Focus on VTE and truths about prophylaxis
Thought shift needed on prophylaxis
Venous thromboembolism (VTE) has hit center stage as a major and preventable cause of death in hospitals and now a core measure for The Joint Commission. As a member of a rehab department with a high-risk population, David Patterson, MD, medical director at Casa Colina Hospital in Pomona, CA, wants to shift the pervasive attitude he sees surrounding VTE.
"Despite the core measures that are coming, there's still a general attitude of physicians [of thinking] let me find a reason a patient shouldn't be put on appropriate prophylaxis. That is basically where I'm changing behavior," he says.
Studies that retrospectively look at charts to determine patients that should have been put on prophylaxis but weren't are remarkable, Patterson says. Often physicians forget, and this is why he promotes using a team approach to preventing VTEs. "If you have to approach these issues like anticoagulation, veno-thromboembolism prevention, then you can't rely on physicians alone. You have to put processes in place that make the physicians a team leader that is part of a team."
Todd Wittenbrock, senior district manager of Eisai Inc., says, "You can go into one hospital and they basically have no management for DVT [deep venous thrombosis] prophylaxis. Then you go into another hospital and they have a complete algorithmic layout of what to do, with all the departments involved. You have guidelines out there like SCIP [surgical care improvement project] and things like that, but there is no real hospital management system working with different departments... And I think that's what The Joint Commission is trying to do. You have to have something on paper that manages this issue."
Patterson says resources on VTE prevention are plentiful — the Mayo Clinic's web site, guidelines from the American College of Clinical Pharmacy, CHEST guidelines, and the Paralyzed Veteran of America's consortium on VTE management including prophylaxis and treatment.
The first area of the core measure set developed by The Joint Commission is "basically your overall VTE/thrombo prophylaxis protocols in your hospital," Patterson says. "They'll want to see there's evidence in the medical record that you are addressing the issue."
It comes down to risk stratification, he adds. "It's going to be more of an exclusion for not giving chemical prophylaxis rather than the opposite way of trying to find the reason why I'm not going to give it. You need to find the reason why you're not giving chemical prophylaxis," he says.
The No. 2 core measure, he says, looks at ICU patients. "That is where the ACCP guidelines, those two additions, that's where they really hit the nail on the head... That's a specific population where generally morbidity and mortality is high but DVT prophylaxis is forgotten about maybe because of the risk of bleeding." He suggests examining the ACCP guidelines on risk stratifying those patients.
Another area The Joint Commission will be looking at is your prophylaxis protocol, Patterson says. "When do you reexamine that patient you didn't put on prophylaxis? I think that's where a lot of hospitals will fall short. They'll forget that part. Reassessment is going to be a key component of the surveyors coming to look at your protocols."
He also points to examining your overlap policy with anticoagulation therapy. You should already have in place a bridging protocol with the anticoagulation core measures that went into effect at the beginning of the year, he says.
He says one challenging area that needs more clarification is the standard concerning how discharge instructions are written out to address issues such as follow-up monitoring, compliance, dietary restrictions, and adverse drug reactions and interactions. On discharge, too, he says you must think about when the next blood draw is. That's a high-risk discharge. "So [TJC] is definitely going to look at that. Now part of the core measures in '09 for anticoagulation addressed that. Were dietary restrictions given to the patient during the hospitalization, at discharge? But the core measures didn't really hit hard about this follow-up issue. So that will be a change for hospitals."
Venous thromboembolism (VTE) has hit center stage as a major and preventable cause of death in hospitals and now a core measure for The Joint Commission.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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