Hospital-Acquired VTE: What We Have Learned Martha J. Radford, MD Chief Quality Officer NYU Langone...
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Transcript of Hospital-Acquired VTE: What We Have Learned Martha J. Radford, MD Chief Quality Officer NYU Langone...
![Page 1: Hospital-Acquired VTE: What We Have Learned Martha J. Radford, MD Chief Quality Officer NYU Langone Medical Center September 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062408/56649f295503460f94c42e80/html5/thumbnails/1.jpg)
Hospital-Acquired VTE: What We Have Learned
Martha J. Radford, MDChief Quality Officer
NYU Langone Medical CenterSeptember 2009
![Page 2: Hospital-Acquired VTE: What We Have Learned Martha J. Radford, MD Chief Quality Officer NYU Langone Medical Center September 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062408/56649f295503460f94c42e80/html5/thumbnails/2.jpg)
VTE Prevention in the USA
2005 2006 2007 2008 2009 2010
SCIP Measures
SCIP on Intranet POA HAC
Chest Guidelines
Ortho GuidelinesAHRQ PSIs
![Page 3: Hospital-Acquired VTE: What We Have Learned Martha J. Radford, MD Chief Quality Officer NYU Langone Medical Center September 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062408/56649f295503460f94c42e80/html5/thumbnails/3.jpg)
VTE Prevention in the USA
2005 2006 2007 2008 2009 2010
SCIP Measures
SCIP on Intranet POA HAC
Chest Guidelines
Ortho GuidelinesAHRQ PSIs
AHRQ Validation
![Page 4: Hospital-Acquired VTE: What We Have Learned Martha J. Radford, MD Chief Quality Officer NYU Langone Medical Center September 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062408/56649f295503460f94c42e80/html5/thumbnails/4.jpg)
VTE Prevention at NYULMC
2005 2006 2007 2008 2009 2010
SCIP Measures
SCIP on Intranet POA HAC
Chest Guidelines
Ortho GuidelinesAHRQ PSIs
InternalSCIP
SCIP VTE in P4P
2010 Goal: NoPreventable VTE
VTE Prophyin CPOE
Dept VTE Standards
HAC Review
![Page 5: Hospital-Acquired VTE: What We Have Learned Martha J. Radford, MD Chief Quality Officer NYU Langone Medical Center September 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062408/56649f295503460f94c42e80/html5/thumbnails/5.jpg)
We Learned from AHRQ Validation: Our Coding Needs Improvement
• Of the 17 2006 VTE PSI cases we reviewed for the AHRQ validation study, our coding was incorrect for 5 (29%).
• This began a focus on VTE coding quality that continues today.
• The appearance of VTE following ortho procedures as a HAC has solidified the need for accurate VTE coding.
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NYULMC VTE Coding Accuracy
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Coding Errors at NYULMC
• One fourth to one third: no evidence for VTE
• Two thirds to three fourths: VTE was present on admission– If date of study demonstrating VTE was after the
date of admission, VTE not coded as “present on admission”.
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Coding Interventions at NYULMC
• Outreach to coders about impact of their coding on quality and safety assessment.
• Ongoing feedback to coders about coding errors
• Organizational focus on clinical documentation, clinical documentation specialists interact frequently with coders.
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Actual Hospital-Acquired VTE
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VTE Prevention at NYULMC
2005 2006 2007 2008 2009 2010
SCIP Measures
SCIP on Intranet POA HAC
Chest Guidelines
Ortho GuidelinesAHRQ PSIs
InternalSCIP
SCIP VTE in P4P
2010 Goal: NoPreventable VTE
VTE Prophyin CPOE
Dept VTE Standards
HAC Review
![Page 11: Hospital-Acquired VTE: What We Have Learned Martha J. Radford, MD Chief Quality Officer NYU Langone Medical Center September 2009.](https://reader035.fdocuments.us/reader035/viewer/2022062408/56649f295503460f94c42e80/html5/thumbnails/11.jpg)
Department Standards for VTE Prophylaxis
• 2006: Medicine department• 2007: Surgery departments (8)• 2008: Departments’ CPOE order sets• 2009: Required order module (medicine)• 2010: Organization-wide goal to eliminate
preventable VTE: ACCOUNTABILITY
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Department Standards
• Risk assessment
• Documentation of contraindications to VTE prophylaxis
• VTE prophylaxis ordering options
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At first Purely Optional
Medicine Admission Order Set
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Medicine Admission Order Set: VTE Compulsory
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You cannot enter entire order set unless either a VTE order is entered or you have documented why VTE prophylaxis is not indicated
Medicine Admission Order Set: VTE Compulsory
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Surgical Department Standards and Order Sets
Challenges include:• Bleeding risk of great concern• Start VTE prophylaxis on admission, or postop?• What happens with epidural anesthesia?• Conflicting guidelines: orthopedics
ALL surgical services place intermittent compression devices before or in the OR, but this may not be sufficient for some patients at particularly high risk.
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Increasing Accountability
• Every quarter we send to all department chairs a “quality safety score card” that displays the department’s performance on a variety of quality performance measures:– Administrative measures: admissions, hospital
mortality, length of stay, 30-day readmissions.– Nationally-reported quality performance
measures.– AHRQ patient safety indicators.– Internal quality and safety measures.
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Department Quality-Safety Score CardAHRQ Patient Safety Indicators (green = at or below UHC median;
red = above UHC median) rate per 1000 Department NYULMC
Complications of anesthesia - PSI01 0.0 0.3Death in low mortality DRG - PSI02 0.0 0.0
Decubitus ulcer - PSI03 5.9 5.1Death among inpatients with serious treatable complications - PSI04 16.7 89.7
Iatrogenic pneumothorax - PSI06 0.0 0.5Infections due to medical care - PSI07 2.4 1.7
Post-operative hip fracture - PSI08 0.0 0.0Post-operative hemorrhage or hematoma - PSI09 0.0 2.0
Post-operative physiologic/metabolic - PSI10 0.0 0.2Post-operative respiratory failure - PSI11 6.4 10.5
Post-operative PE or DVT - PSI12 17.9 9.9Post-operative sepsis - PSI13 6.2 8.6
Post-operative wound dehiscence - PSI14 0.0 0.0Accidental puncture/ laceration - PSI15 1.7 3.0
Birth trauma - PSI17 3.7OB trauma - vaginal with instrument - PSI18 157.5OB trauma - vaginal w/o instrument - PSI19 25.7
OB trauma - cesarean section - PSI20 1.4
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Department Score Card: Numerator Cases
• Also included: – Patient identifiers– Attending physician
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Analytic Report from EMR
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Internal Quality Report Posted on Intranet
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What Have We Learned?
• Accurate coding needs attention from clinicians.
• Computerized order entry with decision support can be harnessed to improve VTE prophylaxis.
• Decreasing the rate of hospital-acquired VTE—real and apparent—is possible.
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What Do Hospitals Need from Measures?
Actionable performance data:• Timely, reliable measures• With “drill down” to the “unit of actionability”
– For VTE prophylaxis at NYULMC, this is the department
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What Has AHRQ Learned?
• What is the variability in hospital coding practice?
• Are the AHRQ PSIs sufficiently reliable as safety measures to permit fair hospital comparison?