Breast Cancer Treatment Guidelines

my name's elliott haut and i'm here with the rest of thejohns hopkins vte collaborative. we are a group of physicians, nurses, pharmacists,and researchers who are working on preventionof venous thromboembolism. we have a jam-packed section foryou today, and each one of is gonna betalking about different parts. we're gonna takequestions at the end. we've got about 45 minutesworth of slides, and then

please send in your questionsvia chat or on twitter. so without further ado,i'm gonna move ahead and tell you what we'regonna talk about, which is basic epidemiology andpublic reporting about vte. and then we're gonna touch onsystems approaches, the impact of missed doses, the role ofnurses, and patient engagement. so to get us startedis peggy kraus. peggy is a pharmacist whoworks with our group. >> thank you.

so like elliott said,i'm the pharmacist. so i'm gonna just go over a fewthings to start off before we get into the nittygritty of our research. so most of youprobably are aware, vte stands venousthromboembolism. which essentially composes ofa dvt, or deep vein thrombosis, and a pe, or pulmonary embolism. although, if you have a patientwith the more rare occurrences such as a splenic vein or

hepatic vein, those wouldcount as a vte as well. so we have been talkingabout vtes since the 1800s. as you can see, rudolf virchowstarted discussing clots way back when and there has been this triadthat's been developed. so any one of these three thingsoccur, then the patient is at risk for having a clot,whether it be stasis, injury to the vessel wallsuch as in trauma, or if somebody's born witha hypercoagulable state or

develops a hypercoagulablestate, they can be at risk for developing a vte. so why are we worried about vte? in 2008, the surgeon generalput out a call to action to prevent dvt and pe. as many as 350,000,up to 600,000, or maybe more, in the us alone will sufferfrom a vte each and every year. we also know that vte is deadly. we have over 100,000deaths per year from pes.

and this is combined,this is more than breast cancer, motor vehicle accidents,and aids combined. now, one thing that weare trying to do here is help raise awareness, because most of you probably areaware of breast cancer, there's a boatload of organizations thatare helping raise awareness. the same thing with aids andmotor vehicle accidents, but yet you don't hear a lot aboutpreventing blood clots and how deadly they can be.

hang on. okay. there we go. so we had our firstdvt symposium way back in 2009, it doesn't seem like it wasthat long ago, but it was. and we actually werelucky enough to get the surgeon general to be one ofour keynote speakers right after they had put outthe call to action. most of you are probably awarethat there's a plethora of risk

factors for blood clots ranginganywhere from the older you get to trauma, just beingin the hospital, being pregnant, infection, recent strokes andsuch. so we also know that there'sa cost associated with vte. there's been a few studies thatshow each dvt can cost depending on which study from around12,000 up to 16,000 per patient per event. and as you know, most likely some patients willhave more than one blood clot.

if we look at the long-termeffects from developing a blood clot such as venous stasis andulcers that can occur, we're looking at a cost ofaround 250 million each year. we know that vte is preventable,most of the time. however, we know that notall events are preventable, even despite gettingthe absolute best prophylaxis that is out there. there have been at leasteight randomized controlled clinical trials done in theorthopedic population between

total knee replacements andtotal hip replacements that show they stilldevelop vte, symptomatic, not just those that are found onscans, up to 2.5% of the time. so when cms came out with theirruling that they were going to make vte a never eventafter total knee and hip arthoplasty, dr haut and dr streiff put together thiscommentary saying that this is an impossible measureto meet because we cannot prevent all events [inaudible]each type of surgery.

you also will see the plethoraof guidelines out there, anywhere from the accp, collegeamerican chest physicians, which put out their guidelines, traumawith the east association, ortho's got their ownguidelines, ob-gyn, and the american collegeof physicians. now, despite havingall these guidelines, raising awareness, we stillhave an under-utilization of dvt prophylaxis in our patients. in this study from 2004 from dr.goldhaber and dr.

tapson, they showed thatonly 42% of their patients were getting prophylaxis priorto their development of a vte. here's an international study,because the previous study was only in the us, that showedpretty much the same thing. in 32 countries, we still havean underutilization of vte prophylaxis. while surgery tends to doa little bit better job than the medicine population,it's still well underutilized. so this has led to [cough]a call to help raise awareness,

because there's clearly adisconnect between the evidence out there and the execution,that can prevent dvt to the point where it's reallybecome a public health crisis. dr. goldhaber hadthis quote with the american public healthassociation in 2003. so ahrq also has put outstatements that dvt and pe are the most common causeof preventable hospital death. so just a sidenote, soif you could put us on mute, cuz i know somebody's is havinga coughing attack like i was

afraid i might do. so if you could put us on mute,that would be terrific. thanks a lot. we also know that dvt is one ofthe ways we can really improve patient safety, and it should be one of ournumber one strategies. also, ahrq has putthat prophylaxis for vte should be one of your topten when it comes to improving patient safety practicesin your institution.

again, to kind of promoteour little group, dr. haut and brandyn lau alsowrote the chapter for ahrq regardingthe prevention of vte, a brief update review which iswell worth your time reading. so now dr.haut is going to take over and talk about surveillance bias andpublic reporting of vte. >> hi, so people ask mehow i got interested in dvt, and i think you'regonna understand after the next couple of minutes.

there's a lot of conflict outthere about screening high-risk asymptomatic patients for dvt. this is mostly inthe trauma literature, but in other groups as well. and the idea behind it isthat if you screen high-risk patients, you are gonnafind events and treat them before they becomea fatal pulmonary embolism. however, there's anotherside of the coin, which is that there is a con.

it may be very expensive, notcost effective, and you might also end up anticoagulatingpatients who might not need it, and there can be harm fromthat anticoagulation. so if we go to the guidelineson the topic, there's actually conflicting guidelines fromeast, which is one of the trauma organizations, and the americancollege of chest physicians. east suggests that this,at least in trauma patients, this may be cost-effective anddecrease the incidence of pe. however, the american college ofchest physicians suggests that

this should not be performed. so now we've got differentorganizations that are giving different opinions. and what that did wasit made us wonder, should we be screening patients? we're not. so we got a call from the statetelling us that our trauma center had the highestdvt rate in the state. and we said, well,

maybe that's just becausewe're screening more patients, we're getting lotsmore ultrasounds. so we did this smallstudy at our center. we did a before andafter study and found that after we implementeda protocol to screen a lot of trauma patients, we did fourtimes as many ultrasounds and got ten times as manydvts identified. we then went ahead and looked atthis on a national level using the national trauma data bank.

and this paper was entitled themore we look, the more we find. if you break trauma centersinto four different groups by the number of ultrasoundsthey do per patient, the group that does the mostultrasounds has a seven fold higher dvt rate then the otherthree groups of hospitals. the more you look,the more you find, at least in trauma patients. people said well,maybe that's an issue of different patient populations.

so we actually did a patientlevel analysis, controlling for all these patient levelvariables that are known to evoke dvt. and found that if you'rea patient at a center that does a lot of ultrasounds, you are twice as likelyto have a dvt identified. i'm not gonna say you're twiceas likely to get a dvt, but you're twice as likely tohave it identified and put into a registry.

and then when you ask traumasurgeons what their opinion, their opinion is aboutthree-quarters of us think that we should be screening highrisk asymptomatic patients. the other quarterare really not sure or disagree with that statement. so there is variationin practice. and this is a classicexample of surveillance bias. the more you look, the more youfind, and those providers who do more testing may appearto provide worse care,

even though it's reallyjust a testing phenomenon. so what are the implicationsof that? the implications are thatthat variability in screening leads to variability in dvtrates that are reported, and those rates are biased. and you can't just look atthe outcome rate of dvt alone. it's probably notthe best outcome measure. so sometimes, we've talkedabout this before, we all feel like dilbert when the boss tellsus that we'll just use the test

results anyway because it'sthe only data we have. none of us were very happywith that answer, and we hopefully came upwith a better idea. and that better idea is thisdefinition of preventable harm. so we suggested that theperformance measures could link the process of care withthe adverse outcomes, so this preventable harm isa vte in patients who got no prophylaxis orsuboptimal prophylaxis. so we spoke,we gave that suggestion.

and cms actually listened,and if you keep up with the literature,that's the new vte-6. so vte-6 is and the incidenceof potentially preventable vte. and when you lookat that definition it's patients who are diagnosedwith confirmed vte who did not receive vte prophylaxiswhile in the hospital. that's the ideabehind that measure. so, the papers i just mentionedbefore were all on trauma patients in this differenceof opinion, mostly in trauma.

so then the question becomes, does this occur in otherpatient populations as well? so this is a paper in jamafrom a few years ago now about surgical patients. this looked at 11 types ofsurgical patients, wide ranging types of surgery, cardiac,vascular, cancer surgery, orthopedic surgery, etc, almosta million medicare patients. and if you look at the maingraphic from this paper, it shows the exact same thing.

the more imaging youdo looking for vte, the more events you find,whether it's vte or dvt or pe separately, the more youlook, the more you find. this is not justa phenomenon in trauma, it happens in surgicalpatients as well. and this is one graph fromone project, we had a masters of public health student dothis, his thesis project. this, if you look at hospitalsand look at the relationship between their process measure,scip vte-2, that's the process

where they're giving appropriateprophylaxis versus the outcome, which is psi-12,there's really no relationship. it's a really, really flat line,and everybody or most of the peopleare clustered, the hospitals are clusteredway at the end near 100%. most hospitals are doing very,very well, and there's no relationship betweenthe process and the outcome. and if you actually compare thehospitals that reported being 100% perfect for vte prophylaxisversus the lowest end hospitals

in the bottom six, basicallythe same exact outcome rate. so it just goes to showthat this specific measure that was used as the initialmeasure of the process is really not a good measure. it doesn't really correlatewith the outcomes and doesn't really help you. so the jury is still out. we're still not sure whatwe should be doing and what we should be reportingrelated to vte as far as

public reporting. is it a process? is it an outcome? is it the combination? we should know that vte-1, the prophylaxis measure,is now being retired. so that is no longer gonnabe a reportable measure, because it really wasnot all that helpful. so, i'm gonna turn this overright now to mike stripe who's

gonna talk to us aboutkinda systems approach, improve vte prevention andvte outcomes. >> thank you very much, elliot. so i'm mike stripe, a hematologist at hopkins that'sbeen working with our group for the last, i guess,eight, nine, ten years. so can you take a systemsapproach to improving the vte prophylaxis, and we did lookat this starting back in 2005. but it's important to notethat while education,

which was part of our approach,is not enough. that you really have touse multiple, different, active strategies as shownon this systematic review, including remindingclinicians and providing them assistance in riskstratification and selection of risk appropriate prophylaxisto have the biggest impact. and in this paper from bmj fromnow a few years ago, we kind of go through the history of howwe used what peter pronovost, the trip model,

which is translatingresearch into practice. we use that same model thathe applied in surgical site inspections andapplied that to vte. and as you see, we've had somesuccess with that approach. so initially in 2005, when wewere starting this process, we did not have electronicorder sets yet. we were still using paper ordersets, and so this is a version of one of our paper ordersets that shows at the top, we have risk factors, then belowhad been the risk categories.

in the middle, had the differentrisk appropriate prophylaxis selections, and then had contra indicationsat the bottom of the sheet. and while this helps organizeclinicians' thinking or approach to dvt prophylaxis, it was suboptimal in that wecouldn't ensure that it was in every chart at the time ofthe mission or transfer. it made it verydifficult to get data out of this system as tosee how we were doing.

and so once we starteda transition to an electronic order entry system,we got together and redesigned our approach usinga computer order entry. we made a mandatory riskassessment tool that would then lead the clinician into riskappropriate prophylaxis using a few questions to riskstratified patients, vt risk, and their bleeding risk. and then gave them advancedcomputerized clinical decision support to help them givethem selections that would be

appropriate for their patient,based on their risk. and this is a screenshot ofone of those vte order stats. you see at the top,it has patient information about weight, also gives them acalculated chlorine clearance if in case they're gonna usea lightweight heparin, and then has several questionsthat look at major and minor risk factors, as wellas risk factors for bleeding. and then when they'veanswered those questions, then it gives them therecommended prophylaxis options

that would lead to optimalprophylaxis for their patient. and so what we found withthe benefits of this approach, well one is instead of paperorder sets where they weren't all within the charts, this putvte prevention in the work flow. it was part of the order setsfor admission and transfer. it helped the clinicians dothis rapidly, so it took a few seconds and guided them torisk appropriate prophylaxis. and it allowed us also tomake any literature advances that occurred with literature,

we could try to translate theseinto changes in the order sets. and that made it muchmore effective for performance monitoring andreporting, which was very difficultwith our paper order sets. the keys to our success, as itwas reported in this paper, was that we had a multidisciplinaryteam from the start. we had interested physicians,nurses, pharmacists that workedon the front lines. we had medical informatics,professionals that helped

us design and buildthe system and then extract the data out of the system, sothat we had seamless reporting. we also were fortunate tohave leadership buy-in. we collaborated with allthe service teams to different specialties to make sure theorder sets we designed would fit with their practice, butwere yet evidence based and educated the providers on theevidence bases in their area. and then the computer systemallowed us to not only measure baseline performance, butalso conduct ongoing performance

assessments so that we cantrack how we were doing. so did it improve ourprophylaxis and our outcomes? well, we did two studiesthat suggest it did. that this is the first studypublished in 2012 looking at our trauma service. and it's a singlecenter study obviously. a pre/post study. we had one year of databefore the order set went into effect and then threeyears of post order set data.

and what we found,on the next slide, you see that there's a dramaticincrease in prophylaxis compliance, wentfrom 62% almost 85%. during this time period you alsosee a concombinent decrease in all thrombotic events. and more importantly yousee a significant decrease in preventable harm sothat patients who are getting prophylaxis and thus weare doing all that we possibly could to preventthrombotic events.

and so preventable harm wentfrom about 1% to about 0.17% of the population,a dramatic change. we also saw the same thing indepartment of medicine where we had an order set guidingprophylaxis selection in that group of patience,again it was a pre post study. about a thousand patients beforethe order set introduction and almost a thousandin the post period. what we saw was significantincreases in optimal it was appropriate forthe patients' risk level.

in addition we saw dramaticreductions in the number of patients that got noprophylaxis from 24% to 4% and then on this table you cansee that if we only follow patients out to about 90 days,there was a significant reduction in total vte fromabout 2.5% to less than 1%. and more importantly,preventable harms, you see highlighted in thisred box, went from 1.1% of patients to no patients inan opposed implementation period had preventable eventsof thromboembolism.

and so when in 2010, the northamerican thrombosis forum sponsored a competition ofdifferent approaches and strategies to decrease vte. we submitted our intervention,and we're fortunate to receive one of their dvteam careawards for our work. and it's also been recentlyhighlighted by hrq and their guide to effectivequality improvement as one of the they selected asproviding a model for how you can prevent a hospitalacquired venous thromboembolism.

and so now i'm gonna turnthe program over to brandon lau, who is our medical informaticianto talk about other strategies to improve vteprophylaxis administration with performance feedback. >> thank you very much, ed. my name is brandon lau. i'm a clinical informatician bytraining and i've been working with the vte collaborative forsome time trying to figure out how we can empower cliniciansand nurses and patients

with this data to help improvevte prevention practices. and that's what i'm going tobe talking to you about now. what we saw in the lastcouple of slides is that after implementation ofclinical decision support, about 85 to 90% of patientsare now being prescribed risk appropriate prophylaxis. so that's down to the individualpatient level if patients are getting what is appropriatefor their level of risk. and what that tells me is thatsomewhere between 10 and 15% of

patients aren't being prescribedrisk appropriate prophylaxis. and because we've been ableto move forward with this decision support tool tocollect data electronically, we thought that it might presentan opportunity to really harness the power of analyticsand electronic information. and bring performance data rightto the front line providers to try to incentivizeperformance improvement. and our first thought withthis was to give feedback to attending physicians,

which you'll see highlightedin the dark blue lines here. but, to the eye, correctly,there isn't really much of a difference between attendingphysicians under proportion of patients who are prescribedappropriate prophylaxis. the primary reason for thisis that attending physicians rarely, if ever,write bt prophylaxis orders. instead, what you can seein the light blue lines are the proportion of residentswho write appropriate prophylaxis orders for theproportion of their patients.

and you see whyvarying differences, a lot of residents dothe right thing all the time. some residents do the rightthing none of the time and a smatery of residents do theright thing some of the times. and because they're quasirandomly paired with attendings. it doesn't really seem as thoughthere's any different between attendings on risk appropriateprophylaxis prescriptions. so we thought that residentswould be ideal target to give individualized feedbackabout prescribing habits.

and that's what we did. we started by giving theprevious three months of data, which you'll see inthe first figure. and you'll see a lotof red in this. and think about who it is thatwe're talking about here. very, very competitiveresidents, surgical residents, wanting to be the best, drivingto be the best, and we rank order them to tell one of themthat they are in last place. and that fact alone droveperformance on a month

by month basis where we wentfrom the mid 80s of patients being prescribed appropriateprophylaxis to the high 90s. and this is the highlysustainable intervention of using electronically availabledata to give performance feedback. here we see 15 monthsbefore giving feedback and 15 months after a dramaticimprovement with only one drop off when ournew interns began. but even with that drop,

performance very rapidlyreturned to the high levels that we saw before the newinterns arrived. overcoming this july effect andproviding meaningful feedback to frontline prescribersabout their habits. but this actually bringsup the other question, are we actually targetingthe right thing at this point? as i'd mentioned 85,90% now high 90% of patients are being prescribedappropriate prophylaxis, but is that where we shouldreally be targeting?

and if the classicassumption here is that when patients are prescribedmedications in hospitals they will alwaysbe administered. but is that actually a fact. and when you think aboutoptimal vte prophylaxis, optimal vte prevention, itreally requires risk assessment of patients prescribingthe appropriate medication, for nurses to administerthe medication as prescribed. and perhaps,most importantly for

patients to accept thatmedication as it's prescribed. a lot of work goes intothese various steps. making sure each one is done. and what we found from a smallstudy published by colleagues of us looking at high risk traumaand general surgery patients, is that missing evena single dose matters. missing doses of vte prophylaxisis associated with developing vte, and certainly among patientswho do develop dvt about

a quarter of patients missedone or more of their doses as opposed to 5% of patientswho missed none of their doses. so we can tell thatmissing doses matters. in addition, we found verysimilar findings here. that about half of patients whodeveloped hospital-acquired vte received appropriate care. they were prescribedthe right medication, and they received every dose ofmedication as prescribed. the other half were dividednicely into two groups.

about a quarter of whom, simply were not prescribedthe appropriate prophylaxis. there was an opportunity toimprove on the prescribing side but three quarters missed one ormore of their doses. they were prescribed the bestpractice prophylaxis. but they missed one or more of their doses representingan ideal opportunity to improve. so we did a small study onlooking at a little more than 100,000 doses all prophylaxisat hopkins hospital.

and we found that 12% of doses, 12% of all dosesare not administered. with the greatestdocumented reason for non administrationhas patient refusal. about 60% of all doses misseddue to patient refusal. which might indicatethat there's a problem acrossthe hospital uniformly. but when we look atthe individual floor levels, we see that some floors, about5% of doses on administered, and

then the extreme outliers,we see that somewhere between 25 and 30% of dosesaren't administered. and there's a lot that we couldgain from understanding just the distributionbased on the data but it's really when you take it tothe floor and talk to nurses and talk to patients to find outwhat's really driving them. and so for that i'm going to turn it overto one of our lead nurses deb hopson to talk about what wefound from the frontline nurses.

>> thanks brandon. so, hi everyone, i'm deb hopson. i'm the nurse who's beenon this project with dr. strike from the beginning. so, how he says it eight,nine, or ten years, however long we'vebeen doing this. and like brandon just said,even working from the beginning, we put a lot of focus onmaking sure the patients got the appropriate prophylaxis, andi felt really good as a nurse

that we were moving inthe right direction. but then you see this data herethat brandon just showed you, and i was shocked bythe amount of missed doses and how it was really differenton all of our floors. so we really wanted to find outwhat was happening out there on our nursing unit. and so, whoops, what did i,i hit the button, sorry. so, this is what we did. we started looking onthe nursing units and

wanted to do someresearch out there. and i worked with a pharmacist,stacy elder. and we did some quantitative andqualitative observations of what was going on andi'm gonna show you those. and one of the papers we wrote,and that's there and it is with stacy elder, it'shidden barriers to delivery of pharmacological venousthromboembolism prophylaxis. and we did, we went out there,we did a survey with nurses. we did observations wherethe pharmacists truly observed

the nurses and their interactionwith the patient when they were giving the prophylaxis dosage. and then after we did those,we met with different groups of nurses to find out more,we had focus group meetings. so and this is sorta what we found out fromthe quantitative survey. we had one of the questions, ihave the clinical knowledge and experience to determine if itis necessary to administer the vte prophylaxisinjections to patients.

and this is good,i mean they felt like they did have the knowledge, but with87% medicine and 79% surgery. which, i think is important thatnurses have the knowledge, but not that it's necessary toadminister because that's a prescribed dose. and then andalso the second one, nurses use their clinicaldecision-making skills to determine when to omitunnecessary doses of prescribed vte prophylaxis injections foreach individual patient.

this, as a nurse, andthe doctors in the room and everybody will tell you, wheni found out this i was shocked as a nurse that we were makingdecisions on whether or not a routine prescribedmedication for a patient should be given ornot. it's not a prn medication. so i was really shocked andi wanted to know more of what was going on, sois vte prophylaxis optional? and these were some of thecomments when we had the focus

group meeting. one nurse would sayi push harder for my patients to acceptheparin if they have sickle cell disease asopposed to say pneumonia or something where they're justhere for iv antibiotics. i was like mm-hm. and then another one. sometimes if it is the middle ofthe night and they are due for their heparin and the patient'sasleep, i'm not gonna wake them

up if i don't really feel theyneed that vte prophylaxis. and one of our favorite onesis the ambulation myth. we make the clinicaldecision all the time as to whether a patient needsvte prophylaxis every day, based on how muchthe patient is ambulating. and then another one, andwe observed this, hey ms. r, it's time for your heparindose, but as long as i see you out in the hallway high-fivingme, we can hold off for now. now really?

so we looked at that and we knew that there is not enoughon ambulation to tell us for sure how much a patientshould be doing or not. there's not enoughliterature out there. so we really, at that point,knew that we not only needed nursing education, but againto go along with what brandon showed you most of those misseddoses were patient refusal. so we also needed that we wantedto focus on the patient's side. so that's when our teamtogether looked at the grant.

and we got the grant from the patient-centered outcomesresearch institute and that's when we started thisproject, the pcori project. and it was a three year project, which we're ending injuly of this year. but you can see our projectis titled presenting venous thromboembolism, empoweringpatients and enabling patient-centered care viahealth information technology. and with that, the objectivesare to really help the patient

so that they can makeinformed decisions. and we wanted to focus on thatpatient-nurse communication, along with empoweringthe patients so that they can take an active role intheir preventive care for vte. and then also, one ofthe biggest parts to this and doreen, our nurse researcher onthe project, will go over this, but really getsthe patients engaged. and we wanted to talkto them as soon as possible after theymissed the dose,

when they did that patientrefusal of that vte prophylaxis. so we decided to get a lotof major players involved, a lot of the nationalorganizations and key stakeholders andthose are listed here. you can see, we had clotcare,north american thrombosis forum and national bloodclot alliance. we even involved our own patientand family advisory council so that we could really get inputwith them on what they wanted so that we knew how toapproach this big

problem of patient refusal. and then here's the website andyou can go to the pcori website at any time andit's research in action and you can find everythingthat we're doing. and with that i'llturn it over to doreen. >> hi this is doreen. i'm a nurse educator forthe department of surgery and have been working with thecollaborative for about two and a half, three years now.

and i'm going to be talkingabout how nursing education can improve vte prophylaxisadministration. as brandon had talked about anddeb had talked about, we're looking at impacting all aspectsof the vte prophylaxis process. so when you're lookingat education and delivering education models,what we really seem to evaluate for the mostpart historically is we're looking more at the effectiveand the cognitive domain. so we look at the reactionof the learner to

an education model. did they like it? did they learn? and we measure thatby surveys usually. but truly is liking it andlearning the education actually translated intoa change in behavior. and in relationship to vteprophylaxis, do we stop missed doses and then ultimately are weable to impact vte events? so we partnered with centralnursing education to build

an educational program toimpact all of these aspects. we looked at learner-centric andinteractive scenario-based dynamic educationmodule, and delivered it to a set group of bedsidenurses at this institution. it was a learner-based,scenario-based platform. we actually looked at patientsafety events that had been reported and developedthe scenarios based on that. we used critical thinking andworked in multi-disciplinary venues to getthe information across.

the platform itself was fairlygeneric, it was a storyboard. one of the negatives with thisis that some of the avatars were a little more laura croft asopposed to our natural patients population that we have. but really engaging the user ingoing through these scenarios. and if the user was gettingthe information incorrectly, they weren't penalized, they were able to movethroughout the scenario. but, if the user had wronganswers to any of these

scenarios then they wereremediated at that time. so where is this gonna go? does this work? does in those domains thatkirkpatrick measures, are we going to change behavior? is this effect goingto be sustained? is there a honeymoon phaseassociated with this? do we need an injectionof education and how is that gonna look like?

are we going to be rollingthis out to more nurses, just our whole hospital orthe health system? are we able to deliverthis to other hospitals? at this point in time,we're sharing these modules with the illinois surgical qualityimprovement collaborative. so seeing how this impacts. again those last two levelsin the kirkpatrick model will show whether we are actuallyable to impact behavior and ultimately decrease vte events.

so what do patients really want? when you're developingthe patient education, so we've already talked about physiciansand providers risk assessment, we've talked about the educationthat we need from the nurses to impact the administrationof the vte prophylaxis. and now we're looking at whatpatients really want that are gonna impact that refusal. and how did we do that? we used a modifieddelphi method.

we surveyed patients,patients and family members, the end users. we recruited themusing social media, select websites, facebook,twitter, and we got more than 400 respondents from all of theinternational organizations and our internal organization thatdeb had actually discussed. what do patients want? we asked. what are patientswilling to read?

what is the venue? who is to deliverthe information? how long is that informationsupposed to be and what does it actually look like? when we got that information,we not only took the information and built the educationaldelivery method, but we also reviewedthose face to face. we had focus groups, we wentout into the community and reviewed this.

so we weren't the ones that weredeveloping the information and the education in the deliverysystem, the patients were. so what did the patienteducation bundle look like? what did the patientspecifically want? well they wanted paper. it's just showing enough in thisday and age with all of our different again social mediavideos and access to a lot of online gaming, patientsreally wanted a paper form. so we utilized a template thatwas built on some adult learning

theory, but the informationwithin that paper was written literally by the patient. interestingly enough, we would ask them yourword smithing things, you know what was the comfortlevel of different terminology. patients liked informationsuch as shots and belly. now when we would reviewedthis again with providers, the providers would like tochange that to injections and injections or abdomen but whenthe patient spoke, we listened.

we actually used whatthe patients had wanted. you need to makeit easy to find. an information paper is only asgood as the ability to hand it to a patient. when you're developingthis type of education, make sure that it'seasily searchable. we used keywords that werecommon terminology and also had it so that when you enter thosekeywords, this patient education form would be at the top of thelist when you did your search.

we made it in multiplelanguages and a large font. again, the information is onlyas good as the patient's ability to understand it. truly patient centered,if you have a patient who speaks english or understands english,then that's wonderful. but it doesn't really showthe value that you have for the patient itself in trulypatient centred care, if you are able to hand that patient aneducational information packet, that's in their language.

i had an elderly gentlemanwho was russian and the look on his facewhen i handed him our patient education packetin russian was priceless. he was engaged, this wasa patient that was going to have a discussion and we would beable to talk about what it meant to help keep himsafe from clots. so with the video,what did patients want? they wanted a ten minute or lessvideo, they wanted physicians, nurses and patients talking,they wanted to see

someone who looked like them,who was talking about the fact that they had a clot or whatthey did to help prevent a clot. we had an oscar winning directorand we took all of that information that the patientsgave, put it into this video and then we screened it for ourpatient family advisory council. more importantly, we made those changes basedon the feedback that we got. these are some ofthe patients that we had. we had physicians patients.

we filmed them intheir own homes. we showed them whattests they wanted. again, all information that wereceived from the patients and what they wanted andhow they wanted to learn. so what did our interventionactually look like? we had a real time alert ofany non-administered dose. this alert came to a pager oran e-mail. you don't need to go and talk to patients necessarilythat are taking the medication,

you need to target the patientsthat are refusing. if patients that are takingit want to speak to someone, you're able to do that, butyou want to do a real-time one on one discussion withthe patients that are refusing. once the page would come in,the nurse educator would go and then it was a bundledapproach and again patient-centred care sowhat the patient wanted. did they want the paper? did they want towatch the video?

did they wanna discusswith the nurse? did they want none of this? this intervention usuallywent one of three ways. you would have the discussion,educate the patient, and then the patient would take theirprescribed vte prophylaxis. sometimes we'dhave patients that wouldn't necessarilywant the shot. they understoodthe importance but the shot was not necessarilysomething that for

whatever reason, they were ableto deal with at that time. and at that time again, usingthat patient intervention or patient-centered intervention,we would work with them to get the best, maybe not the bestevidence prophylaxis, but the right prophylaxis forthat patient. and then other times, we would have patientsthat truly would refuse. this was an informed refusal,this was an educated refusal and again, patient centered care.

this project was rolled out fromapril 2015 through december 2015 and at this point in time, we'relooking at the effects of this. where do we go from here? we're looking atgetting the word out. how do we get patients,as you could see, the amount of patientsthat we have aren't aware of how importantdt prophylaxis is. so getting the word outnationally, internationally, we need to look atsustainability, how are we going

to maintain the progressthat we're able to achieve. >> so all in all, i think we'vecovered quite a bit today. we've toucheda little bit on many, many different aspectsof vte prophylaxis. we got a feel for our wholeentire team who had a chance to present andwe do have some acknowledgments. this is our group at a couple ofdifferent pictures along the way and it's important to noticethat we've invited many important speakers,nationally and internationally,

to our vte symposium. on the bottom, somewhere inthat bottom left-hand picture, you'll see bill gertz in there. richard white is overon the bottom right and it's important to see patients. so if you look in the top leftpart at the four people sitting at that table, those arepatients who present every year. we have a patient panel at ourvte symposium where patients get up and

tell their own personal storiesof what did it feel like? what did i had to wheni had my dvt or my pe? so you can get a feel forpatient perspective. and as we're talking aboutengaging with the community, that's some of us ina little more casual attire, attending a nbc,national blood clot alliance. a walk to help support acommunity engagement in some of our group with some ofthe members of the nbca locally. and then these are our emailsand a few of us are active on

twitter and happy to answerquestions along the way there. all these slides and eventually, the audio will be put up onthe armstrong website and then the final site i'm goingto leave up while we do our question and answer sessionis some other resources. so just as a reminder,we heard a lot about the paper forms that werecreated, the education. those are out there for free. you can go to the armstronginstitute website and

download the version. you can download it in english. you could download it in englishin a large font version and a series of translatedinto other languages to use with your patient. the patient education videothat already got mentioned, you can go there to watch it. you can see whatthe video looks like. you can watch it tolearn yourself and

you could show it to patients. there's also a link to our pcoriresearch in action website which really is talking aboutthe active project we have going on andan article from last summer in the wall street journal thatfocused on the group and what we're doing here andreally trying to highlight and improve public awareness ofhow important blood clots are. so with that, i think we'regonna end the presentation side. i know there are lots and lotsof different questions that have

come in via chat thatwe're gonna try to answer. peggy's been following themalong on her computer and i think what we'll do is, peggy, will be triaging them,asking them to the group and then the other, or the six of uswill all get together and try to answer the question dependingon our personal expertise. >> okay, so i know someare chomping at the bit here, but the first question i said iwould save till the end is what vte risk scoring tool doyou use, and is it for

all patients, surgical,medical, etc? >> yes, as mike strikes said, these older sets we designedback in 2007, 2008. so at that time period,there was no evidence-based risk stratification model,so we at that time, i think in conjunct you knowwhat you in association what you'd see in the chestguidelines at that time was that every patient that came out ofa hospital was assumed at risk. i think this is particularlymore important for

the medical patients thanthe surgical patients but every patient was at risk. and so our riskstratification model was basically based onthe medenox study. high-risk patients got high-riskprophylaxis, the enoxaparin or tid heparin, lower riskpatients got bid heparin, and patients that hadcontraindications to pharmacologic prophylaxis gotsequential compression devices. and in our medicine population,about 20% of them get

scbs as their prophylaxis,cuz they have contraindications. now, we're making a migration toepic where on the medical side, because there's a realizationthere are low-risk patients in the medicine patient populationthat we're gonna use in our epic order sets that are goingto be launched on july 1st. on the medicine side,we'll be using the improved risk score that alex spyropoulosand group identified, and i think we figured it was themost evidence-based risk score for medical patients, sowe're gonna be using that.

and then on the surgical side, i guess i'll turn itover to [inaudible]. we don't use the samerisk stratification for medicine, surgery, trauma. in all of our original ordersets, they were all based on literature at the time,in those different specialties. and elliot, i don't know if you->> and i would say that on surgery, we use kind of a modifiedbucket approach.

our patients in surgery are veryhigh risk, high risk, or moderate risk. we don't find anybody who'sreally admitted to the hospital who's low risk. it's very hard in this day andage to find a surgical patient who is at low risk who'sadmitted to the hospital, all those patientsare going home. so, i would tell you thatthere's many different risks scores that are out there.

you know, there's the capriniscore, the roger's score, there's all these differentapproaches that can be done, the pagent score in medicine,etc. there's no data that i've seenthat any one is better than another. i think the most critical partis that you use something, so you standardize it sothat everybody gets some sort of risk assessment,whether it's a point scoring or a bucket or whatever, so thatyou're really considering it for

every patient and then givingthat patient the appropriate prophylaxis based on theirrisk stratification. >> i guess there was onequestion i think i saw over. peggy that there was justa concern about bleeding complications, have wemonitored those pre and post? and bleeding complications, major bleeding wasextraordinarily uncommon at least in the medical population. it was about 1 in 1,000 patientshad a major bleed in our pre and

our post order set experience. so i think major bleeding isvery uncommon in our patients, and that's because we ask theproviders to risk stratify their patients. if they're a highbleeding risk patient, we're not using pharmacologicalprophylaxis in that patient. sorry. >> no, no.go ahead. i was just gonna say,do you want ambulation,

it's been part ofmany questions here. and mobility versusdvt prophylaxis, especially in medical patients. because some people will notgive, if they can get up and walk around, they typicallydon't give them dvt prophylaxis. so that's been,that's multiple questions. anybody want to address? >> so i think, this is brandon,i think that there hasn't really been some strong evidencethat would actually show what

the association is betweenambulation and vte prevention, particularly in a hospitalizedpatient population. and one of the frequentquestions that i ask the interns who come to hopkinshospital when giving their orientation lecture is,what is the amount of ambulation that equals a standard5,000 unit shot of heparin? and i hear everything froma nebulous two laps around the unit to three miles. and i think, that that reallyunderscores the fact that

we don't really know what the contribution ofambulation is to vte prevention. in reality,it probably does something. i just don't think that anyonereally has the evidence to really say that it works everytime, and this is how much. >> there's many, many, manydifferent randomized trials for the pharmacological medications. there's very littledata on ambulation. and as brandon points out,we don't know the dose,

we don't know the frequency,we don't know any of that. so i think, when people puttogether evidence-based approaches to vte prophylaxis, idon't know what you can have any very strong evidencethat ambulation alone or in combination withanything else works. it's certainly good patientcare, and there's lots of huge pushes at our hospitaland others for ambulation, getting patients out of bed,and physical therapy, etc. but the data that that preventsvte is really pretty sparse.

>> well, and if anything,i think, mike and elliot, you can talk to this too, we're evenfinding, especially in surgery, that patients going home aftersurgery, because of our nsqip database, that they're evendeveloping vtes within 30 days. so now we're even looking atprophylaxis at discharge and how long do we needto do that too. so, i think, we know thatmobility in the hospital and immediately after dischargeis not the same mobility that patients were doing priorto being hospitalized.

>> right, and this issue ofpost-discharge prophylaxis is a really important question. there've been a few studieson medicine, patients, and the data are conflicting. and some show that theprophylaxis actually leads to more bleeding and doesn't reallynecessarily help with events. there are some specific surgicalpatient populations where the data is relatively strong. certainly on some orthopedics,

especially joint replacementprocedures, hip fracture, as well as some abdominalpelvic cancer surgery, the extent of prophylaxis doeshave a relatively strong data. >> so, it looks like there'sa question in here about obstetrics patients in ourpreferred screening tool. so, there's no evidence-basedscreening tool in obstetrics. so when we put the order setstogether with the obstetrical positions, the ob department,that as you indicate in your question about an olderpatient or an obese patient

with a c-section,that those are risk factors. certainly obesity, age,c-section puts at higher risk. so patients that had surgicaldeliveries tend to get pharmacologic prophylaxiswhile they're in the hospital. we're not sending any obpatients home with prophylaxis. but so, there's a varietyof risk factors in the ob population, medicaldisorders and such, and those patients willget prophylaxis. most of them don't getprophylaxis in the hospital,

it's only the high-risk patientsthat get surgical deliveries and have serious medical problems or previous thrombotic eventsthat are getting prophylaxis. >> what about weight and bmi? >> so yeah, i mean, so as far asweight and prophylaxis, i mean, our bariatric surgery groupuses, i guess, increased doses of enoxaparin forprophylaxis in those patients. so instead of 40 once a day, they're using 40 twice a day inpeople that have bmis over 40.

and i think in bmis over 50,they're using 60 twice a day based on the bariatricsurgery literature. we're not doing that inmedicine, although there are certainly studies lookingat the medical population and showing that higher doses invery large patients are probably appropriate tomedical patients too. but they're notrandomized studies, these are retrospectiveobservational studies. >> and we did a systematicreview through

ahrq a few years ago that reallylooked to answer this question in the obese patients. and really,except in bariatic surgery, there's a paucity of dataon what we should be doing. lots of different people andlots of different institutions are doing it differently, doubledosing their enoxaparin or increasing theirheparin amount per day. but there's really not strongevidence on what should be done. >> so, there's also been,

how much longer do wewant to go [inaudible]? so, there's a question aboutthe not much discussion about sequential compression devicesor other mechanical prophylaxis. >> where, i mean- [crosstalk]>> well, do you wanna give the->> i mean, in medicine, we're using itin about 20% of patients that are contraindicated topharmacologic prophylaxis. in surgery, they use a lotof combined prophylaxis. we don't do that in medicine,they're either pharmacologic or

mechanical prophylaxis. but in your high risk surgerypatients, i'm sure, yeah, they'll use both. >> we use pharmacologic and we use sequential compressiondevices up until discharge. so we motivate it and engage the family members tohelp the nursing staff out. all of our patient roomsnow have scd pumps available in them, and

so the patient gets connectedto the sequential compression devices as soon as they'redone ambulating or in the bed. whether it's the bed orthe chair, we hook them back up. and like i said, we've evenstarted engaging family members to help with that. >> and then teds, i mean, what->> yeah, we found out, the study a couple years ago,we found out that, we were using both teds and scds, andthis tells my age in a way, of nursing, because years agowhat we found out when we

first started using sequentialcompression devices, patients were complaining because itwas sticking to their legs. it was the old type ofdevices that were very, they had a lot ofplastic on them, and patients felt they were hot,and sticking to their legs. so at that time we startedusing both teds and scds, the teds making the scdsmore comfortable. and then recently we found out,especially in our surgical icus, that patients weren'tmeasured appropriately for

scd's prior to goinginto surgery, but then they were fluidoverloaded in surgery. and when they wereout in our icus, we were seeing pressureulcers from the ted. so now, our standard is prettymuch scds for all our patients. if teds are needed, or ifthey're requested, we can still get them, but we now use sedsin our operating room and all our surgical units,without the ted. >> and it looks likethere's a question,

i was just looking over peg'sshoulder about neurosurgery, and what we do with neurosurgery and>> [laugh] >> so neurosurgery, they approach working with theneurosurgeons here, is we use, they prefer unfractionatedheparin to low molecular weight heparin, and so, although thereare data with low molecular weight heparin,we use unfractionated heparin. there are obviously nopreoperative dosing of anticoagulants.

they use scds during the case,and until the patient's ambulatory, they use, starting24 hours after the surgery, if hemostasis is achieved, they'll start unfractionatedheparin prophylaxis. so that's what the neurosurgerygroup does here. >> there's another questionthat i wanna try to reply to. this one here says,it sounds like we prophylax 96% of patients, and that's muchhigher than the accp guidelines recommend, cuz there's gonnabe many low-risk patients.

and i think what we need to dois clarify, that that 96% is we gave the appropriateprophylaxis to the patient, based on the clinical decisionsupport tool recommendation. >> right, right. >> and it might be that theclinical decision support tool recommendation suggestsheparin twice a day, and we ordered heparin twice a day,that counts. it might be thatit suggests that the patient is contraindicated,so they get mechanical only, and

as long as we givemechanical only, that's the appropriate order forthat specific patient. so it's not that we gaveprophylaxis and ordered, for example, low molecular weightheparin to 96% of our patients. we were following therecommendation of the decision support tool, 96% of the time,which is a key difference. and if we do agree,there's gonna be patients, whether you believe that thelow-risk patients who shouldn't be getting anything,whether they exist or

not, that's still up for debate. but there certainly aren'tpatients who are contraindicated for reasons, and we should notbe giving them prophylaxis, cuz it's gonna weigh,the risk and benefit then goes inthe wrong direction. >> and it looks like there'sanother question here about hip fracture patients, anddelays in surgery. what chemoprophylaxisis recommended? and, generally,

on the orthopedic service formany years, low molecular weight heparinwas the prophylaxis of choice. that has changed some,i would say, in the last years, as aspirin's become moreacceptable, although our group, i think, prefersan anticoagulant approach. so we would recommend lowmolecular weight heparin prophylaxis, untilthe surgery is performed. if you're gonna do surgery andyou give a prophylaxis preoperatively, you would startyour surgery 12 hours after your

last dose of prophylactic lowmolecular weight heparin. and then restart it 12hours after the surgery, if hemostasis is appropriate. nowadays, i think they're usinga lot more aspirin in low-risk patients, and low molecularweight heparin in higher-risk patients, is the approach ofour orthopedic surgeons here. and that's reflected in our neworder sets, not our current orders sets, but the onesthat'll be active in july. >> there's one question hereabout the pediatric population.

>> actually, more than onequestion about the pediatrics. >> i've only seen some of them,i apologize. >> [laugh]>> but there's at least one questionabout the pediatric population, and at least the generalanswer to that is, the data on that is not nearlyas good as the adult population. there's tons of studiesin the adult populations. there are many fewer,i don't personally know of any randomized trials inthe pediatric population.

some have extrapolateddown to the younger, kind of teenage group,the post-puberty patients. we've looked at this in trauma,and patients in trauma seem to matchup with the adults aroundthe ages, somewhere between 13 and 16, they reach adult risk,and we treat them like adults. but the data in there'sa lot more sparse. so what we've done, is we dohave a risk assessment tour for pediatrics, that was puttogether with our pediatricians and our pediatric hemotologist,based on

a little more expert opinion,rather then the pure evidence. and it really guides people tothe most highest-risk patients, the older patients, the oneswith thrombophilia, etc., to consider prophylaxis inthat patient population. >> so just to add to that,cuz i didn't respond to one of the questions with regards, wehave a pediatric anticoagulation management service, which isalso looking at a point scoring system for risk assessingthe pediatric population. and they're still looking athow well this is performing.

>> yeah, i think neil goldenbergand cliff takemoto, who are the pediatrichematologists at hopkins and at st. pete children's, they've collected evidenceof a pediatric service, and are putting together a riskoffer for pediatric patients. >> and they're usingthe first version of that, in their border sets currently. >> does not need camcorder. >> and so it looks likethere's a question in scds,

as far as a concern, thatthe only data are in stroke and surgery patients. and i think that does point outa limitation in the scd data, that it's almost all surgicaldata, or from the recent claw trials' stroke patients, buti guess we've extrapolated from the stroke patient population tothe medicine patient population. we've kinda considered them asa high-risk medicine patient. and then there'slots of data in this surgery literaturethat it's effective.

and so, we're constrainedby the data, but if you have felt that aspersuasive enough that that should be what weshould use in patients, that are contraindicatedto receiving prophylaxis. and have been persuaded thatthe teds stockings, since as deb shared, we've had the similarexperience to the clots trial that, ted stockings causeskin breakdown in patients. and so i've deemphasizedted stockings as a method of prophylaxis in our patients.

>> thanks so much everyone,for joining our webinar today. we really enjoyedthe discussion. we'll be sending out the slides,as we mentioned, by march 15th. and you have ourcontact information, so please feel free toreach out to us. thanks again for joining us. >> thanks for joining. >> yeah, thanks everybody.