Simple 'Three Bucket' Tool Helps Prevent Huge Cause of Inpatient Death

Cheryl Clark, for HealthLeaders Media , June 9, 2010

By using this tool, instead of other strategies which take a lot longer and often involve complex mathematical calculations or require following pages, Maynard and colleagues at UCSD found amazing results.

When they categorized their patients in this way, the number of patients in the hospital who were given blood-thinning medication went from 40% to 70%. "The rest were either low-risk or were contraindicated," he says. Detailed audits on randomly selected inpatients revealed improvement from 50% having adequate prophylaxis, as defined by the above protocol at the onset of the improvement effort to over 98% having adequate prophylaxis currently.

"High rates of adherence to the VTE protocol resulted in a 40% decline in the incidence of hospital acquired VTE in our institution," he wrote in a summary of the experiment in the January issue of the Journal of Hospital Medicine.

"This is really pretty low-hanging fruit," Maynard says.

In 2008, Lancet published the ENDORSE report by British researchers, who looked at 70,000 patients in 358 U.S. hospitals, and found only 39.5% of medical patients and 58.5% of surgical patients received drugs such as heparin or enoxaparin or have sequential mechanical compression devices applied. The study was called the Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting.

Maynard says hospitals aren't doing what they need to do for a number of reasons.

In the November issue of the Journal of Thrombosis and Thrombolysis, he and co-author Jason Stein wrote that physicians lack familiarity with prevention guidelines or disagree with them. Some underestimate their patients VTE risk, or have concerns that any medication they give the patients will cause them to bleed. Most believe that protocols to assess risk are "resource intensive or difficult to implement in a practical fashion."

Many hospitals and doctors have just gotten into the habit of accepting VTE as unavoidable part of hospital care.

They absolutely should not, says Maynard.

He says that hospital officials need to get more concerned about preventing VTE because "the Stick" is coming. Not only does the National Quality Forum endorse these and other measures, but the Centers for Medicare and Medicaid Services will not reimburse for care of a patient with a hospital-acquired DVT or PE that occurs with a knee or hip replacement. Instead, reimbursement is paid "as though the complication had not occurred." CMS may soon extend that non-reimbursement rule for the care of any patient who gets a preventable VTE.

Also, public reporting of hospitals' incidence of VTE is likely to come soon, and the Joint Commission now offers hospitals the option of using VTE as one of their core measures for evaluation on certain services, a measure that may soon become mandatory, and hospital-wide rather than just confined to the orthopedic service, Maynard says.

Today, Maynard explains, several hundred hospitals are using the tool and getting experience through collaborative efforts organized by the Society of Hospital Medicine, the Institute for Healthcare Improvement Expedition to Prevent VTE, AHRQ, and other entities.

"We thought we were on to something several years ago and started telling people how to do this even before we had great data," Maynard says. Even before they had a chance to publish, he says they "had enough data to know that it was working."

Maynard says that the Three Bucket approach gets hospitals a long way toward reducing VTE mortality and morbidity rates, but it's not the only thing that's needed.

"You also have to have the right infrastructure, the right institutional support and the ability and will to standardize the prevention process," he says. That requires an interdisciplinary team, " a lot of medical leaders, the nurses and pharmacists, all onboard with this process to get this done."  Other strategies, such as pharmacist review of all orders for patients who are not on prophylaxis, would reduce the VTE death rate even more.

With so many lives at stake, that sounds like something every hospital would want to do.

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