As part of the QualityBLUE Pay for Performance partnership between Highmark Blue Cross Blue Shield and Penn State Hershey Medical Center, hospital-acquired venous thromboembolism (VTE) was identified as an area for quality improvement. This coincided with the release of the latest ACCP Guidelines on Antithrombolytic and Thrombolytic Therapy (8th Ed.) in the summer of 2008.
An interdisciplinary team of nurses, physicians, pharmacists, quality improvement specialists, and informatics specialists was assembled to determine how to implement the new guidelines at HMC. Through the use of Clinical Knowledge Management and the Analyze-Understand-Redesign-Implement cycle, we made tremendous gains in this QI project, including a sustained 25% reduction in nosocomial VTEs, reduced mortality associated with nosocomial VTEs, and cost avoidance estimated at $2-4 million annually. Let me walk you through the use of the CKM process and the AURI cycle in this QI initiative.
The CKM Process
Capturing & Classifying: At the time of the project initiation, HMC had been using an electronic medical record (EMR) with computerized physician order entry (CPOE) for greater than two years. This mean that in addition to the best practices outlined in the ACCP Guidelines, we also had data from greater than 50,000 inpatient visits available to us. This included: risk stratification data like demographics and clinical conditions; use of pharmocologic and non-pharmocologic prophylaxis; time elapsed from admission to first prophylaxis dose; rate of occurrence of nosocomial VTE.
Retrieving: Queries were developed to gather information about current VTE prophylaxis behavior from HMC's clinical database. Results from the queries were transferred into Excel spreadsheets.
Evaluating: Rates and timing of appropriate prophylaxis and rates of development of nosocomial VTEs were determined to identify gaps between current recommendations and current HMC practice. Underutilization of risk-scoring at admission as well as underutilization of pharmacologic and mechanical prophylaxis were identified. Inappropriate risk stratification was common as was inappropriate use of prophylaxis.
Concurrently, the pharmacists and clinicians from both Medical and Surgical services condensed the ACCP Guidelines to an easy-reference pocket card that contained risk stratification guidelines and appropriate treatment options.
Sharing: Required education for all pharmacists, physicians, and nurses was provided along with the quick-reference pocket cards. The education reviewed the new ACCP Guidelines as well as required changes to HMC practice.
Action: Based on the education and availability of the pocket cards, there was a modest improvement in guideline compliance and a slight decrease in hospital acquired VTEs.
A second cycle of the CKM process was then initiated. The data that was captured and classified after the roll-out of the education and pocket cards was retrieved and evaluated. It was determined that significant opportunities for improvement were as of yet untapped. It was also determined that a more structured and standardized approach was needed to accommodate the resident learning curve.
The sharing step was multifaceted. A clinical decision support (CDS) tool was created that included forcing functions at the time of admission that required VTE risk stratification on all patients. Residents were provided with the stratification criteria at the time of the risk assessment. Interactive alerts were developed to present providers with prophylaxis guidelines based on patient risk stratification at the time of order entry. Providers were required to either place appropriate prophylaxis orders or document contraindications.
The resulting actions from the providers were immediate. There was an increase in appropriate prophylaxis and a decrease in nosocomial VTEs. This reduction has been sustained for two years and through two intern classes. Partial results were presented at the Society of Medical Decision Making Annual Conference in October, 2010.
The AURI Cycle
As you can see from the above, the traditional Plan-Do-Study-Act (PDSA) cycle was not followed during this initiative. Most notably, no system changes were made until the data was carefully analyzed and understood by all team members. However, the AURI cycle was extremely effective in producing sustained behavioral change and improved outcomes. Let's examine how the steps of the CKM process fit into the AURI cycle.
Analyze: The retrieval and evaluation of both internal and external data to create new knowledge comprises this part of the AURI cycle. In this QI project, retrieving and evaluating data from HMC's EMR and studying and condensing the ACCP Guidelines represents the analyze component. The new knowledge gained from the analyze phase was three-fold: the correct prophylaxis choices were often clear to experienced clinicians but not to inexperienced residents; ideally, a single drug would be suggested for pharmacoprophylaxis; risk stratification was rarely performed at admission.
Understand: Sharing the new knowledge derived from the analysis phase with the quality improvement team comprises this part of the AURI cycle. The team identified barriers such as baseline resident knowledge, inability to use a single low-molecular weight heparin, insufficient availability of mechanical prophylaxis devices, and concerns for the feasibility of improvement with voluntary compliance.
Redesign: The redesign phase is a result of the CKM process rather than a step in the CKM process. The new standard of practice at HMC that involved risk stratification of all patients at the time of admission based on a standard risk stratification system as well as the testing of multiple models of mechanical prophylaxis devices by the Department of Nursing comprises this part of the AURI cycle.
Implementation: Sharing new knowledge derived from the analysis phase with all clinicians and other stakeholders comprises this part of the AURI cycle. The first barrier to success, baseline resident knowledge, was tackled during the roll-out of required education. Additionally, the Operations Department purchased an adequate number of machines and made them easily accessible. The EHR was modified to capture the use of mechanical prophylaxis devices and the use of pharmacoprophylaxis continued to be captured. We were not able to capture the timing of the risk assessment, which unfortunately, had to be done manually on a small sample of the patients.
Despite seeing modest gains, a second AURI cycle was needed to address the remaining two barriers. As noted above, the analysis phase identified the need for a more structured, standardized approach. The understanding phase led to the new knowledge that risk assessment needed to be required instead of voluntary, prophylaxis needed to be simplified, and appropriate guidelines needed to be shared in real-time with residents. The redesign phase resulted in the clinical decision support tool described above as well as a policy change that Pharmacy would substitute appropriate low-molecular weight heparin for patients with renal failure. The implement phase was the education and go-live of the CDS tool.
The time elapsed from the beginning of the first AURI cycle to the implementation of the second AURI cycle was only 9 months. As you can see, the CKM process and the AURI cycle can allow for rapid institutional improvement and identification of barriers to improvement. The success of this project highlights the way that efficient quality improvement methodologies result in significant financial gains as well as reduced morbidity and mortality.