For several years, PIH Health, a two-hospital regional healthcare network, had seen little improvement in its hospital-acquired venous thromboembolism (VTE) rates. Clinical leaders knew that significant changes were needed in order to see the improvement in outcomes they were seeking. The creation of interactive dashboards was central to the effort.
In 2016, when the Agency for Healthcare Research and Quality (AHRQ) came out with its new guide, “Preventing Hospital-Associated Venous Thromboembolism, A Guide for Effective Quality Improvement,” it spurred Whittier, Calif.-based PIH Health’s efforts to change its entire VTE prevention strategy, with a goal of reducing its hospital-acquired VTE rates by 20 percent.
A multidisciplinary VTE prevention team made up of members from quality, nursing, pharmacy, clinical informatics, and physician leaders from medicine, surgery, ICU, and hematology/oncology performed a workflow assessment. They examined the entire VTE prevention process, starting with the risk assessment, to the VTE prophylaxis orders, and ending with the administration of the pharmacologic and non-pharmacologic therapies.
Previously, the VTE risk assessment was performed by the floor nurse after the patient was admitted, using the Caprini scoring tool. This posed a number of challenges, PIH Health said. Not only was the tool time-intensive to fill out (roughly 30 questions total), but the hospitalists were often placing admission orders in the emergency department, leading to placement of VTE prophylaxis orders before the VTE risk assessment was completed, explained Davis Lee, M.D., chief medical information officer. PIH decided to completely change this process.
“We replaced the Caprini scoring tool with a simplified four-bucket model, which now includes Low risk, Moderate risk, High risk, and Joint risk,” says Lee. Also, the physicians were now responsible for choosing the VTE risk within the VTE prophylaxis order set, which would then provide decision-support to guide them to the appropriate orders for that specific risk. They also embedded the VTE prophylaxis order set on all admission and post-op order sets, and put in a hard stop alert if they tried to skip it.
“We had to completely re-do that work flow so that it is driven by the physicians and the risk assessment is done at the point of care when the physician is doing the VTE prophylaxis order set,” Lee says.
Despite these efforts, PIH Health was not seeing the improvements it had expected, and realized that it needed a better way to monitor outcomes and processes. With assistance from Allscripts, they created new interactive dashboards to help the front-line staff, as well as quality and administrative leadership departments access real-time data.
The real-time dashboard of admitted patients displays the physician VTE risk assessment score, alongside the nursing VTE risk score, as well as the current VTE prophylaxis orders. They measured the appropriateness of the prophylaxis orders as well as the use of “bleeding risk” as a contraindication for pharmacologic prophylaxis. A physician scorecard was developed that allowed PIH Health to track, by physician, the risk assessments performed, and compliance of completing it within 24 hours.
To analyze missed VTE prophylaxis doses, another dashboard looked at the missed doses by medication type, medication frequency, and time of day of the scheduled injections. A custom timeline view was created that would show the sequence of events related to VTE prophylaxis, from admission to discharge.
Lee stresses the importance of having real-time data in the dashboards. “You want to be able to take the appropriate actions while the patient is still in house,” he says. “That is the only time when you are going to make a tangible difference in patient care. Otherwise you are playing catchup constantly to see if changes work. Now we can see if a risk assessment wasn’t done or if they didn't put a patient on the appropriate prophylaxis. We can make changes in real time. That is going to change outcomes, rather than working with retrospective data.”
PIH Health’s’ hospital-acquired VTE rates are now down from 3.9 to 0.74 per 1,000 visits (average January to September 2018). The 81 percent reduction easily passed its goal of 20 percent.
PIH Health, which now has 98 percent of its physicians compliant with the new work flow, may apply the dashboard approach to other challenges. “Sepsis is a never-ending outcome measure we are always looking at,” Lee says. “C. Diff is another big priority for our organization that we want to be able to track and have real-time decision support for. Those are the next two big ones we are going to be looking at.”
