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Venous thromboembolism (VTE), including both deep vein thrombosis (DVT) and pulmonary embolism, is a major cause of preventable hospital death and long‐term morbidity. VTE accounts for approximately 100,000 to 200,000 hospital deaths annually,[1] and preventable DVT costs an estimated $2.5 billion annually, with each case resulting in direct hospital costs of an estimated $25,977.[2] Although VTE is less common in children, its incidence is increasing in the medically ill hospitalized pediatric patient. The most recent analysis of a large national children's hospital database showed VTE rates increasing from 34 to 58 per 10,000 admissions from 2001 to 2007.[3] Rates in pediatric trauma patients are higher, at 60 to 100 per 10,000 admissions.[4, 5, 6]

The Joint Commission, the Surgeon General, and the Centers for Disease Control and Prevention have supported initiatives to increase awareness and promote strategies designed to prevent hospital acquired VTE.[7, 8] There are several high‐quality, evidence‐based VTE prophylaxis (VTE‐P) guidelines for adult hospitalized populations.[9, 10, 11] Pediatric VTE‐P guidelines are not well established, but the literature regarding VTE risk stratification and prophylaxis guidelines for medically complex children is growing.[12, 13, 14, 15, 16, 17]

A significant challenge has been developing systems that ensure that evidence and consensus‐based care recommendations are reliably implemented. This summary will describe the methods applied across an integrated health system that includes 22 acute care facilities and 1 pediatric hospital across 5 states that have resulted in a significant reduction in preventable VTE.

SETTING

Mayo Clinic is an integrated health system that owns 22 acute care facilities across 5 states, housing 3971 beds with approximately 122,000 admissions per year. Mayo Clinic Rochester, Arizona, and Florida are all tertiary academic medical centers with trauma and transplant programs. During this project, Arizona and Florida utilized a common build of the Cerner (Kansas City, MO) electronic health record (EHR). The other facilities, collectively referred to as the Mayo Clinic Health System (MCHS) hospitals, include 1 level II trauma center and 11 critical access hospitals and serve communities of varying sizes in Minnesota, Wisconsin, and Iowa. A different build of the Cerner EHR served the MCHS during this project.

Mayo Clinic Rochester is responsible for nearly 50% of all admissions and procedures. Mayo Eugenio Litta Children's Hospital, Rochester, Minnesota is a tertiary children's hospital facility housing 44 general pediatric beds, 26 neonatal intensive care unit beds, 24 intermediate nursery special care beds, and 16 pediatric intensive care unit beds. Mayo Clinic Rochester used the GE Centricity (GE Healthcare, Wauwatosa, WI) EHR and custom‐designed computerized decision support.

METHODS

Mayo Clinic has developed a system to deliberately speed the diffusion of best practices across our system to drive reliable, evidence‐based care, reduce unwanted variation in processes and outcomes, and improve value.[18] The 3 main components of this system are (1) discovery: wherein we learn a practice that demonstrably solves the clinical problem well in at least 1 of our facilities, (2) assessment of readiness for diffusion, and (3) diffusion of the best practice across all of Mayo Clinic. The diffusion process is active and equipped with a project team and execution timeline. Both adult and pediatric projects began with discovery phases. The adult program has fully diffused; the pediatric program is diffusing at this writing.

ADULT ACUTE CARE PATIENTS

RESULTS

Adult Acute Care Patients

Mayo Clinic used CMS Core Measures in all 22 hospitals in the system from 2013 onward. The results are shown in Figure 1. Of note, VTE‐1 has improved from its project start values in the mid‐80% range to consistently above 95% for the last 6 quarters (most recently above 97%), VTE‐2 has averaged 97.3%, and most recently is at 100%, and VTE‐6 has declined from about 12% to 0% in the recent quarters.

Figure 1

Figure 2 shows the number of VTE‐P alerts generated during 1 month by service in Mayo Clinic Rochester. We display these data as control charts so that practices on services with a statistically excessive number of alerts can be targeted for improvement. Similar data are available at all institutions.

Figure 2

Pediatric Patients

The PICU had an average of 101 admissions per month during study period (range, 72120) with a mean of 11 patients per day (range, 912 patients). Prior to the VTE‐P pilot, none had VTE risks documented. A total of 773 patients were screened for VTE in the intensive care unit during the study period, of which 194 were identified with 2 or greater VTE risk factors (25%). Sixty‐six of 194 patients (34%) had pharmacologic and/or mechanical prophylaxis (n = 83, 44%) selected for VTE‐P. No bleeding events were reported among these patients. During the discovery pilot, the VTE screening tool resulted in >92% compliance with risk documentation, >64% appropriate VTE‐P use, and 0 VTE events. The subsequently improved screening tool resulted in approximately 88% compliance over the subsequent 6 months of use, and in 9 months 2 VTE were diagnosed (both occurring in hospital units not using the screening tool).

An electronic VTE‐P tollgate for pediatric patients went live on March 17, 2016 (Figure 3). We have also developed a CDS alert for pediatric patients not having an appropriate VTE‐P plan documented, and alert frequency reports will allow focused improvement efforts if needed.

Figure 3

DISCUSSION

Our VTE‐P system has resulted in significant reductions in preventable VTE. The key components of our system are: (1) Ensure that a VTE‐P is declared at admission by providing a mandatory VTE‐P tollgate that requires the provider to assess the risk for VTE and provide an appropriate order for VTE‐P. (2) Use clinical decision support to provide ongoing surveillance and alerting providers when there is a lapse in the VTE‐P plan. With these, we have driven CMS Core Measures VTE‐6 to 0 over 3 quarters.

Different VTE‐P strategies have been implemented among hospitalized medically ill patients. Despite the morbidity and mortality risks inherent to VTE, some studies have shown that more than half and nearly 79% of high‐risk hospitalized medical patients received no VTE prevention.[19] Among those who received prophylactic therapy, inadequate duration or type was prescribed in nearly 44%.[20] Electronic orders have resulted in improved prophylaxis in some literature reports.[21, 22] One study showed that a physician alert reduced VTE incidence from 4.13 to 2.23 events per 10,000 patients.[21] Our system, combining prompted electronic orders with clinical decision support for ongoing real‐time monitoring for VTE‐P plans appears to have been effective in producing reliable ordering of VTE‐P in both adults and children.

However, our system has limitations, some inherent in its design and others not addressed yet. Intrinsically, we depend upon clinicians to rightly gauge the patient risk for VTE‐P. Because a significant majority of our patients have at least moderate risk for VTE, the construction of the order sets tend to guide the clinician to select some form of prophylaxis. However, our system does not specifically provide guidance as to what VTE‐P to choose. If the clinician deems the patient at low risk, the CDS criteria will accept this judgment for up to 3 days without questioning the provider. Similarly, by national criteria, some patients at very high risk would ideally receive both mechanical and pharmacologic VTE‐P.[23] Our monitoring system does not distinguish between very high risk and moderately high risk when determining if a valid VTE‐P is in place. Audits of clinician decision making have shown that at present the appropriate decisions are being made 98% of the time, but this could change over time and with new guideline recommendations. Another challenge concerns the difference between ordering and delivering prophylaxis. When ordered, pharmacologic VTE‐P is reliably delivered. In contrast, providing ongoing delivery of ordered mechanical VTE‐P is more challenging. In addition, our current system does not extend to VTE‐P plans for discharge. Future clinical decision support might suggest which patients should receive combined prophylaxis while in the hospital or which home‐going prophylaxis plans should be considered.

We acknowledged the limitations of diffusing a VTE and bleeding risk‐assessment tool that has not been validated in our hospitalized pediatric population. Validation of pediatric VTE risk assessment tools have been recently developed but not widely validated in large prospective studies to be considered the standard of care.[6, 12] Based on our own institutional experience, the vast majority of VTE events occurred in pediatric patients with a central venous catheter (CVC) and other risk factors for thrombosis, and this category was arbitrarily chosen as one to consider pharmacologic prophylaxis if no bleeding risk factors and a central line to be in placed greater than 7 days duration. Although, pediatric evidence guidelines do not support the use of pharmacologic prophylaxis in patients with CVC,[15] risk factors for thrombosis in children, although less frequent than adults, are still present, and VTE‐P should be assessed and individualized in each patient considered at risk for thrombosis. Other groups have attempted a similar approach as the one taken by our group, with variations in the criteria used for thromboprophylaxis in the pediatric population.[5, 14] Our data illustrate that not all pediatric patients require pharmacologic prophylaxis (34%), and VTE‐P should be individualized based on patient risk factors for thrombosis and bleeding risk.

A strength of our system is derived from the substantial clinician and expert input, the codification of consensus, and the hard wiring of that consensus into the electronic ordering, clinical decision rules, and reporting environment. As new advances to VTE‐P are developed, we will strive to codify those new processes into our workflow, building on our past success.

Venous thromboembolism (VTE), including both deep vein thrombosis (DVT) and pulmonary embolism, is a major cause of preventable hospital death and long‐term morbidity. VTE accounts for approximately 100,000 to 200,000 hospital deaths annually,[1] and preventable DVT costs an estimated $2.5 billion annually, with each case resulting in direct hospital costs of an estimated $25,977.[2] Although VTE is less common in children, its incidence is increasing in the medically ill hospitalized pediatric patient. The most recent analysis of a large national children's hospital database showed VTE rates increasing from 34 to 58 per 10,000 admissions from 2001 to 2007.[3] Rates in pediatric trauma patients are higher, at 60 to 100 per 10,000 admissions.[4, 5, 6]

The Joint Commission, the Surgeon General, and the Centers for Disease Control and Prevention have supported initiatives to increase awareness and promote strategies designed to prevent hospital acquired VTE.[7, 8] There are several high‐quality, evidence‐based VTE prophylaxis (VTE‐P) guidelines for adult hospitalized populations.[9, 10, 11] Pediatric VTE‐P guidelines are not well established, but the literature regarding VTE risk stratification and prophylaxis guidelines for medically complex children is growing.[12, 13, 14, 15, 16, 17]

A significant challenge has been developing systems that ensure that evidence and consensus‐based care recommendations are reliably implemented. This summary will describe the methods applied across an integrated health system that includes 22 acute care facilities and 1 pediatric hospital across 5 states that have resulted in a significant reduction in preventable VTE.

SETTING

Mayo Clinic is an integrated health system that owns 22 acute care facilities across 5 states, housing 3971 beds with approximately 122,000 admissions per year. Mayo Clinic Rochester, Arizona, and Florida are all tertiary academic medical centers with trauma and transplant programs. During this project, Arizona and Florida utilized a common build of the Cerner (Kansas City, MO) electronic health record (EHR). The other facilities, collectively referred to as the Mayo Clinic Health System (MCHS) hospitals, include 1 level II trauma center and 11 critical access hospitals and serve communities of varying sizes in Minnesota, Wisconsin, and Iowa. A different build of the Cerner EHR served the MCHS during this project.

Mayo Clinic Rochester is responsible for nearly 50% of all admissions and procedures. Mayo Eugenio Litta Children's Hospital, Rochester, Minnesota is a tertiary children's hospital facility housing 44 general pediatric beds, 26 neonatal intensive care unit beds, 24 intermediate nursery special care beds, and 16 pediatric intensive care unit beds. Mayo Clinic Rochester used the GE Centricity (GE Healthcare, Wauwatosa, WI) EHR and custom‐designed computerized decision support.

METHODS

Mayo Clinic has developed a system to deliberately speed the diffusion of best practices across our system to drive reliable, evidence‐based care, reduce unwanted variation in processes and outcomes, and improve value.[18] The 3 main components of this system are (1) discovery: wherein we learn a practice that demonstrably solves the clinical problem well in at least 1 of our facilities, (2) assessment of readiness for diffusion, and (3) diffusion of the best practice across all of Mayo Clinic. The diffusion process is active and equipped with a project team and execution timeline. Both adult and pediatric projects began with discovery phases. The adult program has fully diffused; the pediatric program is diffusing at this writing.

ADULT ACUTE CARE PATIENTS

RESULTS

Adult Acute Care Patients

Mayo Clinic used CMS Core Measures in all 22 hospitals in the system from 2013 onward. The results are shown in Figure 1. Of note, VTE‐1 has improved from its project start values in the mid‐80% range to consistently above 95% for the last 6 quarters (most recently above 97%), VTE‐2 has averaged 97.3%, and most recently is at 100%, and VTE‐6 has declined from about 12% to 0% in the recent quarters.

Figure 1

Figure 2 shows the number of VTE‐P alerts generated during 1 month by service in Mayo Clinic Rochester. We display these data as control charts so that practices on services with a statistically excessive number of alerts can be targeted for improvement. Similar data are available at all institutions.

Figure 2

Pediatric Patients

The PICU had an average of 101 admissions per month during study period (range, 72120) with a mean of 11 patients per day (range, 912 patients). Prior to the VTE‐P pilot, none had VTE risks documented. A total of 773 patients were screened for VTE in the intensive care unit during the study period, of which 194 were identified with 2 or greater VTE risk factors (25%). Sixty‐six of 194 patients (34%) had pharmacologic and/or mechanical prophylaxis (n = 83, 44%) selected for VTE‐P. No bleeding events were reported among these patients. During the discovery pilot, the VTE screening tool resulted in >92% compliance with risk documentation, >64% appropriate VTE‐P use, and 0 VTE events. The subsequently improved screening tool resulted in approximately 88% compliance over the subsequent 6 months of use, and in 9 months 2 VTE were diagnosed (both occurring in hospital units not using the screening tool).

An electronic VTE‐P tollgate for pediatric patients went live on March 17, 2016 (Figure 3). We have also developed a CDS alert for pediatric patients not having an appropriate VTE‐P plan documented, and alert frequency reports will allow focused improvement efforts if needed.

Figure 3

DISCUSSION

Our VTE‐P system has resulted in significant reductions in preventable VTE. The key components of our system are: (1) Ensure that a VTE‐P is declared at admission by providing a mandatory VTE‐P tollgate that requires the provider to assess the risk for VTE and provide an appropriate order for VTE‐P. (2) Use clinical decision support to provide ongoing surveillance and alerting providers when there is a lapse in the VTE‐P plan. With these, we have driven CMS Core Measures VTE‐6 to 0 over 3 quarters.

Different VTE‐P strategies have been implemented among hospitalized medically ill patients. Despite the morbidity and mortality risks inherent to VTE, some studies have shown that more than half and nearly 79% of high‐risk hospitalized medical patients received no VTE prevention.[19] Among those who received prophylactic therapy, inadequate duration or type was prescribed in nearly 44%.[20] Electronic orders have resulted in improved prophylaxis in some literature reports.[21, 22] One study showed that a physician alert reduced VTE incidence from 4.13 to 2.23 events per 10,000 patients.[21] Our system, combining prompted electronic orders with clinical decision support for ongoing real‐time monitoring for VTE‐P plans appears to have been effective in producing reliable ordering of VTE‐P in both adults and children.

However, our system has limitations, some inherent in its design and others not addressed yet. Intrinsically, we depend upon clinicians to rightly gauge the patient risk for VTE‐P. Because a significant majority of our patients have at least moderate risk for VTE, the construction of the order sets tend to guide the clinician to select some form of prophylaxis. However, our system does not specifically provide guidance as to what VTE‐P to choose. If the clinician deems the patient at low risk, the CDS criteria will accept this judgment for up to 3 days without questioning the provider. Similarly, by national criteria, some patients at very high risk would ideally receive both mechanical and pharmacologic VTE‐P.[23] Our monitoring system does not distinguish between very high risk and moderately high risk when determining if a valid VTE‐P is in place. Audits of clinician decision making have shown that at present the appropriate decisions are being made 98% of the time, but this could change over time and with new guideline recommendations. Another challenge concerns the difference between ordering and delivering prophylaxis. When ordered, pharmacologic VTE‐P is reliably delivered. In contrast, providing ongoing delivery of ordered mechanical VTE‐P is more challenging. In addition, our current system does not extend to VTE‐P plans for discharge. Future clinical decision support might suggest which patients should receive combined prophylaxis while in the hospital or which home‐going prophylaxis plans should be considered.

We acknowledged the limitations of diffusing a VTE and bleeding risk‐assessment tool that has not been validated in our hospitalized pediatric population. Validation of pediatric VTE risk assessment tools have been recently developed but not widely validated in large prospective studies to be considered the standard of care.[6, 12] Based on our own institutional experience, the vast majority of VTE events occurred in pediatric patients with a central venous catheter (CVC) and other risk factors for thrombosis, and this category was arbitrarily chosen as one to consider pharmacologic prophylaxis if no bleeding risk factors and a central line to be in placed greater than 7 days duration. Although, pediatric evidence guidelines do not support the use of pharmacologic prophylaxis in patients with CVC,[15] risk factors for thrombosis in children, although less frequent than adults, are still present, and VTE‐P should be assessed and individualized in each patient considered at risk for thrombosis. Other groups have attempted a similar approach as the one taken by our group, with variations in the criteria used for thromboprophylaxis in the pediatric population.[5, 14] Our data illustrate that not all pediatric patients require pharmacologic prophylaxis (34%), and VTE‐P should be individualized based on patient risk factors for thrombosis and bleeding risk.

A strength of our system is derived from the substantial clinician and expert input, the codification of consensus, and the hard wiring of that consensus into the electronic ordering, clinical decision rules, and reporting environment. As new advances to VTE‐P are developed, we will strive to codify those new processes into our workflow, building on our past success.

Venous thromboembolism (VTE), including both deep vein thrombosis (DVT) and pulmonary embolism, is a major cause of preventable hospital death and long‐term morbidity. VTE accounts for approximately 100,000 to 200,000 hospital deaths annually,[1] and preventable DVT costs an estimated $2.5 billion annually, with each case resulting in direct hospital costs of an estimated $25,977.[2] Although VTE is less common in children, its incidence is increasing in the medically ill hospitalized pediatric patient. The most recent analysis of a large national children's hospital database showed VTE rates increasing from 34 to 58 per 10,000 admissions from 2001 to 2007.[3] Rates in pediatric trauma patients are higher, at 60 to 100 per 10,000 admissions.[4, 5, 6]

The Joint Commission, the Surgeon General, and the Centers for Disease Control and Prevention have supported initiatives to increase awareness and promote strategies designed to prevent hospital acquired VTE.[7, 8] There are several high‐quality, evidence‐based VTE prophylaxis (VTE‐P) guidelines for adult hospitalized populations.[9, 10, 11] Pediatric VTE‐P guidelines are not well established, but the literature regarding VTE risk stratification and prophylaxis guidelines for medically complex children is growing.[12, 13, 14, 15, 16, 17]

A significant challenge has been developing systems that ensure that evidence and consensus‐based care recommendations are reliably implemented. This summary will describe the methods applied across an integrated health system that includes 22 acute care facilities and 1 pediatric hospital across 5 states that have resulted in a significant reduction in preventable VTE.

SETTING

Mayo Clinic is an integrated health system that owns 22 acute care facilities across 5 states, housing 3971 beds with approximately 122,000 admissions per year. Mayo Clinic Rochester, Arizona, and Florida are all tertiary academic medical centers with trauma and transplant programs. During this project, Arizona and Florida utilized a common build of the Cerner (Kansas City, MO) electronic health record (EHR). The other facilities, collectively referred to as the Mayo Clinic Health System (MCHS) hospitals, include 1 level II trauma center and 11 critical access hospitals and serve communities of varying sizes in Minnesota, Wisconsin, and Iowa. A different build of the Cerner EHR served the MCHS during this project.

Mayo Clinic Rochester is responsible for nearly 50% of all admissions and procedures. Mayo Eugenio Litta Children's Hospital, Rochester, Minnesota is a tertiary children's hospital facility housing 44 general pediatric beds, 26 neonatal intensive care unit beds, 24 intermediate nursery special care beds, and 16 pediatric intensive care unit beds. Mayo Clinic Rochester used the GE Centricity (GE Healthcare, Wauwatosa, WI) EHR and custom‐designed computerized decision support.

METHODS

Mayo Clinic has developed a system to deliberately speed the diffusion of best practices across our system to drive reliable, evidence‐based care, reduce unwanted variation in processes and outcomes, and improve value.[18] The 3 main components of this system are (1) discovery: wherein we learn a practice that demonstrably solves the clinical problem well in at least 1 of our facilities, (2) assessment of readiness for diffusion, and (3) diffusion of the best practice across all of Mayo Clinic. The diffusion process is active and equipped with a project team and execution timeline. Both adult and pediatric projects began with discovery phases. The adult program has fully diffused; the pediatric program is diffusing at this writing.

ADULT ACUTE CARE PATIENTS

RESULTS

Adult Acute Care Patients

Mayo Clinic used CMS Core Measures in all 22 hospitals in the system from 2013 onward. The results are shown in Figure 1. Of note, VTE‐1 has improved from its project start values in the mid‐80% range to consistently above 95% for the last 6 quarters (most recently above 97%), VTE‐2 has averaged 97.3%, and most recently is at 100%, and VTE‐6 has declined from about 12% to 0% in the recent quarters.

Figure 1

Figure 2 shows the number of VTE‐P alerts generated during 1 month by service in Mayo Clinic Rochester. We display these data as control charts so that practices on services with a statistically excessive number of alerts can be targeted for improvement. Similar data are available at all institutions.

Figure 2

Pediatric Patients

The PICU had an average of 101 admissions per month during study period (range, 72120) with a mean of 11 patients per day (range, 912 patients). Prior to the VTE‐P pilot, none had VTE risks documented. A total of 773 patients were screened for VTE in the intensive care unit during the study period, of which 194 were identified with 2 or greater VTE risk factors (25%). Sixty‐six of 194 patients (34%) had pharmacologic and/or mechanical prophylaxis (n = 83, 44%) selected for VTE‐P. No bleeding events were reported among these patients. During the discovery pilot, the VTE screening tool resulted in >92% compliance with risk documentation, >64% appropriate VTE‐P use, and 0 VTE events. The subsequently improved screening tool resulted in approximately 88% compliance over the subsequent 6 months of use, and in 9 months 2 VTE were diagnosed (both occurring in hospital units not using the screening tool).

An electronic VTE‐P tollgate for pediatric patients went live on March 17, 2016 (Figure 3). We have also developed a CDS alert for pediatric patients not having an appropriate VTE‐P plan documented, and alert frequency reports will allow focused improvement efforts if needed.

Figure 3

DISCUSSION

Our VTE‐P system has resulted in significant reductions in preventable VTE. The key components of our system are: (1) Ensure that a VTE‐P is declared at admission by providing a mandatory VTE‐P tollgate that requires the provider to assess the risk for VTE and provide an appropriate order for VTE‐P. (2) Use clinical decision support to provide ongoing surveillance and alerting providers when there is a lapse in the VTE‐P plan. With these, we have driven CMS Core Measures VTE‐6 to 0 over 3 quarters.

Different VTE‐P strategies have been implemented among hospitalized medically ill patients. Despite the morbidity and mortality risks inherent to VTE, some studies have shown that more than half and nearly 79% of high‐risk hospitalized medical patients received no VTE prevention.[19] Among those who received prophylactic therapy, inadequate duration or type was prescribed in nearly 44%.[20] Electronic orders have resulted in improved prophylaxis in some literature reports.[21, 22] One study showed that a physician alert reduced VTE incidence from 4.13 to 2.23 events per 10,000 patients.[21] Our system, combining prompted electronic orders with clinical decision support for ongoing real‐time monitoring for VTE‐P plans appears to have been effective in producing reliable ordering of VTE‐P in both adults and children.

However, our system has limitations, some inherent in its design and others not addressed yet. Intrinsically, we depend upon clinicians to rightly gauge the patient risk for VTE‐P. Because a significant majority of our patients have at least moderate risk for VTE, the construction of the order sets tend to guide the clinician to select some form of prophylaxis. However, our system does not specifically provide guidance as to what VTE‐P to choose. If the clinician deems the patient at low risk, the CDS criteria will accept this judgment for up to 3 days without questioning the provider. Similarly, by national criteria, some patients at very high risk would ideally receive both mechanical and pharmacologic VTE‐P.[23] Our monitoring system does not distinguish between very high risk and moderately high risk when determining if a valid VTE‐P is in place. Audits of clinician decision making have shown that at present the appropriate decisions are being made 98% of the time, but this could change over time and with new guideline recommendations. Another challenge concerns the difference between ordering and delivering prophylaxis. When ordered, pharmacologic VTE‐P is reliably delivered. In contrast, providing ongoing delivery of ordered mechanical VTE‐P is more challenging. In addition, our current system does not extend to VTE‐P plans for discharge. Future clinical decision support might suggest which patients should receive combined prophylaxis while in the hospital or which home‐going prophylaxis plans should be considered.

We acknowledged the limitations of diffusing a VTE and bleeding risk‐assessment tool that has not been validated in our hospitalized pediatric population. Validation of pediatric VTE risk assessment tools have been recently developed but not widely validated in large prospective studies to be considered the standard of care.[6, 12] Based on our own institutional experience, the vast majority of VTE events occurred in pediatric patients with a central venous catheter (CVC) and other risk factors for thrombosis, and this category was arbitrarily chosen as one to consider pharmacologic prophylaxis if no bleeding risk factors and a central line to be in placed greater than 7 days duration. Although, pediatric evidence guidelines do not support the use of pharmacologic prophylaxis in patients with CVC,[15] risk factors for thrombosis in children, although less frequent than adults, are still present, and VTE‐P should be assessed and individualized in each patient considered at risk for thrombosis. Other groups have attempted a similar approach as the one taken by our group, with variations in the criteria used for thromboprophylaxis in the pediatric population.[5, 14] Our data illustrate that not all pediatric patients require pharmacologic prophylaxis (34%), and VTE‐P should be individualized based on patient risk factors for thrombosis and bleeding risk.

A strength of our system is derived from the substantial clinician and expert input, the codification of consensus, and the hard wiring of that consensus into the electronic ordering, clinical decision rules, and reporting environment. As new advances to VTE‐P are developed, we will strive to codify those new processes into our workflow, building on our past success.

Venous thromboembolism (VTE), blood clots occurring as deep vein thrombosis, pulmonary embolism, or both, is an important and growing public health issue. The precise number of people affected by VTE is unknown; however, estimates suggest that up to 900,000 events resulting in as many as 100,000 premature deaths occur in the United States yearly with healthcare costs as high as $10 billion.[1, 2, 3] Although anyone can develop VTE, research has shown that half of VTE events occurring in the outpatient setting are directly linked to a recent hospitalization or surgery.[4] In patients with cancer, VTE is a leading cause of death after the cancer itself.[5, 6] Fortunately, many of these healthcare‐associated VTE (HA‐VTE) cases can be prevented. Recent analyses have shown that as many as 70% of HA‐VTE cases are preventable through appropriate prophylaxis,[7, 8, 9] yet reports suggest that fewer than half of hospital patients receive VTE prophylaxis in accordance with accepted evidence‐based guidelines.[10] Appropriate prevention of HA‐VTE can result in a significant reduction in overall VTE occurrence, thereby decreasing healthcare burden and unnecessary deaths.

In November 2015, the Centers for Disease Control and Prevention (CDC) released the Healthcare‐Associated VTE Prevention Challenge (http://www.cdc.gov/ncbddd/dvt/ha‐vte‐challenge.html) to identify, highlight, and reward hospitals, managed care organizations, and hospital networks that implemented innovative, effective, and sustainable strategies to prevent HA‐VTE.

This issue of the Journal of Hospital Medicine showcases the initiatives of several of the CDC's HA‐VTE prevention champions. These champions range from a small community hospital to some of the country's largest health systems, and they represent both rural and urban areas. Together they cared for more than 450,000 patients admitted to hospitals across the United States in 2014. They were able to improve VTE prevention within their institutions and organizations by implementing successful and sustainable VTE prevention strategies such as engaging teams of different healthcare experts to support and promote prevention activities, informing patients and providers about the need for and benefits of VTE prevention, and using technology (such as electronic risk assessment and clinical decision support tools and alerts) to ensure that all patients are assessed for their risk for VTE and bleeding. These tools also help ensure that patients, when appropriate, are provided with and use appropriate prevention measures for their level of risk. Moreover, they provided real‐time feedback, scorecards, and dashboards for providers and organizations to monitor performance and identify areas for improvement.

The CDC and the Agency for Healthcare Research and Quality (AHRQ) are partnering to disseminate and promote these best practices. In addition to this challenge, the CDC, AHRQ and the Joint Commission Center for Transforming Healthcare are working on activities and programs dedicated to improving prevention of HA‐VTE. These are summarized below.

AGENCY FOR HEALTHCARE RESEARCH AND QUALITY

The AHRQ works to reduce the incidence of VTE among patients at risk of developing the condition by conducting research and providing support for quality‐improvement efforts. In 2008, AHRQ published an evidence‐based resource for prevention of VTE based on quality‐improvement principles that were successfully applied by the University of California, San Diego Medical Center, and Emory University Hospitals in an AHRQ‐funded research project. This resource, Preventing Hospital‐Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement, was updated in 2014 and is available at http://www.ahrq.gov/professionals/quality‐patient‐safety/patient‐safety‐resources/resources/vtguide/emndex.html. The guide is intended to assist quality‐improvement practitioners who wish to improve prevention of HA‐VTE in their own organizations.

Since its original release, hospital quality‐improvement teams have used the guide to close the gap between available evidence about how to prevent VTE and successful implementation of that knowledge so that hospitals can improve care as effectively and efficiently as possible. The guide includes examples of risk assessment methodologies and evaluation metrics along with other key elements that help front‐line providers establish or enhance VTE prevention programs.

AHRQ maintains an active patient safety program that spans a wide range of patient safety problems including VTE that is aimed at making healthcare safer. The AHRQ works with many different healthcare stakeholders to (1) better understand threats to patient safety and (2) develop and refine strategies that put this knowledge to work to prevent patient harm. For example, the AHRQ provides extramural research grants to investigators studying new methods of identifying patients at risk for VTE and ways to improve VTE prophylaxis in hospital patients undergoing medical treatment and surgical procedures.

In addition to a collaborative partnership with the CDC on the 2015 Healthcare‐Associated VTE Prevention Challenge, the AHRQ also partners with other federal agencies and is an active contributor to the Department of Health and Human Services National Action Plan for Adverse Drug Event Prevention. The plan outlines opportunities to advance patient safety through the prevention of adverse drug events and the promotion of medication safety among 3 drug classes including anticoagulants, a key component for VTE prevention. Patients and their families are critically important partners for improving patient safety, and the significant potential for their impact is represented by the AHRQ tools and resources such as an information video and guide for patients about the safe use of blood thinners (http://www.ahrq.gov/patients‐consumers/diagnosis‐treatment/treatments/btpills/btpills.html).

THE JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE

The Joint Commission Center for Transforming Healthcare commenced the Preventing Venous Thromboembolism project in October 2014, with 5 participating hospitals and health centers in collaboration with the CDC. The hospitals and health centers participating on this project include: Cleveland Clinic, The Johns Hopkins Hospital, Kaiser Permanente South Bay Medical Center, Massachusetts General Hospital, and Texas Health Resources.

Often, VTE risk factors are not consistently assessed across all hospital patients, and there is much variation to the selection of appropriate mechanical and/or pharmacological prophylaxis. In addition, the current accepted guidelines are not implemented consistently across hospitals. VTE rates can be reduced with accurate risk assessment and appropriate utilization of pharmacological and/or mechanical prophylaxis. However, there are multiple barriers to consistent, successful implementation of preventative measures. During the first year of this project, the participants utilized Robust Process Improvement, a fact‐based, systematic, and data‐driven problem‐solving methodology that incorporates tools and concepts from Lean, Six Sigma, and change management, to assist them in identifying the root causes and barriers to preventing VTE in at‐risk patients.

Aggregate preliminary findings show that some of the contributing factors to VTE prevention included issues with staff attitudes and beliefs, staff and patient education, risk assessments, order sets, ineffective mechanical and pharmacological prophylaxis, and patient refusal. The participating organizations are currently developing and implementing solutions targeted to their specific root causes. The solutions will be tested, validated, and then spread to other healthcare organizations. Project findings are tentatively scheduled for release in 2017.

The Joint Commission has been committed to preventing VTE for over a decade, beginning with the development of the VTE measures, which were the result of the National Consensus Standards for the Prevention and Care of Deep Vein Thrombosis project with the National Quality Forum that formally began in January 2005. In addition, The Joint Commission and Joint Commission Resources have also aimed to reduce harm and improve the quality of care for VTE patients through the Hospital Engagement Network collaborative, publications related to improving VTE patient safety, and research on improving transitions of care and discharge instructions for patients with VTE.

CENTERS FOR DISEASE CONTROL AND PREVENTION

The CDC's Division of Blood Disorders works to prevent VTE and to reduce sickness and death among those who develop VTE. The CDC's primary VTE activities focus on developing improved methods and innovative tools for monitoring and understanding VTE occurrence and the effectiveness of VTE prevention activities, conducting epidemiologic studies on the causes and outcomes of VTE and its complications, and working internally and with partners to develop and promote education and awareness materials to inform the public and healthcare providers about the importance of knowing VTE risk factors to improve prevention, and the importance of knowing the signs and symptoms of VTE to ensure early and accurate diagnosis and treatment of VTE. Recently, the CDC collaborated with the National Blood Clot Alliance, through their Stop the Clot, Spread the Word Campaign, to develop and promote prevention of VTE among hospitalized patients (https://www.stoptheclot.org/spreadtheword). To learn more about the CDC's VTE programs please visit http://www.cdc.gov/ncbddd/dvt/emndex.html.

The CDC, AHRQ, and The Joint Commission hope that readers will find the successes of the HA‐VTE Prevention Champions' initiatives informative and encouraging. They are examples of how any healthcare setting, from a small hospital to a large healthcare system, can implement approaches and tools to improve prevention of HA‐VTE.

Venous thromboembolism (VTE), blood clots occurring as deep vein thrombosis, pulmonary embolism, or both, is an important and growing public health issue. The precise number of people affected by VTE is unknown; however, estimates suggest that up to 900,000 events resulting in as many as 100,000 premature deaths occur in the United States yearly with healthcare costs as high as $10 billion.[1, 2, 3] Although anyone can develop VTE, research has shown that half of VTE events occurring in the outpatient setting are directly linked to a recent hospitalization or surgery.[4] In patients with cancer, VTE is a leading cause of death after the cancer itself.[5, 6] Fortunately, many of these healthcare‐associated VTE (HA‐VTE) cases can be prevented. Recent analyses have shown that as many as 70% of HA‐VTE cases are preventable through appropriate prophylaxis,[7, 8, 9] yet reports suggest that fewer than half of hospital patients receive VTE prophylaxis in accordance with accepted evidence‐based guidelines.[10] Appropriate prevention of HA‐VTE can result in a significant reduction in overall VTE occurrence, thereby decreasing healthcare burden and unnecessary deaths.

In November 2015, the Centers for Disease Control and Prevention (CDC) released the Healthcare‐Associated VTE Prevention Challenge (http://www.cdc.gov/ncbddd/dvt/ha‐vte‐challenge.html) to identify, highlight, and reward hospitals, managed care organizations, and hospital networks that implemented innovative, effective, and sustainable strategies to prevent HA‐VTE.

This issue of the Journal of Hospital Medicine showcases the initiatives of several of the CDC's HA‐VTE prevention champions. These champions range from a small community hospital to some of the country's largest health systems, and they represent both rural and urban areas. Together they cared for more than 450,000 patients admitted to hospitals across the United States in 2014. They were able to improve VTE prevention within their institutions and organizations by implementing successful and sustainable VTE prevention strategies such as engaging teams of different healthcare experts to support and promote prevention activities, informing patients and providers about the need for and benefits of VTE prevention, and using technology (such as electronic risk assessment and clinical decision support tools and alerts) to ensure that all patients are assessed for their risk for VTE and bleeding. These tools also help ensure that patients, when appropriate, are provided with and use appropriate prevention measures for their level of risk. Moreover, they provided real‐time feedback, scorecards, and dashboards for providers and organizations to monitor performance and identify areas for improvement.

The CDC and the Agency for Healthcare Research and Quality (AHRQ) are partnering to disseminate and promote these best practices. In addition to this challenge, the CDC, AHRQ and the Joint Commission Center for Transforming Healthcare are working on activities and programs dedicated to improving prevention of HA‐VTE. These are summarized below.

AGENCY FOR HEALTHCARE RESEARCH AND QUALITY

The AHRQ works to reduce the incidence of VTE among patients at risk of developing the condition by conducting research and providing support for quality‐improvement efforts. In 2008, AHRQ published an evidence‐based resource for prevention of VTE based on quality‐improvement principles that were successfully applied by the University of California, San Diego Medical Center, and Emory University Hospitals in an AHRQ‐funded research project. This resource, Preventing Hospital‐Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement, was updated in 2014 and is available at http://www.ahrq.gov/professionals/quality‐patient‐safety/patient‐safety‐resources/resources/vtguide/emndex.html. The guide is intended to assist quality‐improvement practitioners who wish to improve prevention of HA‐VTE in their own organizations.

Since its original release, hospital quality‐improvement teams have used the guide to close the gap between available evidence about how to prevent VTE and successful implementation of that knowledge so that hospitals can improve care as effectively and efficiently as possible. The guide includes examples of risk assessment methodologies and evaluation metrics along with other key elements that help front‐line providers establish or enhance VTE prevention programs.

AHRQ maintains an active patient safety program that spans a wide range of patient safety problems including VTE that is aimed at making healthcare safer. The AHRQ works with many different healthcare stakeholders to (1) better understand threats to patient safety and (2) develop and refine strategies that put this knowledge to work to prevent patient harm. For example, the AHRQ provides extramural research grants to investigators studying new methods of identifying patients at risk for VTE and ways to improve VTE prophylaxis in hospital patients undergoing medical treatment and surgical procedures.

In addition to a collaborative partnership with the CDC on the 2015 Healthcare‐Associated VTE Prevention Challenge, the AHRQ also partners with other federal agencies and is an active contributor to the Department of Health and Human Services National Action Plan for Adverse Drug Event Prevention. The plan outlines opportunities to advance patient safety through the prevention of adverse drug events and the promotion of medication safety among 3 drug classes including anticoagulants, a key component for VTE prevention. Patients and their families are critically important partners for improving patient safety, and the significant potential for their impact is represented by the AHRQ tools and resources such as an information video and guide for patients about the safe use of blood thinners (http://www.ahrq.gov/patients‐consumers/diagnosis‐treatment/treatments/btpills/btpills.html).

THE JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE

The Joint Commission Center for Transforming Healthcare commenced the Preventing Venous Thromboembolism project in October 2014, with 5 participating hospitals and health centers in collaboration with the CDC. The hospitals and health centers participating on this project include: Cleveland Clinic, The Johns Hopkins Hospital, Kaiser Permanente South Bay Medical Center, Massachusetts General Hospital, and Texas Health Resources.

Often, VTE risk factors are not consistently assessed across all hospital patients, and there is much variation to the selection of appropriate mechanical and/or pharmacological prophylaxis. In addition, the current accepted guidelines are not implemented consistently across hospitals. VTE rates can be reduced with accurate risk assessment and appropriate utilization of pharmacological and/or mechanical prophylaxis. However, there are multiple barriers to consistent, successful implementation of preventative measures. During the first year of this project, the participants utilized Robust Process Improvement, a fact‐based, systematic, and data‐driven problem‐solving methodology that incorporates tools and concepts from Lean, Six Sigma, and change management, to assist them in identifying the root causes and barriers to preventing VTE in at‐risk patients.

Aggregate preliminary findings show that some of the contributing factors to VTE prevention included issues with staff attitudes and beliefs, staff and patient education, risk assessments, order sets, ineffective mechanical and pharmacological prophylaxis, and patient refusal. The participating organizations are currently developing and implementing solutions targeted to their specific root causes. The solutions will be tested, validated, and then spread to other healthcare organizations. Project findings are tentatively scheduled for release in 2017.

The Joint Commission has been committed to preventing VTE for over a decade, beginning with the development of the VTE measures, which were the result of the National Consensus Standards for the Prevention and Care of Deep Vein Thrombosis project with the National Quality Forum that formally began in January 2005. In addition, The Joint Commission and Joint Commission Resources have also aimed to reduce harm and improve the quality of care for VTE patients through the Hospital Engagement Network collaborative, publications related to improving VTE patient safety, and research on improving transitions of care and discharge instructions for patients with VTE.

CENTERS FOR DISEASE CONTROL AND PREVENTION

The CDC's Division of Blood Disorders works to prevent VTE and to reduce sickness and death among those who develop VTE. The CDC's primary VTE activities focus on developing improved methods and innovative tools for monitoring and understanding VTE occurrence and the effectiveness of VTE prevention activities, conducting epidemiologic studies on the causes and outcomes of VTE and its complications, and working internally and with partners to develop and promote education and awareness materials to inform the public and healthcare providers about the importance of knowing VTE risk factors to improve prevention, and the importance of knowing the signs and symptoms of VTE to ensure early and accurate diagnosis and treatment of VTE. Recently, the CDC collaborated with the National Blood Clot Alliance, through their Stop the Clot, Spread the Word Campaign, to develop and promote prevention of VTE among hospitalized patients (https://www.stoptheclot.org/spreadtheword). To learn more about the CDC's VTE programs please visit http://www.cdc.gov/ncbddd/dvt/emndex.html.

The CDC, AHRQ, and The Joint Commission hope that readers will find the successes of the HA‐VTE Prevention Champions' initiatives informative and encouraging. They are examples of how any healthcare setting, from a small hospital to a large healthcare system, can implement approaches and tools to improve prevention of HA‐VTE.

Venous thromboembolism (VTE), blood clots occurring as deep vein thrombosis, pulmonary embolism, or both, is an important and growing public health issue. The precise number of people affected by VTE is unknown; however, estimates suggest that up to 900,000 events resulting in as many as 100,000 premature deaths occur in the United States yearly with healthcare costs as high as $10 billion.[1, 2, 3] Although anyone can develop VTE, research has shown that half of VTE events occurring in the outpatient setting are directly linked to a recent hospitalization or surgery.[4] In patients with cancer, VTE is a leading cause of death after the cancer itself.[5, 6] Fortunately, many of these healthcare‐associated VTE (HA‐VTE) cases can be prevented. Recent analyses have shown that as many as 70% of HA‐VTE cases are preventable through appropriate prophylaxis,[7, 8, 9] yet reports suggest that fewer than half of hospital patients receive VTE prophylaxis in accordance with accepted evidence‐based guidelines.[10] Appropriate prevention of HA‐VTE can result in a significant reduction in overall VTE occurrence, thereby decreasing healthcare burden and unnecessary deaths.

In November 2015, the Centers for Disease Control and Prevention (CDC) released the Healthcare‐Associated VTE Prevention Challenge (http://www.cdc.gov/ncbddd/dvt/ha‐vte‐challenge.html) to identify, highlight, and reward hospitals, managed care organizations, and hospital networks that implemented innovative, effective, and sustainable strategies to prevent HA‐VTE.

This issue of the Journal of Hospital Medicine showcases the initiatives of several of the CDC's HA‐VTE prevention champions. These champions range from a small community hospital to some of the country's largest health systems, and they represent both rural and urban areas. Together they cared for more than 450,000 patients admitted to hospitals across the United States in 2014. They were able to improve VTE prevention within their institutions and organizations by implementing successful and sustainable VTE prevention strategies such as engaging teams of different healthcare experts to support and promote prevention activities, informing patients and providers about the need for and benefits of VTE prevention, and using technology (such as electronic risk assessment and clinical decision support tools and alerts) to ensure that all patients are assessed for their risk for VTE and bleeding. These tools also help ensure that patients, when appropriate, are provided with and use appropriate prevention measures for their level of risk. Moreover, they provided real‐time feedback, scorecards, and dashboards for providers and organizations to monitor performance and identify areas for improvement.

The CDC and the Agency for Healthcare Research and Quality (AHRQ) are partnering to disseminate and promote these best practices. In addition to this challenge, the CDC, AHRQ and the Joint Commission Center for Transforming Healthcare are working on activities and programs dedicated to improving prevention of HA‐VTE. These are summarized below.

AGENCY FOR HEALTHCARE RESEARCH AND QUALITY

The AHRQ works to reduce the incidence of VTE among patients at risk of developing the condition by conducting research and providing support for quality‐improvement efforts. In 2008, AHRQ published an evidence‐based resource for prevention of VTE based on quality‐improvement principles that were successfully applied by the University of California, San Diego Medical Center, and Emory University Hospitals in an AHRQ‐funded research project. This resource, Preventing Hospital‐Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement, was updated in 2014 and is available at http://www.ahrq.gov/professionals/quality‐patient‐safety/patient‐safety‐resources/resources/vtguide/emndex.html. The guide is intended to assist quality‐improvement practitioners who wish to improve prevention of HA‐VTE in their own organizations.

Since its original release, hospital quality‐improvement teams have used the guide to close the gap between available evidence about how to prevent VTE and successful implementation of that knowledge so that hospitals can improve care as effectively and efficiently as possible. The guide includes examples of risk assessment methodologies and evaluation metrics along with other key elements that help front‐line providers establish or enhance VTE prevention programs.

AHRQ maintains an active patient safety program that spans a wide range of patient safety problems including VTE that is aimed at making healthcare safer. The AHRQ works with many different healthcare stakeholders to (1) better understand threats to patient safety and (2) develop and refine strategies that put this knowledge to work to prevent patient harm. For example, the AHRQ provides extramural research grants to investigators studying new methods of identifying patients at risk for VTE and ways to improve VTE prophylaxis in hospital patients undergoing medical treatment and surgical procedures.

In addition to a collaborative partnership with the CDC on the 2015 Healthcare‐Associated VTE Prevention Challenge, the AHRQ also partners with other federal agencies and is an active contributor to the Department of Health and Human Services National Action Plan for Adverse Drug Event Prevention. The plan outlines opportunities to advance patient safety through the prevention of adverse drug events and the promotion of medication safety among 3 drug classes including anticoagulants, a key component for VTE prevention. Patients and their families are critically important partners for improving patient safety, and the significant potential for their impact is represented by the AHRQ tools and resources such as an information video and guide for patients about the safe use of blood thinners (http://www.ahrq.gov/patients‐consumers/diagnosis‐treatment/treatments/btpills/btpills.html).

THE JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE

The Joint Commission Center for Transforming Healthcare commenced the Preventing Venous Thromboembolism project in October 2014, with 5 participating hospitals and health centers in collaboration with the CDC. The hospitals and health centers participating on this project include: Cleveland Clinic, The Johns Hopkins Hospital, Kaiser Permanente South Bay Medical Center, Massachusetts General Hospital, and Texas Health Resources.

Often, VTE risk factors are not consistently assessed across all hospital patients, and there is much variation to the selection of appropriate mechanical and/or pharmacological prophylaxis. In addition, the current accepted guidelines are not implemented consistently across hospitals. VTE rates can be reduced with accurate risk assessment and appropriate utilization of pharmacological and/or mechanical prophylaxis. However, there are multiple barriers to consistent, successful implementation of preventative measures. During the first year of this project, the participants utilized Robust Process Improvement, a fact‐based, systematic, and data‐driven problem‐solving methodology that incorporates tools and concepts from Lean, Six Sigma, and change management, to assist them in identifying the root causes and barriers to preventing VTE in at‐risk patients.

Aggregate preliminary findings show that some of the contributing factors to VTE prevention included issues with staff attitudes and beliefs, staff and patient education, risk assessments, order sets, ineffective mechanical and pharmacological prophylaxis, and patient refusal. The participating organizations are currently developing and implementing solutions targeted to their specific root causes. The solutions will be tested, validated, and then spread to other healthcare organizations. Project findings are tentatively scheduled for release in 2017.

The Joint Commission has been committed to preventing VTE for over a decade, beginning with the development of the VTE measures, which were the result of the National Consensus Standards for the Prevention and Care of Deep Vein Thrombosis project with the National Quality Forum that formally began in January 2005. In addition, The Joint Commission and Joint Commission Resources have also aimed to reduce harm and improve the quality of care for VTE patients through the Hospital Engagement Network collaborative, publications related to improving VTE patient safety, and research on improving transitions of care and discharge instructions for patients with VTE.

CENTERS FOR DISEASE CONTROL AND PREVENTION

The CDC's Division of Blood Disorders works to prevent VTE and to reduce sickness and death among those who develop VTE. The CDC's primary VTE activities focus on developing improved methods and innovative tools for monitoring and understanding VTE occurrence and the effectiveness of VTE prevention activities, conducting epidemiologic studies on the causes and outcomes of VTE and its complications, and working internally and with partners to develop and promote education and awareness materials to inform the public and healthcare providers about the importance of knowing VTE risk factors to improve prevention, and the importance of knowing the signs and symptoms of VTE to ensure early and accurate diagnosis and treatment of VTE. Recently, the CDC collaborated with the National Blood Clot Alliance, through their Stop the Clot, Spread the Word Campaign, to develop and promote prevention of VTE among hospitalized patients (https://www.stoptheclot.org/spreadtheword). To learn more about the CDC's VTE programs please visit http://www.cdc.gov/ncbddd/dvt/emndex.html.

The CDC, AHRQ, and The Joint Commission hope that readers will find the successes of the HA‐VTE Prevention Champions' initiatives informative and encouraging. They are examples of how any healthcare setting, from a small hospital to a large healthcare system, can implement approaches and tools to improve prevention of HA‐VTE.

Venous thromboembolism (VTE), which encompasses deep venous thrombosis and pulmonary embolism, is an important cause of preventable morbidity and mortality.[1] Each year it is estimated as many as 600,000 American's suffer VTE and as many as 100,000 die.[2] Consequently, patient safety and healthcare quality, accrediting organizations such as The Joint Commission, and federal agencies such as the Centers for Disease Control and Prevention and Agency for Healthcare Research and Quality (AHRQ) have made VTE prevention a priority.[3, 4, 5]

Despite widespread recognition that VTE prophylaxis is an important patient safety measure, poor performance is common. The ENDORSE (Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting) study of over 68,000 hospitalized patients in 32 countries noted only 58.5% of surgical patients and 39.5% medical patients received American College of Chest Physicians (ACCP) guideline‐appropriate VTE prophylaxis.[6] In 2005, an audit of the surgical services at The Johns Hopkins Hospital found that only 33% of 322 randomly selected patients were prescribed prophylaxis consistent with the ACCP guidelines.

Achieving defect‐free VTE prevention requires attention to each step in the process: (1) assessment of both VTE and bleeding risk, (2) prescription of risk‐appropriate VTE prophylaxis, and (3) administration of risk‐appropriate VTE prophylaxis. In 2005, to improve our VTE prevention performance at Johns Hopkins Hospital, the Center for Innovations organized a VTE Collaborative of 2 physicians, 1 nurse, and 1 pharmacist dedicated to VTE quality improvement. Since then, the group has grown dramatically, adding a clinical informatics expert and numerous other members and coming under the auspices of The Armstrong Institute for Patient Safety. Recognizing that many, though not all, VTEs are potentially preventable,[7, 8] the mission of the Johns Hopkins VTE Collaborative is to ensure that all hospitalized patients receive risk‐appropriate, best‐practice VTE prophylaxis. This article chronicles the innovative strategies that the Johns Hopkins VTE Collaborative has employed over the past decade to improve our hospital's performance in VTE prevention (Table 1).

ENSURING EVERY PATIENT IS PRESCRIBED RISK‐APPROPRIATE PROPHYLAXIS

With the support of hospital leadership, the VTE Collaborative held a series of events in 2005 with medical and surgical providers to review the current evidence supporting VTE prophylaxis and achieve consensus on appropriate practice based upon the 2004 ACCP VTE Prophylaxis Guideline. The result was the development of 5 evidence‐based, paper VTE prophylaxis order sets that guided the ordering provider on the assessment of VTE and bleeding risk and facilitated the selection of risk‐appropriate VTE prophylaxis. Because there were no validated VTE or bleeding risk assessment tools at the time we developed our order sets, we used specialty‐specific VTE risk factors derived from the 2004 ACCP Guideline. To identify patients inappropriate for pharmacologic prophylaxis, we used exclusion criteria derived from contemporary randomized clinical trials of pharmacologic prophylaxis in the target populations (ie, active bleeding, abnormal activated partial thromboplastin time not due to a lupus inhibitor) or mutually agreed upon thresholds after discussion with individual provider groups (platelet count <50,000/L). On the Johns Hopkins Hospital inpatient acute rehabilitation unit, introduction of the paper order sets increased adherence with ACCP guidelines from 27% to 98% (P < 0.0001) and reduced symptomatic VTE from 49 per 1000 admissions to 8 per 1000 admissions (P = 0.0001).[9] This study demonstrated that paper order sets used consistently by a dedicated group of providers can result in sustained improvements in practice. Paper order sets remain a low‐tech, easy‐to‐implement strategy that can be applied in any healthcare setting. Other services also saw improvements in risk‐appropriate prophylaxis prescription. In a follow‐up cross‐sectional analysis of the surgical services at Johns Hopkins, we found that appropriate VTE prophylaxis prescription improved from 33% to 62% in a sample of 226 patients. Unfortunately, paper order sets had several disadvantages including (1) the inherent difficulty of making them a mandatory part of the admission or transfer process, (2) their existence outside the usual clinical workflow, and (3) the labor‐ and time‐intensive data collection that made it difficult to provide credible, timely performance reports to providers and leadership.

These disadvantages and our adoption of a computerized provider order entry system prompted us to pursue the development and implementation of mandatory, evidence‐based, specialty‐specific computerized clinical decision support (CCDS) VTE prophylaxis order sets. Using the Translating Research Into Practice approach to quality improvement,[10] we collaborated with providers to design 16 different evidence‐based specialty‐specific CCDS VTE order sets. These CCDS VTE order sets, which are imbedded in the specialty‐specific admission and transfer order sets, assist providers in assessing patients' VTE and bleeding risk factors and provide evidence‐based risk‐appropriate VTE prophylaxis (see Supporting Figure 1 in the online version of this article). Individual patient data are saved in an administrative database and can be easily aggregated for research analyses and quality improvement/performance reporting. A detailed discussion of our strategy for change is discussed in Streiff et al.[11] Because pharmacologic prophylaxis is not appropriate for every patient, and not all VTE are preventable, even with perfect prophylaxis, the goals of our collaborative are to ensure that every patient is ordered VTE prophylaxis consistent with their risk profile (risk‐appropriate prophylaxis) and to eliminate preventable episodes of VTE (VTE that occurs in the setting of suboptimal prophylaxis). In a prepost quasi‐experimental study of 1599 trauma patients, the CCDS VTE order set increased risk‐appropriate prophylaxis prescription from 66.2% to 84.4% (P < .001) and reduced the incidence of potentially preventable harm from VTE from 1% to 0.17% (P = 0.04) (Figure 1).[12] On the medical service, the CCDS VTE order set improved risk‐appropriate VTE prophylaxis prescription from 65.6% to 90.1% (P < 0.0001) and reduced the incidence of potentially preventable harm attributable to VTE from 1.1% to 0% (P = 0.001). There was no increase in major bleeding (International Society of Thrombosis and Hemostasis definition: hemoglobin decline of 2 grams/dL or transfusion of 2 or more units of blood or bleeding into a critical organ such as brain, gastrointestinal tract, or eye) postorder set implementation (0.3% vs 0.1%, P = 0.625) or all‐cause mortality (1.3% vs 2.0%, P = 0.285).[13]

Figure 1

These order sets demonstrated that CCDS tools can lead to significant improvements in prescribing practices and reductions in preventable harm from VTE without increasing the risk of major bleeding complications. In addition to improving the quality of care, the order sets also improved the consistency of care. In a retrospective analysis, we found that implementation of CCDS VTE order sets eliminated racial disparities in prescribing practices. In the preimplementation group, risk‐appropriate VTE prophylaxis was prescribed for 70.1% of black patients and 56.6% of white patients on the trauma service (P = 0.025) and 69.5% of black patients and 61.7% of white patients on the medical service (P = 0.015). After implementation of the CCDS VTE order sets, care improved for all patients such that the previously observed disparities were eliminated (trauma service 84.5% vs 85.5%, P = 0.99 and medical service 91.8% vs 88.0%, P = 0.082).[14] These data indicate that standardizing care can potentially eliminate disparities in clinical practice.

Although implementation of mandatory evidence‐based, specialty‐specific CDSS VTE order sets led to substantial improvements in VTE prophylaxis ordering, high performance was not uniform across our institution. On the medical service, substantial disparities in adherence to order set recommendations existed. On the housestaff services, over 90% of patients consistently received risk‐appropriate VTE prophylaxis compared with only 85% on the hospitalist service. Examination of individual provider performance found that some providers only ordered risk‐appropriate prophylaxis 50% of the time, whereas others were doing so 98% of the time. To address this disparity, we conducted a retrospective analysis of a prospective performance improvement project conducted on the Johns Hopkins Hospitalist service studying the impact of individualized hospitalist attending feedback on VTE prevention practices. During the preintervention period (January 2009December 2010), guideline‐adherent VTE prophylaxis was ordered for 86% (95% confidence interval [CI]: 85%‐88%) of patients. Six months after initiation of direct face‐to‐face provider feedback (January 2011June 2011), guideline‐adherent VTE prophylaxis rates rose to 90% (95% CI: 88‐93). Subsequently (July 2011December 2012), a pay‐for‐performance (P4P) initiative was added to direct face‐to‐face provider feedback. During the P4P initiative, provider incentive per relative value unit (RVU) was progressively increased with increasing performance on provision of risk‐appropriate VTE prophylaxis (adherence <80% = no bonus to $0.50 per RVU for adherence 95%). During this period, prescription of guideline‐adherent prophylaxis rose to 94% (95% CI: 93%‐96%).[15] These initiatives transformed the hospitalist unit from a consistently low‐performance unit to a high‐performance unit.

Similar findings were noted on the trauma service. Although the original plan was to provide feedback to attending trauma surgeons, that plan changed when we found that performance was driven entirely by resident practice; residents write the VTE prophylaxis orders, which is then attributed to attending performance. Resident performance varied widely; 42 of 75 (56%) residents on the trauma service ordered risk‐appropriate prophylaxis for 100% of their patients. In contrast, 7 (9.3%) residents never ordered optimal prophylaxis for any of their patients.[16] To motivate all residents to prescribe optimal prophylaxis, we developed an individualized resident VTE prophylaxis scorecard (Figure 2). This prospective cohort study of 2420 patients and 49 general surgery residents compared resident VTE prophylaxis performance on the general surgery service during 3 periods: period 1 (baseline, July 2013September 2013), period 2 (surgery resident scorecard, October 2013December 2013), period 3 (resident scorecard plus individualized 1‐on‐1 coaching, January 2014March 2014). At baseline, 89.4% of patients were prescribed appropriate VTE prophylaxis, and only 45% of residents prescribed risk‐appropriate prophylaxis for all their patients. During the scorecard period, 95.4% of patients were prescribed risk‐appropriate VTE prophylaxis (P < 0.001). During the scorecard plus coaching period, risk‐appropriate prophylaxis rose to 96.4%. These prescribing practice changes were durable. During the 15 months prior to issuing scorecards, 88.0% of patients (3718/4226) were prescribed risk‐appropriate prophylaxis. After implementation, 95.8% of patients (3799/3966) were prescribed risk‐appropriate prophylaxis (P < 0.001) (see Supporting Figure 2 in the online version of this article). During the baseline period, 7 of 865 patients (0.81%) had a VTE during their hospital stay, of which 3 (0.35%) were potentially preventable. In contrast, none of the 3 of 784 patients who suffered VTE during the postimplementation period had a potentially preventable event (0.35% vs 0%, P = 0.046).[17] These studies demonstrate that providing physicians with their own specific data can be a powerful tool for performance improvement that may be applicable to many other quality and safety measures. Our group recently received funding from the AHRQ to scale this work to other residents, nurse practitioners, physician assistants, and attending physicians (1R01HS024547, Individualized Performance Feedback on Venous Thromboembolism Prevention Practice).

Figure 2

IMPROVING VTE PROPHYLAXIS ADMINISTRATION

Ordering VTE prophylaxis does not ensure its administration. We conducted a retrospective review of electronic administration records of 10,526 consecutive patients admitted over a 7‐month period at The Johns Hopkins Hospital. Twelve percent of the over 100,000 ordered doses of VTE prophylaxis were not administered, and the proportion of nonadministered doses on individual floors varied 5‐fold from 5.4% to 26.9%. The proportion of nonadministered doses was significantly higher on medical floors compared with all other services (17.5% vs 8.1%, odds ratio [OR]: 2.1 [95% CI: 2.0‐2.2]). Patient or family member refusal was the most common cause for nonadministered doses of VTE prophylaxis accounting for 59% of all missed doses. Eight percent of patients missed more than half their prescribed doses, and 5% of patients missed over 75% of ordered doses of VTE prophylaxis. Consistent with the Pareto principle, over 80% of the missed doses of prophylaxis were accounted for by just 20% of the patients.[18] A retrospective analysis of hospital‐acquired VTE at Johns Hopkins found that 39% of events occurred in patients who missed 1 or more doses of appropriate VTE prophylaxis.[19] Louis et al. noted that nonadministration of 1 dose of VTE prophylaxis was associated with a significant increase in risk for hospital acquired VTE.[20] These data indicate the need for more aggressive interventions to reduce missed doses to improve VTE prevention.

To fully understand the root causes of VTE prophylaxis non‐administration, we conducted a series of studies examining each of the participants in the VTE prevention care pathway, physicians, nurses, and patients. In a survey of 122 resident physicians, we found significant differences in clinical practice between medicine and surgery residents. Medicine residents were more likely to believe that VTE prophylaxis was overprescribed, and that it was appropriate for nurses to make judgement calls about whether patients needed the prophylaxis that was prescribed.[21] In a mixed methods study that included a written survey and qualitative observations of nursing practice, we found that some nurses presented pharmacologic VTE prophylaxis injections as optional to patients. Furthermore, nurses on units where nonadministration was higher were more likely to believe that VTE prophylaxis was prescribed for patients unnecessarily, and that they could use their clinical judgement to determine when it was appropriate to omit doses of pharmacologic prophylaxis.[22] Our team also examined patient preferences in regard to VTE prophylaxis. In a survey of 227 consecutive medical and surgical inpatients, we found that 60% of patients would prefer an oral route of administration if available. Patients with a preference for a parenteral route of administration (27.5%) were less likely to refuse prophylaxis (37.5% vs 51.3%, P < 0.0001).[23] These findings underscore the fact that unit culture, nursing attitudes and beliefs, and patient preferences have an important influence on medication administration, and that nursepatient communication is an important target for modifying adherence.

PATIENT‐CENTERED APPROACHES TO IMPROVE VTE PROPHYLAXIS ADMINISTRATION

To address nurse‐ and patient‐related factors that influence VTE prophylaxis administration, we applied for and received a Patient Centered Outcomes Research Institute contract to develop patient‐centered interventions to engage and empower patients to take an active role in their preventive care. To achieve these aims, we partnered with 3 national patient advocacy organizations, the National Blood Clot Alliance, the North American Thrombosis Forum, and ClotCare, as well as our local Johns Hopkins Patient and Family Advisory Council. Using a modified Delphi method, we engaged patient stakeholders from the 4 collaborating organizations to build consensus on patient‐centered VTE education methods. Input from this Delphi assessment was used to build educational materials including paper brochures published in 8 different languages and a 10‐minute educational video filmed by an Oscar‐winning documentary director featuring both clinicians and patients relating their VTE experience and the importance of VTE prevention.[24] These educational materials are available for public use (http://www.hopkinsmedicine.org/armstrong_institute/emmprovement_projects/VTE/) and are being used in a trial of a patient‐centered intervention bundle to reduce rates of VTE prophylaxis nonadministration. We also conducted a cluster‐randomized trial to compare different approaches to nurse education (https://clinicaltrials.gov/ct2/show/NCT02301793).

ENGAGING TRAINEES IN MULTIDISCIPLINARY PATIENT SAFETY/QUALITY IMPROVEMENT INITIATIVES

Trainees from many healthcare‐related disciplines have played a critical role in our quest to improve VTE prevention. Over the past 10 years, we have mentored countless medical students, public health graduate students, nursing students, residents, and postdoctoral fellows in research projects that have resulted in numerous high‐quality publications. Trainees have helped to dispel staff concerns about patient falls in connection of intermittent pneumatic compression devices,[25] identify the weaknesses of current publicly reported VTE measures,[26, 27, 28, 29] identify opportunities to improve VTE prevention practices within clinical specialties,[30, 31, 32] define the role of surveillance bias in VTE outcomes reporting,[33, 34, 35] discover and fully explore the important problem of missed doses of VTE prophylaxis,[18, 21, 22, 23, 36] and summarize knowledge about VTE prevention via systematic reviews and meta‐analyses.[37, 38, 39] These collaborations have been a classic win‐win. The mentees learn critical skills while growing their curriculum vitae with contributions to the literature, allowing them to progress in their careers (ie, obtain a residency match, faculty positions). The faculty have leveraged this work to obtain over $3 million in extramural funding to develop interventions to study and improve the quality of VTE preventive care for hospitalized patients.

In healthcare, we have not yet achieved defect‐free VTE prevention; however, we have a better understanding of the path to accomplishing this goal. In this article we describe our goal of zero harm from VTE and our learning journey to realize that goal. Although the journey never ends, a critical ingredient to the success of our program has been the multidisciplinary nature of our VTE collaborative team. The combination of expertise from medicine, surgery, nursing, pharmacy, clinical informatics, and public health has facilitated the development of innovative strategies to improve VTE prevention that integrate seamlessly into clinical workflow. The approach used for VTE can be applied to eliminate other types of harms.

Venous thromboembolism (VTE), which encompasses deep venous thrombosis and pulmonary embolism, is an important cause of preventable morbidity and mortality.[1] Each year it is estimated as many as 600,000 American's suffer VTE and as many as 100,000 die.[2] Consequently, patient safety and healthcare quality, accrediting organizations such as The Joint Commission, and federal agencies such as the Centers for Disease Control and Prevention and Agency for Healthcare Research and Quality (AHRQ) have made VTE prevention a priority.[3, 4, 5]

Despite widespread recognition that VTE prophylaxis is an important patient safety measure, poor performance is common. The ENDORSE (Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting) study of over 68,000 hospitalized patients in 32 countries noted only 58.5% of surgical patients and 39.5% medical patients received American College of Chest Physicians (ACCP) guideline‐appropriate VTE prophylaxis.[6] In 2005, an audit of the surgical services at The Johns Hopkins Hospital found that only 33% of 322 randomly selected patients were prescribed prophylaxis consistent with the ACCP guidelines.

Achieving defect‐free VTE prevention requires attention to each step in the process: (1) assessment of both VTE and bleeding risk, (2) prescription of risk‐appropriate VTE prophylaxis, and (3) administration of risk‐appropriate VTE prophylaxis. In 2005, to improve our VTE prevention performance at Johns Hopkins Hospital, the Center for Innovations organized a VTE Collaborative of 2 physicians, 1 nurse, and 1 pharmacist dedicated to VTE quality improvement. Since then, the group has grown dramatically, adding a clinical informatics expert and numerous other members and coming under the auspices of The Armstrong Institute for Patient Safety. Recognizing that many, though not all, VTEs are potentially preventable,[7, 8] the mission of the Johns Hopkins VTE Collaborative is to ensure that all hospitalized patients receive risk‐appropriate, best‐practice VTE prophylaxis. This article chronicles the innovative strategies that the Johns Hopkins VTE Collaborative has employed over the past decade to improve our hospital's performance in VTE prevention (Table 1).

ENSURING EVERY PATIENT IS PRESCRIBED RISK‐APPROPRIATE PROPHYLAXIS

With the support of hospital leadership, the VTE Collaborative held a series of events in 2005 with medical and surgical providers to review the current evidence supporting VTE prophylaxis and achieve consensus on appropriate practice based upon the 2004 ACCP VTE Prophylaxis Guideline. The result was the development of 5 evidence‐based, paper VTE prophylaxis order sets that guided the ordering provider on the assessment of VTE and bleeding risk and facilitated the selection of risk‐appropriate VTE prophylaxis. Because there were no validated VTE or bleeding risk assessment tools at the time we developed our order sets, we used specialty‐specific VTE risk factors derived from the 2004 ACCP Guideline. To identify patients inappropriate for pharmacologic prophylaxis, we used exclusion criteria derived from contemporary randomized clinical trials of pharmacologic prophylaxis in the target populations (ie, active bleeding, abnormal activated partial thromboplastin time not due to a lupus inhibitor) or mutually agreed upon thresholds after discussion with individual provider groups (platelet count <50,000/L). On the Johns Hopkins Hospital inpatient acute rehabilitation unit, introduction of the paper order sets increased adherence with ACCP guidelines from 27% to 98% (P < 0.0001) and reduced symptomatic VTE from 49 per 1000 admissions to 8 per 1000 admissions (P = 0.0001).[9] This study demonstrated that paper order sets used consistently by a dedicated group of providers can result in sustained improvements in practice. Paper order sets remain a low‐tech, easy‐to‐implement strategy that can be applied in any healthcare setting. Other services also saw improvements in risk‐appropriate prophylaxis prescription. In a follow‐up cross‐sectional analysis of the surgical services at Johns Hopkins, we found that appropriate VTE prophylaxis prescription improved from 33% to 62% in a sample of 226 patients. Unfortunately, paper order sets had several disadvantages including (1) the inherent difficulty of making them a mandatory part of the admission or transfer process, (2) their existence outside the usual clinical workflow, and (3) the labor‐ and time‐intensive data collection that made it difficult to provide credible, timely performance reports to providers and leadership.

These disadvantages and our adoption of a computerized provider order entry system prompted us to pursue the development and implementation of mandatory, evidence‐based, specialty‐specific computerized clinical decision support (CCDS) VTE prophylaxis order sets. Using the Translating Research Into Practice approach to quality improvement,[10] we collaborated with providers to design 16 different evidence‐based specialty‐specific CCDS VTE order sets. These CCDS VTE order sets, which are imbedded in the specialty‐specific admission and transfer order sets, assist providers in assessing patients' VTE and bleeding risk factors and provide evidence‐based risk‐appropriate VTE prophylaxis (see Supporting Figure 1 in the online version of this article). Individual patient data are saved in an administrative database and can be easily aggregated for research analyses and quality improvement/performance reporting. A detailed discussion of our strategy for change is discussed in Streiff et al.[11] Because pharmacologic prophylaxis is not appropriate for every patient, and not all VTE are preventable, even with perfect prophylaxis, the goals of our collaborative are to ensure that every patient is ordered VTE prophylaxis consistent with their risk profile (risk‐appropriate prophylaxis) and to eliminate preventable episodes of VTE (VTE that occurs in the setting of suboptimal prophylaxis). In a prepost quasi‐experimental study of 1599 trauma patients, the CCDS VTE order set increased risk‐appropriate prophylaxis prescription from 66.2% to 84.4% (P < .001) and reduced the incidence of potentially preventable harm from VTE from 1% to 0.17% (P = 0.04) (Figure 1).[12] On the medical service, the CCDS VTE order set improved risk‐appropriate VTE prophylaxis prescription from 65.6% to 90.1% (P < 0.0001) and reduced the incidence of potentially preventable harm attributable to VTE from 1.1% to 0% (P = 0.001). There was no increase in major bleeding (International Society of Thrombosis and Hemostasis definition: hemoglobin decline of 2 grams/dL or transfusion of 2 or more units of blood or bleeding into a critical organ such as brain, gastrointestinal tract, or eye) postorder set implementation (0.3% vs 0.1%, P = 0.625) or all‐cause mortality (1.3% vs 2.0%, P = 0.285).[13]

Figure 1

These order sets demonstrated that CCDS tools can lead to significant improvements in prescribing practices and reductions in preventable harm from VTE without increasing the risk of major bleeding complications. In addition to improving the quality of care, the order sets also improved the consistency of care. In a retrospective analysis, we found that implementation of CCDS VTE order sets eliminated racial disparities in prescribing practices. In the preimplementation group, risk‐appropriate VTE prophylaxis was prescribed for 70.1% of black patients and 56.6% of white patients on the trauma service (P = 0.025) and 69.5% of black patients and 61.7% of white patients on the medical service (P = 0.015). After implementation of the CCDS VTE order sets, care improved for all patients such that the previously observed disparities were eliminated (trauma service 84.5% vs 85.5%, P = 0.99 and medical service 91.8% vs 88.0%, P = 0.082).[14] These data indicate that standardizing care can potentially eliminate disparities in clinical practice.

Although implementation of mandatory evidence‐based, specialty‐specific CDSS VTE order sets led to substantial improvements in VTE prophylaxis ordering, high performance was not uniform across our institution. On the medical service, substantial disparities in adherence to order set recommendations existed. On the housestaff services, over 90% of patients consistently received risk‐appropriate VTE prophylaxis compared with only 85% on the hospitalist service. Examination of individual provider performance found that some providers only ordered risk‐appropriate prophylaxis 50% of the time, whereas others were doing so 98% of the time. To address this disparity, we conducted a retrospective analysis of a prospective performance improvement project conducted on the Johns Hopkins Hospitalist service studying the impact of individualized hospitalist attending feedback on VTE prevention practices. During the preintervention period (January 2009December 2010), guideline‐adherent VTE prophylaxis was ordered for 86% (95% confidence interval [CI]: 85%‐88%) of patients. Six months after initiation of direct face‐to‐face provider feedback (January 2011June 2011), guideline‐adherent VTE prophylaxis rates rose to 90% (95% CI: 88‐93). Subsequently (July 2011December 2012), a pay‐for‐performance (P4P) initiative was added to direct face‐to‐face provider feedback. During the P4P initiative, provider incentive per relative value unit (RVU) was progressively increased with increasing performance on provision of risk‐appropriate VTE prophylaxis (adherence <80% = no bonus to $0.50 per RVU for adherence 95%). During this period, prescription of guideline‐adherent prophylaxis rose to 94% (95% CI: 93%‐96%).[15] These initiatives transformed the hospitalist unit from a consistently low‐performance unit to a high‐performance unit.

Similar findings were noted on the trauma service. Although the original plan was to provide feedback to attending trauma surgeons, that plan changed when we found that performance was driven entirely by resident practice; residents write the VTE prophylaxis orders, which is then attributed to attending performance. Resident performance varied widely; 42 of 75 (56%) residents on the trauma service ordered risk‐appropriate prophylaxis for 100% of their patients. In contrast, 7 (9.3%) residents never ordered optimal prophylaxis for any of their patients.[16] To motivate all residents to prescribe optimal prophylaxis, we developed an individualized resident VTE prophylaxis scorecard (Figure 2). This prospective cohort study of 2420 patients and 49 general surgery residents compared resident VTE prophylaxis performance on the general surgery service during 3 periods: period 1 (baseline, July 2013September 2013), period 2 (surgery resident scorecard, October 2013December 2013), period 3 (resident scorecard plus individualized 1‐on‐1 coaching, January 2014March 2014). At baseline, 89.4% of patients were prescribed appropriate VTE prophylaxis, and only 45% of residents prescribed risk‐appropriate prophylaxis for all their patients. During the scorecard period, 95.4% of patients were prescribed risk‐appropriate VTE prophylaxis (P < 0.001). During the scorecard plus coaching period, risk‐appropriate prophylaxis rose to 96.4%. These prescribing practice changes were durable. During the 15 months prior to issuing scorecards, 88.0% of patients (3718/4226) were prescribed risk‐appropriate prophylaxis. After implementation, 95.8% of patients (3799/3966) were prescribed risk‐appropriate prophylaxis (P < 0.001) (see Supporting Figure 2 in the online version of this article). During the baseline period, 7 of 865 patients (0.81%) had a VTE during their hospital stay, of which 3 (0.35%) were potentially preventable. In contrast, none of the 3 of 784 patients who suffered VTE during the postimplementation period had a potentially preventable event (0.35% vs 0%, P = 0.046).[17] These studies demonstrate that providing physicians with their own specific data can be a powerful tool for performance improvement that may be applicable to many other quality and safety measures. Our group recently received funding from the AHRQ to scale this work to other residents, nurse practitioners, physician assistants, and attending physicians (1R01HS024547, Individualized Performance Feedback on Venous Thromboembolism Prevention Practice).

Figure 2

IMPROVING VTE PROPHYLAXIS ADMINISTRATION

Ordering VTE prophylaxis does not ensure its administration. We conducted a retrospective review of electronic administration records of 10,526 consecutive patients admitted over a 7‐month period at The Johns Hopkins Hospital. Twelve percent of the over 100,000 ordered doses of VTE prophylaxis were not administered, and the proportion of nonadministered doses on individual floors varied 5‐fold from 5.4% to 26.9%. The proportion of nonadministered doses was significantly higher on medical floors compared with all other services (17.5% vs 8.1%, odds ratio [OR]: 2.1 [95% CI: 2.0‐2.2]). Patient or family member refusal was the most common cause for nonadministered doses of VTE prophylaxis accounting for 59% of all missed doses. Eight percent of patients missed more than half their prescribed doses, and 5% of patients missed over 75% of ordered doses of VTE prophylaxis. Consistent with the Pareto principle, over 80% of the missed doses of prophylaxis were accounted for by just 20% of the patients.[18] A retrospective analysis of hospital‐acquired VTE at Johns Hopkins found that 39% of events occurred in patients who missed 1 or more doses of appropriate VTE prophylaxis.[19] Louis et al. noted that nonadministration of 1 dose of VTE prophylaxis was associated with a significant increase in risk for hospital acquired VTE.[20] These data indicate the need for more aggressive interventions to reduce missed doses to improve VTE prevention.

To fully understand the root causes of VTE prophylaxis non‐administration, we conducted a series of studies examining each of the participants in the VTE prevention care pathway, physicians, nurses, and patients. In a survey of 122 resident physicians, we found significant differences in clinical practice between medicine and surgery residents. Medicine residents were more likely to believe that VTE prophylaxis was overprescribed, and that it was appropriate for nurses to make judgement calls about whether patients needed the prophylaxis that was prescribed.[21] In a mixed methods study that included a written survey and qualitative observations of nursing practice, we found that some nurses presented pharmacologic VTE prophylaxis injections as optional to patients. Furthermore, nurses on units where nonadministration was higher were more likely to believe that VTE prophylaxis was prescribed for patients unnecessarily, and that they could use their clinical judgement to determine when it was appropriate to omit doses of pharmacologic prophylaxis.[22] Our team also examined patient preferences in regard to VTE prophylaxis. In a survey of 227 consecutive medical and surgical inpatients, we found that 60% of patients would prefer an oral route of administration if available. Patients with a preference for a parenteral route of administration (27.5%) were less likely to refuse prophylaxis (37.5% vs 51.3%, P < 0.0001).[23] These findings underscore the fact that unit culture, nursing attitudes and beliefs, and patient preferences have an important influence on medication administration, and that nursepatient communication is an important target for modifying adherence.

PATIENT‐CENTERED APPROACHES TO IMPROVE VTE PROPHYLAXIS ADMINISTRATION

To address nurse‐ and patient‐related factors that influence VTE prophylaxis administration, we applied for and received a Patient Centered Outcomes Research Institute contract to develop patient‐centered interventions to engage and empower patients to take an active role in their preventive care. To achieve these aims, we partnered with 3 national patient advocacy organizations, the National Blood Clot Alliance, the North American Thrombosis Forum, and ClotCare, as well as our local Johns Hopkins Patient and Family Advisory Council. Using a modified Delphi method, we engaged patient stakeholders from the 4 collaborating organizations to build consensus on patient‐centered VTE education methods. Input from this Delphi assessment was used to build educational materials including paper brochures published in 8 different languages and a 10‐minute educational video filmed by an Oscar‐winning documentary director featuring both clinicians and patients relating their VTE experience and the importance of VTE prevention.[24] These educational materials are available for public use (http://www.hopkinsmedicine.org/armstrong_institute/emmprovement_projects/VTE/) and are being used in a trial of a patient‐centered intervention bundle to reduce rates of VTE prophylaxis nonadministration. We also conducted a cluster‐randomized trial to compare different approaches to nurse education (https://clinicaltrials.gov/ct2/show/NCT02301793).

ENGAGING TRAINEES IN MULTIDISCIPLINARY PATIENT SAFETY/QUALITY IMPROVEMENT INITIATIVES

Trainees from many healthcare‐related disciplines have played a critical role in our quest to improve VTE prevention. Over the past 10 years, we have mentored countless medical students, public health graduate students, nursing students, residents, and postdoctoral fellows in research projects that have resulted in numerous high‐quality publications. Trainees have helped to dispel staff concerns about patient falls in connection of intermittent pneumatic compression devices,[25] identify the weaknesses of current publicly reported VTE measures,[26, 27, 28, 29] identify opportunities to improve VTE prevention practices within clinical specialties,[30, 31, 32] define the role of surveillance bias in VTE outcomes reporting,[33, 34, 35] discover and fully explore the important problem of missed doses of VTE prophylaxis,[18, 21, 22, 23, 36] and summarize knowledge about VTE prevention via systematic reviews and meta‐analyses.[37, 38, 39] These collaborations have been a classic win‐win. The mentees learn critical skills while growing their curriculum vitae with contributions to the literature, allowing them to progress in their careers (ie, obtain a residency match, faculty positions). The faculty have leveraged this work to obtain over $3 million in extramural funding to develop interventions to study and improve the quality of VTE preventive care for hospitalized patients.

In healthcare, we have not yet achieved defect‐free VTE prevention; however, we have a better understanding of the path to accomplishing this goal. In this article we describe our goal of zero harm from VTE and our learning journey to realize that goal. Although the journey never ends, a critical ingredient to the success of our program has been the multidisciplinary nature of our VTE collaborative team. The combination of expertise from medicine, surgery, nursing, pharmacy, clinical informatics, and public health has facilitated the development of innovative strategies to improve VTE prevention that integrate seamlessly into clinical workflow. The approach used for VTE can be applied to eliminate other types of harms.

Venous thromboembolism (VTE), which encompasses deep venous thrombosis and pulmonary embolism, is an important cause of preventable morbidity and mortality.[1] Each year it is estimated as many as 600,000 American's suffer VTE and as many as 100,000 die.[2] Consequently, patient safety and healthcare quality, accrediting organizations such as The Joint Commission, and federal agencies such as the Centers for Disease Control and Prevention and Agency for Healthcare Research and Quality (AHRQ) have made VTE prevention a priority.[3, 4, 5]

Despite widespread recognition that VTE prophylaxis is an important patient safety measure, poor performance is common. The ENDORSE (Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting) study of over 68,000 hospitalized patients in 32 countries noted only 58.5% of surgical patients and 39.5% medical patients received American College of Chest Physicians (ACCP) guideline‐appropriate VTE prophylaxis.[6] In 2005, an audit of the surgical services at The Johns Hopkins Hospital found that only 33% of 322 randomly selected patients were prescribed prophylaxis consistent with the ACCP guidelines.

Achieving defect‐free VTE prevention requires attention to each step in the process: (1) assessment of both VTE and bleeding risk, (2) prescription of risk‐appropriate VTE prophylaxis, and (3) administration of risk‐appropriate VTE prophylaxis. In 2005, to improve our VTE prevention performance at Johns Hopkins Hospital, the Center for Innovations organized a VTE Collaborative of 2 physicians, 1 nurse, and 1 pharmacist dedicated to VTE quality improvement. Since then, the group has grown dramatically, adding a clinical informatics expert and numerous other members and coming under the auspices of The Armstrong Institute for Patient Safety. Recognizing that many, though not all, VTEs are potentially preventable,[7, 8] the mission of the Johns Hopkins VTE Collaborative is to ensure that all hospitalized patients receive risk‐appropriate, best‐practice VTE prophylaxis. This article chronicles the innovative strategies that the Johns Hopkins VTE Collaborative has employed over the past decade to improve our hospital's performance in VTE prevention (Table 1).

ENSURING EVERY PATIENT IS PRESCRIBED RISK‐APPROPRIATE PROPHYLAXIS

With the support of hospital leadership, the VTE Collaborative held a series of events in 2005 with medical and surgical providers to review the current evidence supporting VTE prophylaxis and achieve consensus on appropriate practice based upon the 2004 ACCP VTE Prophylaxis Guideline. The result was the development of 5 evidence‐based, paper VTE prophylaxis order sets that guided the ordering provider on the assessment of VTE and bleeding risk and facilitated the selection of risk‐appropriate VTE prophylaxis. Because there were no validated VTE or bleeding risk assessment tools at the time we developed our order sets, we used specialty‐specific VTE risk factors derived from the 2004 ACCP Guideline. To identify patients inappropriate for pharmacologic prophylaxis, we used exclusion criteria derived from contemporary randomized clinical trials of pharmacologic prophylaxis in the target populations (ie, active bleeding, abnormal activated partial thromboplastin time not due to a lupus inhibitor) or mutually agreed upon thresholds after discussion with individual provider groups (platelet count <50,000/L). On the Johns Hopkins Hospital inpatient acute rehabilitation unit, introduction of the paper order sets increased adherence with ACCP guidelines from 27% to 98% (P < 0.0001) and reduced symptomatic VTE from 49 per 1000 admissions to 8 per 1000 admissions (P = 0.0001).[9] This study demonstrated that paper order sets used consistently by a dedicated group of providers can result in sustained improvements in practice. Paper order sets remain a low‐tech, easy‐to‐implement strategy that can be applied in any healthcare setting. Other services also saw improvements in risk‐appropriate prophylaxis prescription. In a follow‐up cross‐sectional analysis of the surgical services at Johns Hopkins, we found that appropriate VTE prophylaxis prescription improved from 33% to 62% in a sample of 226 patients. Unfortunately, paper order sets had several disadvantages including (1) the inherent difficulty of making them a mandatory part of the admission or transfer process, (2) their existence outside the usual clinical workflow, and (3) the labor‐ and time‐intensive data collection that made it difficult to provide credible, timely performance reports to providers and leadership.

These disadvantages and our adoption of a computerized provider order entry system prompted us to pursue the development and implementation of mandatory, evidence‐based, specialty‐specific computerized clinical decision support (CCDS) VTE prophylaxis order sets. Using the Translating Research Into Practice approach to quality improvement,[10] we collaborated with providers to design 16 different evidence‐based specialty‐specific CCDS VTE order sets. These CCDS VTE order sets, which are imbedded in the specialty‐specific admission and transfer order sets, assist providers in assessing patients' VTE and bleeding risk factors and provide evidence‐based risk‐appropriate VTE prophylaxis (see Supporting Figure 1 in the online version of this article). Individual patient data are saved in an administrative database and can be easily aggregated for research analyses and quality improvement/performance reporting. A detailed discussion of our strategy for change is discussed in Streiff et al.[11] Because pharmacologic prophylaxis is not appropriate for every patient, and not all VTE are preventable, even with perfect prophylaxis, the goals of our collaborative are to ensure that every patient is ordered VTE prophylaxis consistent with their risk profile (risk‐appropriate prophylaxis) and to eliminate preventable episodes of VTE (VTE that occurs in the setting of suboptimal prophylaxis). In a prepost quasi‐experimental study of 1599 trauma patients, the CCDS VTE order set increased risk‐appropriate prophylaxis prescription from 66.2% to 84.4% (P < .001) and reduced the incidence of potentially preventable harm from VTE from 1% to 0.17% (P = 0.04) (Figure 1).[12] On the medical service, the CCDS VTE order set improved risk‐appropriate VTE prophylaxis prescription from 65.6% to 90.1% (P < 0.0001) and reduced the incidence of potentially preventable harm attributable to VTE from 1.1% to 0% (P = 0.001). There was no increase in major bleeding (International Society of Thrombosis and Hemostasis definition: hemoglobin decline of 2 grams/dL or transfusion of 2 or more units of blood or bleeding into a critical organ such as brain, gastrointestinal tract, or eye) postorder set implementation (0.3% vs 0.1%, P = 0.625) or all‐cause mortality (1.3% vs 2.0%, P = 0.285).[13]

Figure 1

These order sets demonstrated that CCDS tools can lead to significant improvements in prescribing practices and reductions in preventable harm from VTE without increasing the risk of major bleeding complications. In addition to improving the quality of care, the order sets also improved the consistency of care. In a retrospective analysis, we found that implementation of CCDS VTE order sets eliminated racial disparities in prescribing practices. In the preimplementation group, risk‐appropriate VTE prophylaxis was prescribed for 70.1% of black patients and 56.6% of white patients on the trauma service (P = 0.025) and 69.5% of black patients and 61.7% of white patients on the medical service (P = 0.015). After implementation of the CCDS VTE order sets, care improved for all patients such that the previously observed disparities were eliminated (trauma service 84.5% vs 85.5%, P = 0.99 and medical service 91.8% vs 88.0%, P = 0.082).[14] These data indicate that standardizing care can potentially eliminate disparities in clinical practice.

Although implementation of mandatory evidence‐based, specialty‐specific CDSS VTE order sets led to substantial improvements in VTE prophylaxis ordering, high performance was not uniform across our institution. On the medical service, substantial disparities in adherence to order set recommendations existed. On the housestaff services, over 90% of patients consistently received risk‐appropriate VTE prophylaxis compared with only 85% on the hospitalist service. Examination of individual provider performance found that some providers only ordered risk‐appropriate prophylaxis 50% of the time, whereas others were doing so 98% of the time. To address this disparity, we conducted a retrospective analysis of a prospective performance improvement project conducted on the Johns Hopkins Hospitalist service studying the impact of individualized hospitalist attending feedback on VTE prevention practices. During the preintervention period (January 2009December 2010), guideline‐adherent VTE prophylaxis was ordered for 86% (95% confidence interval [CI]: 85%‐88%) of patients. Six months after initiation of direct face‐to‐face provider feedback (January 2011June 2011), guideline‐adherent VTE prophylaxis rates rose to 90% (95% CI: 88‐93). Subsequently (July 2011December 2012), a pay‐for‐performance (P4P) initiative was added to direct face‐to‐face provider feedback. During the P4P initiative, provider incentive per relative value unit (RVU) was progressively increased with increasing performance on provision of risk‐appropriate VTE prophylaxis (adherence <80% = no bonus to $0.50 per RVU for adherence 95%). During this period, prescription of guideline‐adherent prophylaxis rose to 94% (95% CI: 93%‐96%).[15] These initiatives transformed the hospitalist unit from a consistently low‐performance unit to a high‐performance unit.

Similar findings were noted on the trauma service. Although the original plan was to provide feedback to attending trauma surgeons, that plan changed when we found that performance was driven entirely by resident practice; residents write the VTE prophylaxis orders, which is then attributed to attending performance. Resident performance varied widely; 42 of 75 (56%) residents on the trauma service ordered risk‐appropriate prophylaxis for 100% of their patients. In contrast, 7 (9.3%) residents never ordered optimal prophylaxis for any of their patients.[16] To motivate all residents to prescribe optimal prophylaxis, we developed an individualized resident VTE prophylaxis scorecard (Figure 2). This prospective cohort study of 2420 patients and 49 general surgery residents compared resident VTE prophylaxis performance on the general surgery service during 3 periods: period 1 (baseline, July 2013September 2013), period 2 (surgery resident scorecard, October 2013December 2013), period 3 (resident scorecard plus individualized 1‐on‐1 coaching, January 2014March 2014). At baseline, 89.4% of patients were prescribed appropriate VTE prophylaxis, and only 45% of residents prescribed risk‐appropriate prophylaxis for all their patients. During the scorecard period, 95.4% of patients were prescribed risk‐appropriate VTE prophylaxis (P < 0.001). During the scorecard plus coaching period, risk‐appropriate prophylaxis rose to 96.4%. These prescribing practice changes were durable. During the 15 months prior to issuing scorecards, 88.0% of patients (3718/4226) were prescribed risk‐appropriate prophylaxis. After implementation, 95.8% of patients (3799/3966) were prescribed risk‐appropriate prophylaxis (P < 0.001) (see Supporting Figure 2 in the online version of this article). During the baseline period, 7 of 865 patients (0.81%) had a VTE during their hospital stay, of which 3 (0.35%) were potentially preventable. In contrast, none of the 3 of 784 patients who suffered VTE during the postimplementation period had a potentially preventable event (0.35% vs 0%, P = 0.046).[17] These studies demonstrate that providing physicians with their own specific data can be a powerful tool for performance improvement that may be applicable to many other quality and safety measures. Our group recently received funding from the AHRQ to scale this work to other residents, nurse practitioners, physician assistants, and attending physicians (1R01HS024547, Individualized Performance Feedback on Venous Thromboembolism Prevention Practice).

Figure 2

IMPROVING VTE PROPHYLAXIS ADMINISTRATION

Ordering VTE prophylaxis does not ensure its administration. We conducted a retrospective review of electronic administration records of 10,526 consecutive patients admitted over a 7‐month period at The Johns Hopkins Hospital. Twelve percent of the over 100,000 ordered doses of VTE prophylaxis were not administered, and the proportion of nonadministered doses on individual floors varied 5‐fold from 5.4% to 26.9%. The proportion of nonadministered doses was significantly higher on medical floors compared with all other services (17.5% vs 8.1%, odds ratio [OR]: 2.1 [95% CI: 2.0‐2.2]). Patient or family member refusal was the most common cause for nonadministered doses of VTE prophylaxis accounting for 59% of all missed doses. Eight percent of patients missed more than half their prescribed doses, and 5% of patients missed over 75% of ordered doses of VTE prophylaxis. Consistent with the Pareto principle, over 80% of the missed doses of prophylaxis were accounted for by just 20% of the patients.[18] A retrospective analysis of hospital‐acquired VTE at Johns Hopkins found that 39% of events occurred in patients who missed 1 or more doses of appropriate VTE prophylaxis.[19] Louis et al. noted that nonadministration of 1 dose of VTE prophylaxis was associated with a significant increase in risk for hospital acquired VTE.[20] These data indicate the need for more aggressive interventions to reduce missed doses to improve VTE prevention.

To fully understand the root causes of VTE prophylaxis non‐administration, we conducted a series of studies examining each of the participants in the VTE prevention care pathway, physicians, nurses, and patients. In a survey of 122 resident physicians, we found significant differences in clinical practice between medicine and surgery residents. Medicine residents were more likely to believe that VTE prophylaxis was overprescribed, and that it was appropriate for nurses to make judgement calls about whether patients needed the prophylaxis that was prescribed.[21] In a mixed methods study that included a written survey and qualitative observations of nursing practice, we found that some nurses presented pharmacologic VTE prophylaxis injections as optional to patients. Furthermore, nurses on units where nonadministration was higher were more likely to believe that VTE prophylaxis was prescribed for patients unnecessarily, and that they could use their clinical judgement to determine when it was appropriate to omit doses of pharmacologic prophylaxis.[22] Our team also examined patient preferences in regard to VTE prophylaxis. In a survey of 227 consecutive medical and surgical inpatients, we found that 60% of patients would prefer an oral route of administration if available. Patients with a preference for a parenteral route of administration (27.5%) were less likely to refuse prophylaxis (37.5% vs 51.3%, P < 0.0001).[23] These findings underscore the fact that unit culture, nursing attitudes and beliefs, and patient preferences have an important influence on medication administration, and that nursepatient communication is an important target for modifying adherence.

PATIENT‐CENTERED APPROACHES TO IMPROVE VTE PROPHYLAXIS ADMINISTRATION

To address nurse‐ and patient‐related factors that influence VTE prophylaxis administration, we applied for and received a Patient Centered Outcomes Research Institute contract to develop patient‐centered interventions to engage and empower patients to take an active role in their preventive care. To achieve these aims, we partnered with 3 national patient advocacy organizations, the National Blood Clot Alliance, the North American Thrombosis Forum, and ClotCare, as well as our local Johns Hopkins Patient and Family Advisory Council. Using a modified Delphi method, we engaged patient stakeholders from the 4 collaborating organizations to build consensus on patient‐centered VTE education methods. Input from this Delphi assessment was used to build educational materials including paper brochures published in 8 different languages and a 10‐minute educational video filmed by an Oscar‐winning documentary director featuring both clinicians and patients relating their VTE experience and the importance of VTE prevention.[24] These educational materials are available for public use (http://www.hopkinsmedicine.org/armstrong_institute/emmprovement_projects/VTE/) and are being used in a trial of a patient‐centered intervention bundle to reduce rates of VTE prophylaxis nonadministration. We also conducted a cluster‐randomized trial to compare different approaches to nurse education (https://clinicaltrials.gov/ct2/show/NCT02301793).

ENGAGING TRAINEES IN MULTIDISCIPLINARY PATIENT SAFETY/QUALITY IMPROVEMENT INITIATIVES

Trainees from many healthcare‐related disciplines have played a critical role in our quest to improve VTE prevention. Over the past 10 years, we have mentored countless medical students, public health graduate students, nursing students, residents, and postdoctoral fellows in research projects that have resulted in numerous high‐quality publications. Trainees have helped to dispel staff concerns about patient falls in connection of intermittent pneumatic compression devices,[25] identify the weaknesses of current publicly reported VTE measures,[26, 27, 28, 29] identify opportunities to improve VTE prevention practices within clinical specialties,[30, 31, 32] define the role of surveillance bias in VTE outcomes reporting,[33, 34, 35] discover and fully explore the important problem of missed doses of VTE prophylaxis,[18, 21, 22, 23, 36] and summarize knowledge about VTE prevention via systematic reviews and meta‐analyses.[37, 38, 39] These collaborations have been a classic win‐win. The mentees learn critical skills while growing their curriculum vitae with contributions to the literature, allowing them to progress in their careers (ie, obtain a residency match, faculty positions). The faculty have leveraged this work to obtain over $3 million in extramural funding to develop interventions to study and improve the quality of VTE preventive care for hospitalized patients.

In healthcare, we have not yet achieved defect‐free VTE prevention; however, we have a better understanding of the path to accomplishing this goal. In this article we describe our goal of zero harm from VTE and our learning journey to realize that goal. Although the journey never ends, a critical ingredient to the success of our program has been the multidisciplinary nature of our VTE collaborative team. The combination of expertise from medicine, surgery, nursing, pharmacy, clinical informatics, and public health has facilitated the development of innovative strategies to improve VTE prevention that integrate seamlessly into clinical workflow. The approach used for VTE can be applied to eliminate other types of harms.