Paul Santos BS Pharm Pharm D Clinical Coordinator

Paul Santos, BS Pharm. , Pharm. D. Clinical Coordinator, Pharmacy Lakes Region General Hospital, Laconia, NH

About Us • Lakes Region General Healthcare, Laconia NH – – Acute care, not for profit, community hospital, Teaching affiliate with the University of New England Licensed for 137 beds 2011 data Admissions / year 4, 1645 Patient days 19, 046 Average LOS (days) 4. 57 Average daily census 52. 18 2

Timeline of VTE Initiative

LRGH Patient Discharge Sheet • • • VTE Discharge Education Sheet The major complications of Venous Thromboembolism are severe leg swelling and pulmonary embolism when a piece of the blood clot breaks off and goes to the lung. Pulmonary Embolism can cause severe shortness of breath, chest pain, back pain, bloody sputum, and even sudden death. To help prevent these two complications you should do the following: Wear compression stockings when ambulatory Elevate legs whenever possible Take warfarin as directed by the pharmacist or doctor and/or Take Lovenox as directed by the pharmacist or doctor Walk as much as possible Keep well hydrated; drink at least 1 liter of water per day Call your physician or call 911 for any chest pain, unusual back pain, shortness of breath, or signs of bleeding Your next blood test is _________. • ________ will call you with your blood test results to adjust your warfarin dosing as needed. • Your follow-up office visit with your doctor is ________.

LRGH-VTE Prophylaxis May 2011 to April 2012 VTE Prophylaxis Medication Ordered Month/Year VTE Prophylaxis. Compression Device Only Contraindication Documented No VTE Prophylaxis Ordered or Contraindication Documented Total # of Cases May-11 130 66. 18% 15. 38% 14. 60% 3. 84% Jun-11 146 65. 09% 15. 75% 13. 69% 5. 47% Jul-11 154 64. 30% 14. 93% 12. 98% 7. 79% Aug-11 158 60. 14% 17. 08% 13. 29% 9. 49% Sep-11 122 71. 33% 13. 11% 9. 01% 6. 55% Oct-11 114 64. 93% 15. 78% 12. 28% 7. 01% Nov-11 101 66. 34% 15. 84% 11. 88% 5. 94% Dec-11 115 71. 32% 17. 39% 7. 82% 3. 47% Jan-12 107 74. 78% 10. 28% 11. 21% 3. 73% Feb-12 85 76. 48% 12. 94% 8. 23% 2. 35% Mar-12 104 79. 82% 9. 61% 10. 57% 0. 00% Apr-12 119 73. 96% 14. 28% 10. 08% 1. 68%

Denominator for Measurement Tool • • • • These required elements MUST be present as structured data in EMR for Meaningful Use Objective to be satisfied: Inclusion: Order for VTE Prophylaxis (Order for medication and procedure/mechanical prophylaxis) Documentation of reason for not prescribing VTE prophylaxis Exclusion: Patients less than 18 years of age Patients with Length of Stay < 2 days Patients with Length of Stay >120 Days Patients with Comfort Measures Only documented prior to the end of the second day of admission Patients enrolled in Clinical Trials Patients directly admitted to intensive care unit (ICU), or transferred to ICU the day of or the day after hospital admission with ICU LOS ≥ one day Patients with principal diagnosis of Mental Disorder Patients with principal ischemic or hemorrhagic stroke diagnosis Patients with principal or other diagnosis codes of Obstetrics or VTE as defined (see page 3)

LRGH-VTE Prophylaxis May 2011 to April 2012 VTE Prophylaxis Medication Ordered Month/Year VTE Prophylaxis. Compression Device Only Contraindication Documented No VTE Prophylaxis Ordered or Contraindication Documented Total # of Cases May-11 130 66. 18% 15. 38% 14. 60% 3. 84% Jun-11 146 65. 09% 15. 75% 13. 69% 5. 47% Jul-11 154 64. 30% 14. 93% 12. 98% 7. 79% Aug-11 158 60. 14% 17. 08% 13. 29% 9. 49% Sep-11 122 71. 33% 13. 11% 9. 01% 6. 55% Oct-11 114 64. 93% 15. 78% 12. 28% 7. 01% Nov-11 101 66. 34% 15. 84% 11. 88% 5. 94% Dec-11 115 71. 32% 17. 39% 7. 82% 3. 47% Jan-12 107 74. 78% 10. 28% 11. 21% 3. 73% Feb-12 85 76. 48% 12. 94% 8. 23% 2. 35% Mar-12 104 79. 82% 9. 61% 10. 57% 0. 00% Apr-12 119 73. 96% 14. 28% 10. 08% 1. 68%

VTE Prophylaxis Initiative Noncompliance Rate May 2011 -April 2012 No VTE Prophylaxis Ordered or Contraindication Documented 100, 00% 90, 00% 80, 00% 70, 00% 60, 00% 50, 00% No VTE Prophylaxis Ordered or Contraindication Documented 40, 00% 30, 00% 20, 00% 10, 00% 2 р12 ап р1 ма 12 вфе в 12 ян 11 кде 11 яно т-1 1 ок -1 1 се н 1 г-1 ав 11 лию 11 н- ию ма й- 11 0, 00%

Conclusions • Newsletter, and other types written education have been shown to be insufficient, by themselves, at changing behavior. • Accurately assess the volume of workload before committing personnel to a task. • Developing a process that makes it mandatory (or at least difficult) to avoid asking the question. Does this patient need VTE prophylaxis?