE

VTE Prophyin CPOE

Dept VTE Standards

HAC Review

Department Standards for VTE Prophylaxis

• 2006: Medicine department• 2007: Surgery departments (8)• 2008: Departments’ CPOE order sets• 2009: Required order module (medicine)• 2010: Organization-wide goal to eliminate

preventable VTE: ACCOUNTABILITY

Department Standards

• Risk assessment

• Documentation of contraindications to VTE prophylaxis

• VTE prophylaxis ordering options

At first Purely Optional

Medicine Admission Order Set

Medicine Admission Order Set: VTE Compulsory

You cannot enter entire order set unless either a VTE order is entered or you have documented why VTE prophylaxis is not indicated

Medicine Admission Order Set: VTE Compulsory

Surgical Department Standards and Order Sets

Challenges include:• Bleeding risk of great concern• Start VTE prophylaxis on admission, or postop?• What happens with epidural anesthesia?• Conflicting guidelines: orthopedics

ALL surgical services place intermittent compression devices before or in the OR, but this may not be sufficient for some patients at particularly high risk.

Increasing Accountability

• Every quarter we send to all department chairs a “quality safety score card” that displays the department’s performance on a variety of quality performance measures:– Administrative measures: admissions, hospital

mortality, length of stay, 30-day readmissions.– Nationally-reported quality performance

measures.– AHRQ patient safety indicators.– Internal quality and safety measures.

Department Quality-Safety Score CardAHRQ Patient Safety Indicators (green = at or below UHC median;

red = above UHC median) rate per 1000 Department NYULMC

Complications of anesthesia - PSI01 0.0 0.3Death in low mortality DRG - PSI02 0.0 0.0

Decubitus ulcer - PSI03 5.9 5.1Death among inpatients with serious treatable complications - PSI04 16.7 89.7

Iatrogenic pneumothorax - PSI06 0.0 0.5Infections due to medical care - PSI07 2.4 1.7

Post-operative hip fracture - PSI08 0.0 0.0Post-operative hemorrhage or hematoma - PSI09 0.0 2.0

Post-operative physiologic/metabolic - PSI10 0.0 0.2Post-operative respiratory failure - PSI11 6.4 10.5

Post-operative PE or DVT - PSI12 17.9 9.9Post-operative sepsis - PSI13 6.2 8.6

Post-operative wound dehiscence - PSI14 0.0 0.0Accidental puncture/ laceration - PSI15 1.7 3.0

Birth trauma - PSI17 3.7OB trauma - vaginal with instrument - PSI18 157.5OB trauma - vaginal w/o instrument - PSI19 25.7

OB trauma - cesarean section - PSI20 1.4

Department Score Card: Numerator Cases

• Also included: – Patient identifiers– Attending physician

Analytic Report from EMR

Internal Quality Report Posted on Intranet

What Have We Learned?

• Accurate coding needs attention from clinicians.

• Computerized order entry with decision support can be harnessed to improve VTE prophylaxis.

• Decreasing the rate of hospital-acquired VTE—real and apparent—is possible.

What Do Hospitals Need from Measures?

Actionable performance data:• Timely, reliable measures• With “drill down” to the “unit of actionability”

– For VTE prophylaxis at NYULMC, this is the department

What Has AHRQ Learned?

• What is the variability in hospital coding practice?

• Are the AHRQ PSIs sufficiently reliable as safety measures to permit fair hospital comparison?