Published in the August 2008 issue of Today’s Hospitalist
WHEN AN APPARENTLY healthy 25-year-old man admitted for a laparoscopic cholecystectomy developed a venous thromboembolism (VTE) several years ago at St. Mary’s Medical Center in Duluth, Minn., the hospitalists realized that they needed to do more to screen patients.
“Even though people were talking about the risk of VTE, screening was the responsibility of the individual physician and was done on a case-by-case basis,” explains Jeffrey Garland, MD, associate director for hospital operations at the 350-bed facility. The lesson that the case hammered home, he says, was that “any ill patient who comes into the hospital is at risk for VTE.”
Three years ago, the 15 hospitalists at St. Mary’s took action and put VTE screening into their admission order set. While that simple act soon meant that all of the hospitalists’ patients were being screened for VTE, it did nothing to help the 35% of patients who are admitted to St. Mary’s by nonhospitalists.
That led the hospital eight months ago to implement facility-wide screening tool that has pushed VTE screening rates to more than 95%. “As a result,” Dr. Garland says, “our VTE complication rate is basically non-existent “less than 0.5%.”
Poor national performance
Those results are great news, especially in light of the grim statistics surrounding VTE and its two components “deep vein thrombosis (DVT) and pulmonary embolism. Although the precise number of people affected in the U.S. is unknown, the CDC estimates that between 300,000 and 600,000 people each year experience VTE, with the majority having DVT.
Despite the high incidence of VTE in the general population, the number of patients receiving adequate screening and prophylaxis is still low. This is especially true for patients entering the hospital.
An international study published in the Feb. 2, 2008, issue of The Lancet found that 52% of hospital patients “both surgical and medical “were at risk for VTE. Only half of those patients, however, received a recommended method of prophylaxis. That’s one reason that experts estimate that 10% of all in-hospital deaths are due to VTE.
It was precisely this kind of evidence that led Dr. Garland and the hospitalist team, along with the nurses and pharmacists at St. Mary’s, to develop a screening tool “and to lobby other physicians to implement VTE screening as well. Dr. Garland notes that VTE screening wasn’t a very hard sell both because the data were so overwhelming and because the screening is so easy to do.
The tool that he and his colleagues developed creates a paper trail that allows everyone who sees patients to check their VTE status. Because most hospitalized patients will have one or more risk factors for VTE, screening is really a team effort that starts with nurses.
How it works
One problem that Dr. Garland and the St. Mary’s team ran into was that they could not find a national standard to use to screen patients on admission. Instead, the risk assessment order sheet and prophylaxis options they devised were cobbled together from several different studies and sets of guidelines.
The risk assessment tool contains a scoring system that gives patients between 1 and 3 points for every risk category that applies to them. That score is then used to decide on prophylaxis options, which are based on evidence.
Nurses use the risk assessment order sheet as “part of their initial assessment of the admitting orders, to see if patients are placed on some sort of VTE prophylaxis,” Dr. Garland says. A nurse will complete the risk assessment portion of the order sheet, then place it on the patient’s chart to help remind physicians to order some form of prophylaxis.
“If patients have relatively low risk factors such as a minor surgical procedure like endoscopy, they would receive a score of 1,” explains Dr. Garland. “This would suggest early ambulation. But the screening tool gives physicians the option of ordering more aggressive prophylaxis, which is recommended for higher scores.”
By the time a physician sees the patient, all he or she has to do is check a box ordering prophylaxis “and sign his or her name,” he says. “Just the simple action of placing the form on the chart as a reminder has increased physician compliance to over 95%.”
Screening saves lives and money
The tool is not only easy to use, but inexpensive to implement. The hospital didn’t need elaborate training or hi-tech computer systems, Dr. Garland says. Beyond efforts to raise awareness among staff and the paper the tool is printed on, he says, there were few additional costs.
The payoff has been substantial. Dr. Garland estimates that for every case of VTE prevented, the hospital saves $1,500 through reduced length of stay alone. He notes that the screening tool will produce even more financial benefits once Medicare stops paying hospitals to care for certain hospital-acquired complications, a list that includes VTE.
One trick to successfully implementing the tool is to make sure that the form is place on the chart only before prophylaxis has been ordered and before an admitting physician has written orders. “That way, it doesn’t become just one more form on the chart that doctors can overlook,” he says.
And having the nurses and pharmacists as part of the design process was key, he adds. Their involvement helped get buy-in from nonhospitalist physicians, he points out. “They also filled gaps in physician implementation,” Dr. Garland says, “and helped ensure that the protocol is being followed.”
Cornelia Kean is a freelance health care writer based in Montclair, N.J.