PROJECT PROFILE



HANYS’

2010 Pinnacle Award for Quality and Patient Safety

Submission Template and Guidelines

Section I:

A. Contact information required for publication and feedback. Please type in white space only.

|Required Information |Complete below: |

|Full Name |Maryann Demeo |

| | |

| |RN, BSN, MPA |

| | |

| |Assistant Vice President Quality and Resource Management |

| | |

| |South Nassau Communities Hospital |

| | |

| |One Healthy Way |

| |Oceanside, NY 11572 |

| | |

| | |

| |516-632-3890 |

| | |

| | |

| |mdemeo@ |

|Credentials | |

|Title | |

|Organization Name | |

|Organization Address | |

| | |

| | |

|Telephone | |

|E-mail | |

B. Check applicable submission category:

[ ] System or multi-level entity

[ x ] Large Hospital (> 100 mean daily patient census)

[ ] Small Hospital or Outpatient Organization

[ ] Division, Specialty, or Unit-based entity

C. Check if you are a Nassau-Suffolk Hospital Council (NSHC) member and would like this entry to also be submitted for the NSHC Annual Quality Award.

[ x ] Yes

Section II: See brochure for directions. This project narrative section should be (1) written and reviewed for potential publication, (2) must not include any facility-identifying information for the judges’ review, and (3) cannot exceed this one page format using just the white space section, single spaced, and11 pt. Times New Roman.

|Information Required |Please Complete in This Column |

|Name of Initiative |Redesigning Processes to Prevent Hospital Acquired Venous Thromboembolism (VTE) |

| | |

|This section is between 25 and 30 words. | |

|Project Description |Nationally, pulmonary embolism (PE) resulting from deep vein thrombosis (DVT) is a leading |

|(Narrative Summary) |cause of death for hospitalized patients. Many of these deaths can be prevented with the |

| |appropriate pharmacological prophylactic measures, facts which are well-publicized and |

|This section is between 150 and 225 words, depending on use of|supported by The Agency for Healthcare Research and Quality and The Joint Commission among |

|space and bullets. |others. Still, the national rate of appropriate VTE prophylaxis approaches only 40%. Our |

| |institutional incidence of VTE, as well as compliance with existing protocols, was |

| |reviewed. Standardizing protocol, simplifying the protocol order set, designing the order |

| |set’s integration into the clinician workflow and presentation of mandatory physician |

| |education regarding the problems associated with hospital-acquired VTE were all key to the |

| |project’s success. Data were collected during all of 2008 and 2009. The project began |

| |during 2008 and new protocols were fully implemented by July 2009. Prior to implementation,|

| |our rate of hospital-acquired VTE was 0.43 for 1,000 patient days. A rate of 0.35 for 1,000|

| |patient days was achieved in the first six months after implementation. The percentage of |

| |appropriate prophylaxis was initially 66%, increasing to 86%, for the six months following |

| |implementation. |

|Outcomes Achieved |Increased physician awareness of the need for VTE prophylaxis in the majority of |

|Please use bullets |hospitalized patients as evidenced by: |

|A one-page Word document can also be submitted containing one |Percentage of patients receiving appropriate VTE prophylaxis was increased by 30% |

|or more graphics. |Incidence of hospital-acquired VTE declined by 18.6% |

|Lessons Learned |“The simpler, the better” |

|Top three lessons learned utilizing bullets. |For the program to be effective, hospital administration, clinical leadership and the |

| |medical staff must be aligned and committed to the improvement initiative |

|This section is approximately 45 words when using bullets. |Physician compliance increases with ongoing education and awareness programs for medical |

| |staff |

Section III: Additional supporting information cannot exceed two pages. Please do not include identifying information for judges’ review.

|Information Required |Please Complete in This Column |

|Problem Statement |The hospital identified several missed opportunities to provide appropriate prophylaxis to medical patients. The missed |

| |opportunities were found to be due to the lack of uniform level of knowledge about VTE prophylaxis, differing opinions |

| |regarding the standard of care and perceived additional work with form completion. |

|Aim-Goals |Determine baseline measurements for the assessment of the incidence of hospital acquired venous thromboembolism (VTE) |

| |and assessment of appropriate VTE prophylaxis |

| |Once baseline was determined, the following goals were set: |

| |Design a protocol / form based upon best practice that includes exclusions, risk factors, chemoprophylactic dosage |

| |options, renal dose adjustments and additional mechanical prophylaxis options for high risk patients, that is limited to |

| |one page and is simple and user-friendly. |

| |Select standard low-molecular-weight heparin; eliminate unfractionated heparin |

| |Improve the percentage of patients receiving appropriate VTE prophylaxis by 25% in the six months following the selected |

| |intervention implementation. |

| |Reduce the rate of hospital-acquired VTE by 10% from the baseline rate of 0.43 hospital acquired VTE per 1000 patient |

| |days. |

|Methodologies and Change |The Performance Improvement Department identified an opportunity for improvement in the process for assuring appropriate |

|Principles |VTE prophylaxis for our patients. Senior leadership was apprised of the data collection and findings and provided support|

| |and prioritization for this initiative. Two multidisciplinary teams (medical and surgical) were charged with evaluating |

| |the current processes for VTE prophylaxis. Each team was led by a physician team leader who the medical staff held in |

| |high regard and who had expertise in VTE prevention and prophylaxis. The teams utilized a modified failure mode and |

| |effects analysis approach to identify the possible reasons that the current VTE prophylaxis may be underutilized. Once |

| |the major issues were identified the team employed the P-D-M-A-I (plan, design, measure, assess, improve) methodology for|

| |the project. Baseline data were reviewed and the team developed measurable goals and metrics with accompanying timeframe |

| |of 12 to 18 months for project completion. Data regarding the incidence of VTE were run utilizing coded data in the |

| |Midas+( database on a monthly basis and were sorted by PE, upper and lower extremity DVT and VTE-present-on-admission vs.|

| |hospital-acquired. Performance Improvement staff reviewed all open available medical records for during one week in each |

| |quarter to assess for the appropriateness of risk identification and appropriate prophylaxis (approximately 250-300 |

| |records per quarter). Exclusion criteria included obstetrical, psychiatric and pediatric patients. |

| |The team conducted a literature search to identify best practices and identify existing protocols. The current process |

| |for VTE prophylaxis was analyzed and a new standardized one-page protocol/order form was drafted. Key clinical leaders |

| |were recruited to evaluate the protocol/order. In the prior protocol, physicians could select treatment with either |

| |unfractionated heparin, dalteparin or enoxaparin. Following literature research, the team revised the protocol and |

| |limited the prophylaxis to enoxaparin. The revised protocol was designed to be well-integrated into the clinician |

| |workflow and utilized for all admitted patients as well as allow for automatic re-assessment of VTE risk with condition |

| |changes or transfer orders. Mandatory physician education regarding the problems associated with hospital-acquired VTE |

| |was developed and presented. Ongoing evaluation and monitoring have shown continued improvement and achievement of goals.|

|Additional Outcomes Not Listed |Standardized chemoprophylaxis orders, combined with a risk assessment, increased physician compliance with appropriate |

|in Section II |ordering |

| |There was increased surgical prophylaxis for patients with major abdominal surgery including administration of |

| |chemoprophylaxis 2 hours prior to the planned procedure |

| |Bleeding risk assessments became part of the surgical staff standards |

| |Daily (or twice daily) administration of enoxaparin offered lower complication rates than heparin given three times a |

| |day, and offered advantages for nursing time and effort. |

|Sustainability Strategies |Scheduled medical staff educational meetings continue and staff are apprised of goal achievement. |

| |Data continues to be collected for both measures and reported to the Clinical Chairs |

| |Individual physician re-education is provided in any area that does not meet expectations |

| |All new physicians have a complete orientation including all aspects of VTE prophylaxis and requirements |

|Business Case Information |While there was an additional cost associated with the change from dalteparin and unfractionated heparin use to |

| |enoxaparin, the cost was balanced by the program’s impact. Each hospital-acquired DVT provides an incremental cost of |

| |$10,000 while each PE represents an additional cost of about $20,000. VTE prevention reduces length of stay and |

| |readmission as well as morbidity and mortality. |

|Conclusion, Recommendations, or|In addition to maintaining the gain and continuing to improve our VTE prevention program, the initiative also includes |

|Next Steps |the necessity of continued therapy for at risk patients during the post-hospital stage. As lengths of stay decrease, it |

| |is imperative to assure that clinicians prescribe continued anticoagulation prophylaxis for the recommended timeframes. |

| |Patient education regarding discharge medications, especially continued prophylaxis, is provided with full educational |

| |kits that are supplied by the pharmaceutical company. Case Managers, Social Workers and Home Health Care nurses have |

| |partnered with the physicians as well as local pharmacies to assure that patients have the necessary medications and |

| |resources to obtain those medications. |

A one-page Word document containing one or more graphics can also be submitted.

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