A recent observational study by the IMPROVE investigators reported on factors found to be most predictive of in-hospital bleeding in medical patients.61 Active gastroduodenal ulcer, active bleeding within 3 months prior to admission, and a platelet count <50,000 were the strongest independent risk factors. Each set is scored to produce a subtotal, and the four subtotals are summed to yield the total risk factor score.ii Scoring and recommended prophylaxis are noted in an article in Chest. Overview. Patients are targeted for interventions to prevent VTE (anticoagulant or mechanical prophylaxis and efforts to improve mobility) based on the assessment of risk of a VTE event. The first reported an improved c-statistic of 0.773.58 In the validation cohort, the incidence of VTE was 0.20 percent, 1.04 percent, and 4.15 percent in the low- (score 0-1), moderate- (score 2-3), and high-risk (score ≥3) groups, respectively. IPC = intermittent pneumatic compression For example, an orthopedic surgery service focused on total hip replacement might have default orders for their preferred anticoagulant and mechanical prophylaxis in place, or colorectal surgeons with high volumes of cancer surgery might have combination prophylaxis as a default. Explicit definitions of "leeway" times for short-lived bleeding risk factors can also guide assessment of prophylaxis in audits, as well as guide therapy at the point of care. Integration into order sets, coupled with multifaceted interventions, resulted in marked improvements in protocol-defined adequate prophylaxis (from 58 percent to 98 percent) and reduced HA-VTE by 40 percent in medical and surgical populations without any increase in detectable bleeding or heparin-induced thrombocytopenia.19,20. Table 4.2 depicts one example; several others are available in Appendix B. iiThe scoring system can be found in Bahl V, Hu MH, Henke PK, et al. On the other hand, most other medical conditions require reduced mobility and an acute illness to qualify for prophylaxis. The IMPROVE investigators leveraged a VTE registry to derive two kinds of VTE RAMs (Appendix B14) in medical patients.57 One model identified four factors available at admission that were most predictive of VTE during and up to 3 months after hospitalization. Many include critically ill ICU patients in high-risk groups (this is reasonable but not directly supported by clinical trials). Continue To Improve, Hold the Gains, and Spread the Results, Appendix B: Risk Assessment Models, Protocols, and Order Sets, U.S. Department of Health & Human Services. See what certifications are available for your health care setting. Provide actionable recommendations for permutations of VTE and bleeding risk. In spite of these impressive credentials, there are several caveats to those considering the use of individualized point-based models such as the Caprini model. Rockville, MD 20857 __ LMWH (Enoxaparin) 30 mg SubQ q 12 hours. The Rogers risk assessment model was derived from more than 183,000 surgical patients.54 This complex model with 15 weighted risk factors has never been used in clinical practice and is mentioned only because the AT9 guideline recommendations for nonorthopedic surgery patients mention the Rogers model within its recommendations, along with the Caprini model.55. Qualitative models ascribe groups of patients to broad risk categories or "buckets" of risk that are linked to appropriate prophylaxis options for each group, without going through individualized point scoring. Health care professionals whose focus is on patient safety are very familiar with these alarming and frequently cited statistics from the Institute of Medicine: medical errors result in the death of between 44,000 and 98,000 patients every year. Note the approach to ambulation taken in these models. According to a study by RAND Health, the U.S. healthcare system could save more than $81 billion annually, reduce adverse healthcare events, and improve the quality of care if health information technology (HIT) is widely adopted. The Hierarchy of Reliability (Table 1.1) and published experience suggests this approach produces only very modest improvement insufficient to make a meaningful reduction in hospital-associated VTE (HA-VTE) rates.5,6 Widespread, well documented under-prophylaxis7-10 is largely the result of relying on physician judgment, imperfect human memory, and relatively passive interventions such as educational sessions and pocket cards.11 Basic tenets of quality improvement also caution against this approach as it offers no opportunity for measurement, standardization, or even definition of best practice, and this approach would generally not meet meaningful use criteria or help institutions meet The Joint Commission's standards for VTE prevention.1, A second approach is the "opt out" approach (Appendix B.2). (2) The agreement required by division (D)(1) of this section shall include all of the following provisions: No prophylaxis; reassess periodically, ambulate. A validation of a retrospective venous thromboembolism risk scoring method. An official website of the Department of Health and Human Services, Latest available findings on quality of and access to health care. This model has not been externally validated, and the scoring model is cumbersome to integrate into clinical practice. Obtain useful information in regards to patient safety, suicide prevention, pain management, infection control and many more. Internet Citation: Chapter 4. Layering Interventions and Moving Toward Excellence, Chapter 8. Select for Model (PDF File, 298.23 KB). These models tend to be relatively easy to use and have demonstrated success in the literature and unpublished experience in reducing HA-VTE. LMWH = low-molecular-weight heparin There is a tenfold variation in the incidence of HA-VTE. This effort enjoyed the support and "authority gradient" from faculty attending physicians, who cosigned the VTE risk assessments.46, In the unpublished experience at the University of Michigan, success with the Caprini RAM hinged on skillful deployment of a number of CPOE techniques outlined in more detail in Chapter 5. Identify Incomplete and Ineligible Surveys. We develop and implement measures for accountability and quality improvement. This model was updated (Figure 4.3) to be more discriminating in terms of a higher threshold for who receives thromboprophylaxis, in a manner more consistent with AT9 guidance to avoid prophylaxis in those at low risk. These quantitative, or point-based, scoring systems may be devised by expert opinion and review of the literature; they can also be derived empirically. Reliably exclude patients who would be unlikely to develop DVT, minimizing inappropriate over-prophylaxis in those of lower risk. Ideally, empirically derived models are scientifically sound and preferable to expert models, but the expert-derived models (Caprini and Padua, for example) are in more common use, and at least some of them have anecdotal evidence of effectiveness in clinical practice. In the absence of consensus on the best risk assessment model, one approach is to avoid this issue altogether and simply present a prompt to consider prophylaxis. Bleeding risk may be increased by surgery, medications, or factors inherent to the patient. The relative complexity of the model has been overcome with closely supervised environments that enjoy an authority gradient, intelligent use of sophisticated CDS, or a safety net of nonphysician providers who redundantly check accuracy of scoring. While this approach is appealing for the simplicity and effectiveness in inducing high rates of anticoagulant prophylaxis, it can easily result in over-prophylaxis, which is a particular concern in medical populations.12. Learn more about us and the types of organizations and programs we accredit and certify. Large-scale VTE prevention collaborative efforts from SHM, AHRQ/QI organization partnerships, and many others have reported similar positive results, but these efforts did not have a standardized method to monitor outcomes.22,23. Set expectations for your organization's performance that are reasonable, achievable and survey-able. Status posttransplant or multiple major trauma to clear bleeding risk: 48 hours. For all of these grouping variants, the following points should be kept in mind for implementation: Many other variants of grouping VTE risk assessment models are in use across the globe,24-35 including models from Australia and New Zealand,24-26 Italy,27 United States (Johns Hopkins),28-30 and Great Britain (the NHS 2010 National Institute for Health and Clinical Excellence, or NICE, guideline).31-35 Many of these models have shown clinical utility. Our streamlined application process means accreditation evaluation is typically completed within 60 days of image submission. Risk factors that are potent predictors in one model are seemingly inconsequential in the next. Most hospitals avoid complicated scoring systems for bleeding risk and instead provide lists of bleeding risk factors to consider. The Caprini model is embedded in AT9 recommendations for VTE prophylaxis in the nonorthopedic surgical population.42 It is not mentioned in the AT9 guideline for VTE prophylaxis in medical inpatients, but it is a commonly used point-based model for medical inpatients. The Padua RAM has never been tested or shown to be effective as a VTE RAM in order sets. In an external validation study performed in surgical patients, only 0.9 percent of patients were defined as low risk not requiring prophylaxis; 10.4 percent were classified as moderate risk, in whom anticoagulation was optional.40, A closer look at sites that have documented success also raises some important caveats. The “Patient Safety Systems” chapter describes a proactive approach to designing or redesigning a patient-centered system that aims to improve quality of care and patient safety. A venous thromboembolism (VTE) prevention protocol is a standardized VTE risk assessment, linked to a menu of appropriate VTE prophylaxis options for each level of risk, which provides guidance for management of patients with contraindications to pharmacologic prophylaxis. Status post spinal cord open surgery: 5 days leeway. However, the AT9 panel considered bleeding risk to be excessive if patients had any one of the top three risk factors or multiple other risk factors.14 Note that several of these risk factors are also frequently listed as risk factors for VTE. Modified versions of this second model are being deployed in clinical trials to identify potential high-risk medical patients for extended duration prophylaxis.
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