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This article appears in the November 2012 issue of HealthLeaders magazine.
It's been four years since the U.S. Surgeon General stunned providers with these numbers about rates of preventable death and harm:
- 350,000 to 600,000 Americans a year suffer poor health outcomes because of blood clots, and 100,000 of them die
- The single biggest risk factor is the care provided in hospitals
- Far too few clinicians use interventions such as drugs that could prevent more than one-third of these clots
Still, hospital-associated venous thromboembolism remains a major preventable public health problem during and within 90 days of acute care.
"There has been a lot of movement, and hospitals are starting to see some results," says Greg Maynard, MD, a nationally recognized champion in acute care VTE prevention and director of the Center for Innovation and Improvement Science for the University of California, San Diego, where he previously served as chief of hospital medicine.
But in most hospitals across the country, this major problem persists. Maynard says that based on his success at UCSD, half of hospital-associated blood clots occurring today could be prevented with better patient risk assessment and tighter adherence to appropriate drug or mechanical prevention strategies.
"For the majority of hospitals, they think they've done something because they've created an order set for VTE prophylaxis, but they don't know if it's working. They haven't been tracking the numbers. And they're really not measuring anything significant," Maynard says. Joint Commission and Surgical Care Improvement Project measures, now being reported for some conditions, set the bar for success far too low, he says.
"For example, the Joint Commission measures say that to 'pass' you have to have your patient on some prophylaxis in the first 24 hours or say why they're not." Compliance with guidelines is met for even the highest-risk patients if they are on any prophylaxis, rather than on the right prophylaxis, he says, even if they are on a mechanical compression device when a more appropriate anticoagulant medication is safer.
And, Maynard says, requirements today don't push clinicians to change the orders if the patient's situation changes a few days after admission. "In fact, TJC measures don't look at any point in time except the day of admission or transfer to the ICU."
Maynard has tried to simplify risk assessment for all patients with his three-bucket model, which he says led to a 40% reduction in UCSD's rates of VTE over four years. Patients are put into low-, moderate-, or high-risk categories on admission, with only the lowest-risk patients not receiving some form of prophylaxis.
Daily color-coded reports classify all inpatients according to what kind of VTE prophylaxis is in place. This provides measurement on prophylaxis patterns, and allows frontline staff to focus on patients who are on no prophylaxis or mechanical methods only. "This daily measurement, linked with concurrent intervention to address lapses in care, is a powerful strategy we call measure-vention," Maynard says.
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