Advocate Good Samaritan Hospital DVT/PE Reduction Project

Michael McKenna, MDVP, Medical Management

OpportunityCount

Perc

ent

Complication

Count 16 15 116Percent 25.2 9.0 8.8 8.0 7.5 6.3

1486.1 4.1 2.7 2.6 19.7

Cum % 25.2 34.2 43.0 51.0

53

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600

500

400

300

200

100

0

100

80

60

40

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Good Samaritan Hospital Complication Pareto (4Q04-3Q05)

Rate

Dec-

06

Nov-

06

Oct-0

6

Sep-

06

Aug-

06

Jul-0

6

J un-

06

May-0

6

Apr-0

6

Mar-0

6

Feb-

06

J an-

06

Dec-05

Nov-

05

Oct-0

5

Sep-

05

Aug-

05

J ul-0

5

Jun-

05

May-0

5

Apr-0

5

Mar-0

5

Feb-

05

Jan-

05

Dec-04

70

60

50

40

30

20

10

0

_P=27.33

UCL=55.67

LCL=0

Advocate Good Samaritan HospitalMedical DVT/ PE Complication Rate

Control limits frozen using Dec 04 - Nov 05 timeframe. Average monthly volume = 7 (2-18)

DVT/PE Trend – MedicalOverall 64% medical vs 36% surgical

Rate

Dec-06

Nov-06

Oct-06

Sep-06

Aug-06

Jul-0

6

J un-06

May-06

Apr-0

6

Mar-0

6

Feb-

06

J an-06

Dec-05

Nov-05

Oct-05

Sep-

05

Aug-05

J ul-0

5

Jun-05

May-05

Apr-0

5

Mar-05

Feb-05

Jan-05

Dec-04

70

60

50

40

30

20

10

0

_P=24.00

UCL=59.96

LCL=0

Advocate Good Samaritan HospitalSurgical DVT/ PE Complication Rate

Control limits frozen using Dec 04 - Nov 05 timeframe. Average monthly volume = 4 (0-9)

DVT/PE Trend – SurgicalOverall 64% medical vs 36% surgical

Linkage to Strategic Plan: Quality, Physician Partnership, Service, and Finance Pillars

Problem Statement: The DVT/PE complication rate presents an opportunity for improvement for Good Samaritan Hospital. The current DVT/PE complication rate per 1000 is 26.3.

Benefits: Positive impact on patient outcomes (decreased morbidity, increased quality of life, decreased mortality, shorter hospital stay) and patient satisfaction (happy with the quality and service they

received because they did not develop a complication of hospitalization).

Scope: The team will implement a Performance Improvement methodology focusing on a data, measurement, and prompt and appropriate prophylaxis to reduce the DVT/PE complication rate for both medical and surgical patients. Process will be analyzed from admission to discharge.

Goals: Specification Limit (minimum goal): complication rate of 23.7 pre 1000. Target: complication rate of 21.0 per 1000.

Define Opportunity – Team Charter

Sponsor: Dr. McKenna Project/Process Owner: Improvement Leaders: D.Calcagno, T.Esposito

Milestones:Description Date (mo/yr)

#1#2#3

Milestones:Description Date (mo/yr)

#1#2#3

Key Metrics Medical DVT/PE complication rate Surgical DVT/PE complication rate Proper DVT prophylaxis utilization

Improving the Assessment Process

• Accountability moved to nursing– CareConnection Task/prompt

• Revamped assessment form– Risk assessment– Prophylaxis guidelines

• Standard Work– Procedure for completion and physician notification– Potential failure modes identified and addressed (e.g. shift change)– Audit process

• Pilot – Rapid cycle small test of change

• 43 completed assessments on pilot unit• 65% of patients scoring high and highest categories

Category n-size Percentage

Low (0-1) 669 17.3%

Moderate (2) 678 17.5%

High (3-4) 1,223 31.6%

Highest (5+) 1,301 33.6%

% Cases by Risk Category

Patients Contraindicated

4,180 432

Initial Assessment Results

65% of patients scored High or Highest Risk

Data Source: Care Connection- Patients Discharged 11/01/2007-01/31/2008

• Sustained completion rate of 98%• Assessment process also validated for accuracy and reliability

Data Source: Care Connection- Patients Discharged 1/1/2008-9/30/2008

Assessment Results

280260240220200180160140120100806040200

8000

7000

6000

5000

4000

3000

2000

1000

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Time to Assessment

Frequency

Histogram of Time (hours) from Admission to VTE Risk Assessment

Average 3.2Median 2.1Minimum 0.0Maximum 286.5

GSAM VTE Assessment

Completion Time (hours)

Count 1 1 112 6 6 4 3 2 2 2

Percent 2.5 2.5 2.530.0 15.0 15.0 10.0 7.5 5.0 5.0 5.0Cum % 95.0 97.5 100.030.0 45.0 60.0 70.0 77.5 82.5 87.5 92.5

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Pareto Chart of MDC

Improve Prophylaxis

• VTE cases discharged between 8/2007 and 3/2008 were reviewed (n = 40)– DVT/PE was hospital acquired (not present on admission)– Demographic, administrative, and clinical data reviewed– 68% (n = 27) did not receive optimal pharmacological prophylaxis– Largest opportunity included circulatory cases

30% of all DVT/PE cases reviewed grouped into a circulatory MDC

DVT/PE Case Drilldown

• Circulatory cases– N size = 12– 92% (n = 11) surgical cases

– 83% (n = 10) did not receive optimal chemical prophylaxis

DRG_MSDRG_Descrip Count %Coronary bypass w/o cardiac cath w MCC 3 25%Coronary bypass w cardiac cath w MCC 2 17%Acute myocardial infarction, expired w MCC 1 8%Cardiac defib implant w cardiac cath w/o ami/hf/shock 1 8%Cardiac defibrillator implant w/o cardiac cath w MCC 1 8%Cardiac defibrillator implant w/o cardiac cath w/o MCC 1 8%Cardiac valve & oth maj cardiothoracic proc w card cath w MCC 1 8%Major cardiovasc procedures w MCC or thoracic aortic anuerysm repair 1 8%Major cardiovasc procedures w/o MCC 1 8%

DRG/MSDRG Classification

Next Steps

• Case by case review of VTE cases by physicians – Verification of optimal prophylaxis– Follow-up/feedback to individual physicians

• Leverage existing anticoagulation subcommittee for other DVT/PE reduction strategies