Review of VTE (Venous Thromboembolism) Core Measures March 2013

Transcription

1 Review of VTE (Venous Thromboembolism) Core Measures March 2013

2 Introduction to the VTE metric VTE has been added as another Core Measure that Columbia St. Mary s will be publically reporting starting with January 2013 discharges. VTE prophylaxis use is already being measured in the current Core Measure populations of Stroke and the Surgical Care Improvement Project (SCIP). Appropriate prophylaxis measures for these patient populations have been incorporated into the order sets / Power Plans currently in use. The new VTE metric expands these populations to include basically all inpatient populations (i.e. all inpatients over age 18) we serve (excluding patients with principal diagnoses of mental disorders, obstetrics, and stroke; or patients covered under the SCIP VTE selected surgeries). VTE will eventually be a required measure set that will be sent electronically to the Federal Government as part of the Meaningful Use requirements. 2

3 What are the metrics? VTE 1 Venous Thromboembolism Prophylaxis VTE 2 Intensive Care Unit Venous Thromboembolism Prophylaxis VTE 3 VTE Patients with Anticoagulation Overlap Therapy VTE 4 VTE Patients Receiving Unfractionated Heparin with Dosages/Platelet Count Monitoring by Protocol VTE 5 VTE Discharge Instructions VTE 6 Incidence of Potentially-Preventable VTE 3

4 VTE-1 : VTE Prophylaxis Description: Patients who received VTE prophylaxis (chemical or mechanical) or have documentation as to why no VTE prophylaxis was given. Measures VTE prophylaxis received the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission. Rationale: Hospitalized patients at high-risk for VTE may develop an asymptomatic deep vein thrombosis (DVT) and die from pulmonary embolism (PE). The majority of fatal events occur as sudden or abrupt death, underscoring the importance of prevention as the most critical action step for reducing death from PE. 4

5 VTE-2 : Intensive Care Unit VTE Prophylaxis Description: ICU patients who received VTE prophylaxis (chemical or mechanical) or have documentation as to why no VTE prophylaxis was given. Measures VTE prophylaxis received the day of or the day after the initial admission (or transfer) to the Intensive Care Unit or surgery end date for surgeries that start the day of or the day after ICU admission. Rationale: Approximately 2/3 of cases of DVT or PE are associated with recent hospitalization. Criteria for admission to the Intensive Care Unit itself puts patients at an increased risk for developing VTE, and subsequent increased risk of morbidity from PE. 5

6 VTE-3 : VTE Patients with Anticoagulation Overlap Therapy Description: This measure assesses the number of patients diagnosed with confirmed VTE who received an overlap of parenteral (IV) or subcutaneous (subcu) anticoagulation and warfarin therapy. Overlap therapy should be administered for at least 5 days with an INR greater than or equal to 2 prior to discontinuation of the parenteral anticoagulation therapy. For patients who received less than 5 days of overlap therapy, they should be discharged on both parenteral and oral medications or have a documented reason for discontinuation of parenteral therapy. 6

7 VTE-3 : VTE Patients with Anticoagulation Overlap Therapy Rationale: For patients who present with a confirmed acute VTE, parenteral anticoagulation is the first line of therapy because of its rapid onset of action. The oral anticoagulant warfarin has a very slow onset of action, therefore it cannot be used as mono-therapy for acute VTE. The strong (Level I) recommendations to overlay parenteral anticoagulation with warfarin therapy in the initial treatment of VTE events is based on the known effect of warfarin on the coagulation cascade. Studies also support the need for overlap during initial warfarin dosing in order to prevent thrombus extension, embolization to the lungs, and death due to PE. 7

8 Description: VTE-4 : VTE Patients Receiving Un-fractionated Heparin with Dosages/Platelet Count Monitoring by Protocol or Nomogram This measure assesses the number of patients diagnosed with confirmed VTE who received intravenous (IV) un-fractionated heparin therapy doses and had their platelet counts monitored using defined parameters such as a nomogram or protocol. Rationale: Heparin is commonly involved in adverse drug events. Subtherapeutic and supratherapeutic levels can lead to thromboembolic or bleeding complications that may increase the patient s length of stay. The use of weight-based nomograms has increased the likelihood that a therapeutic partial prothromboplastin time (aptt) will be achieved within the first 24 to 48 hours of therapy. The risk of recurrent VTE is reduced when a therapeutic level of heparin is reached quickly. 8

9 VTE-5 : Venous Thromboembolism Warfarin Therapy Discharge Instructions Description: This measure assesses the number of patients with confirmed VTE that are on warfarin with written discharge instructions that address all four criteria : Compliance Issues, Dietary Advice, Follow-Up Monitoring, and Information about the Potential for Adverse Drug Reactions/Interactions. Rationale: In anticoagulation therapy programs, patient education is a vital component to achieve successful outcomes and reduce readmission rates. Patients benefit from education about the potential consequences of both their disease and its treatment. Joint Commission NPSG Reduce the likelihood of patient harm associated with the use of anticoagulant therapy examines same criteria. 9

10 VTE-6 : Hospital Acquired Potentially- Preventable Venous Thromboembolism Description: This measure assesses the number of patients diagnosed with confirmed VTE during hospitalization (not present at admission) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnostic testing order date Rationale: The concept of failure to prevent has generated interest in national health policy organizations to identify evidence-based practice that will improve patient safety in the hospital setting. The incidence of preventable VTE among hospitalized patients contributes to extended hospital stays and the rising costs of healthcare. 10

11 What can you do to assist in meeting this measure? Ensure patients on the Med/Surg and ICU units are actively assessed for VTE prophylaxis immediately upon admission to any unit or upon transfer to a higher level of care (ICU). This is another metric with a time-related component. VTE prophylaxis needs to be initiated within 24 hours of the patient s admission, end surgery date, or transfer to ICU. For patients that are not going to have VTE prophylaxis, there needs to be a documented reason by the physician, physician assistant, or nurse practitioner that documents the reason for not using either mechanical or chemical prophylaxis. There are order statements built into the VTE sub phases that specifically address this. 11

12 What can you do to assist in meeting this measure? When discharging a patient who has been treated for an active VTE and are being prescribed warfarin at discharge, make sure to include the warfarin instruction sheets under the patient education tab in the EHR (Diet Vitamin K and Warfarin and Warfarin, Questions and Answers) as part of the discharge paperwork. Document that the instructions were given in the EHR under Patient Education. Click OK and the information will be added to the depart paperwork. All 4 elements required in VTE-5 are covered in these instruction sheets. This teaching needs to occur even with patients treated for an active VTE that have been on warfarin prior to admission. 12