Many patients being admitted to hospitals today are at risk of developing a potentially deadly medical condition that’s likely not even on their radar. According to the U.S. Surgeon General, this problem affects up to 600,000 patients in the United States each year, with 100,000 of those cases resulting in death — more than AIDS, breast cancer, and motor vehicle accidents combined. The condition? Venous thromboembolism (VTE), more commonly known as blood clots.
Deep vein thrombosis (DVT) occurs when a blood clot forms in a deep vein and becomes potentially fatal if it breaks loose to the lungs, called a pulmonary embolism (PE), where it may block some or all of the blood supply to the lungs. Patients who are suffering from cancer, having surgery, or dealing with major traumas like fractures are at the highest risk.
In 2005, when Johns Hopkins Medicine set out to reduce the incidence of blood clots across its health system, it formed the VTE Collaborative, a group that today includes, among others, a hematologist, a surgical nurse, an anti-coagulation pharmacist, a trauma surgeon, and researchers. Brandyn Lau, an assistant professor of radiology and health sciences informatics at the Johns Hopkins University School of Medicine, also joined the group to contribute his expertise in applying health information technology to improve patient care.
Lau has chosen to focus on VTE because this deadly condition is highly preventable. “There’s strong evidence that shows that best-practice prophylaxis reduces risk of blood clots in hospitalized patients by about 60 percent. That is a huge risk reduction,” says Lau.
Johns Hopkins Medicine’s commitment to the Patient Safety Movement Foundation Actionable Patient Safety Solutions (APSS) #12 aims to reduce embolic events. Lau is passionate about the idea of improving practices in this way. “When you think about improving practices, you’re improving the care for thousands or tens of thousands of patients, which is an incredibly rewarding experience.”
To fulfill its commitment to APSS #12, the VTE Collaborative targeted three areas: risk assessment, prescription of preventive therapy, and administration of prescribed preventive therapy. The system it created ensures that:
- Upon admission, every Johns Hopkins patient is assessed for their individual risk of developing a blood clot
- Based on that assessment, patients are prescribed the appropriate prevention therapy for their risk level
- Complete administration of prescribed, risk-appropriate preventive therapy is monitored and, if the patient misses a dose for any reason, active intervention to provide information on the symptoms, risk factors, and preventive measures for blood clots
Johns Hopkins chose to build a specialty-specific VTE risk-assessment tool into Epic, its electronic health record system which is also used in many hospitals around the country. The information derived from the risk assessment determines the appropriate prevention therapy and then makes a prescription recommendation to the patient’s doctor. To further improve prescribing practices, residents in the Departments of Surgery, Medicine, and Gynecology and Obstetrics receive individualized feedback about their VTE prophylaxis prescribing habits monthly which has ensured that more than 95 percent of patients are prescribed appropriate care to prevent blood clots.
A Surprise in the Data
An unexpected issue revealed itself when Lau examined data on medication dose administration. “We found that 12 percent of doses of medication to prevent blood clots are not administered to patients,” says Lau. “It was absolutely shocking.”
In 60 percent of cases where the doses were skipped, the documented reason was patient refusal. In collaboration with peers at hospitals around the country, Lau finds this high rate of refusal typical, even though many hospitals are unaware it’s even an issue. “Most hospitals only look at whether the first dose is administered, not whether the doses continue to be administered or missed,” explains Lau. “If the medication dose isn’t administered, it can’t possibly be effective.”
VTE prophylaxis typically comes in the form of blood thinners administered in a shot once or even multiple times per day. Combine this discomfort with the fact that the danger of blood clots isn’t widely understood, and it becomes clear why some patients and nurses de-prioritize this part of their care.
With funding from the Patient Centered Outcomes Research Institute, the group set about developing comprehensive VTE education. To make sure the information was truly what patients need and want, the group started there – with the patients. The group partnered with more than 400 individuals across the country and asked what they understood about blood clots, what they wish they had known before they developed the condition, and how they would have liked to have had that information delivered. While there wasn’t a single preference, the group identified three formats that were prioritized by patients: paper, video, and in-person conversations with a clinician.
The patients were clear about their preferences. With the printed paper, patients didn’t want more than a single sheet, front and back. The video needed to be shorter than 10 minutes. For the discussions, patients just wanted a nurse or a doctor whom they could talk to, ask questions, and get answers from in real time.
In the end, the VTE education covered just the basics – symptoms, risks factors, and preventive measures for blood clots – but it was the information patients needed to make an informed decision, and dose administration improved by almost 50 percent.
When it came to delivering this information, the VTE Collaborative again returned to the data. Delivering VTE education to every patient would be an inefficient use of resources in the 60 percent of cases where patients were receiving all of their doses. The system instead triggers an alert when a nurse documents a missed dose in Epic so a nurse educator from the VTE Collaborative can coordinate the education bundle.
Spreading the word
The strategies have shown measurable and reproducible improvements in VTE outcomes at The Johns Hopkins Hospital. To help other hospitals achieve the same success, the Johns Hopkins VTE Collaborative has published the educational bundle, which includes the two-page educational form and the 10-minute video. These tools are freely available at http://bit.ly/bloodclots.
Lau understands that hospitals have limited resources. “We’ve done a lot of the heavy lifting here to develop tools and a data-reporting structure that we as an institution are very happy to share with other hospitals that are using the same type of electronic health record system.”
Lau and the VTE Collaborative are pleased with the project. “We didn’t reduce missed doses by 100 percent but, at the very least, our mission is to make sure patients are informed about the care that’s being offered so they can make an informed decision about what is right for them.”