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CDC Announces Eight Patient Safety Improvement Awards

The CDC announced the list of eight hospitals and healthcare systems that increased patient safety by implementing innovative HA-VTE prevention best practices.

- Eight hospitals and healthcare systems have been recognized as 2015 Healthcare-Associated Venous-Thromboembolism (HA-VTE) Prevention Champions for their patient safety initiatives that reduced the rate of HA-VTE, according to a recent press release.

CDC recognizes patient safety initiatives

VTE-risk assessment practices are recommended for hospitalized patients, but the guidelines are not being consistently applied. The HA-VTE Prevention Champion program acknowledges healthcare settings that have designed innovative and effective best practices for preventing HA-VTE and shares those practices with the larger healthcare system.

The CDC reports that the healthcare systems spend as much as $10 billion per year on 900,000 VTE events in the US. Approximately 100,000 individuals die from VTE each year.

Without appropriate prevention techniques, an estimated 15 percent of hospitalized medical patients will develop HA-VTE.

“Healthcare-associated VTE is a serious and growing public health problem,” said Thomas Frieden, MD, MPH, director of the CDC. “These challenge winners saved lives by implementing innovative VTE prevention strategies in their institutions. We can all learn from their ideas and work together to protect patients from developing deadly blood clots.”

The eight projects reduced the rate of HA-VTE or increased VTE prevention activities by engaging healthcare providers, spreading awareness, using technology to target at-risk patients, and providing real-time feedback on hospital performance.

Healthcare Network or Multi-Hospital System, Large Reach

The first Champion in this category was the Mayo Clinic in Minnesota. The healthcare network developed customized VTE prevention plans for special populations (e.g. neurosurgery, OB-GYN), a VTE Prophylaxis Tollgate, and a standard admission screening tool for pediatric patients in the ICU.

A VTE Prophylaxis Tollgate is an electronic system that monitors and alerts physicians about at-risk patients. The program flags patients who are at least at a moderate risk level for VTE and do not have a prevention plan in place. The system also flags patients who are in the hospital for more than three days, even if they are considered low risk.

The University of California Health, Center for Health Quality and Innovation, was the other Champion in this category. Healthcare professionals organized a multi-professional prevention team and built a collaborative infrastructure for educating staff and sharing best practices for VTE. They also implemented an evidence-based quality improvement framework.

“Through these measures, the project reduced the VTE rate at UC medical centers by 24 percent from 2011-14, preventing about 170 VTE cases and saving $2 million a year,” a UCDMC press release stated.

Healthcare Network or Multi-Hospital System, Medium Reach

In this category, the University of Wisconsin Health was recognized for designing an anticoagulation stewardship program led by pharmacists.

Pharmacists monitored patients by ensuring appropriate VTE prophylaxis procedures.. The initiative also conducted cost/benefit assessments, which showed that the healthcare facility saved $500,000 by reducing pre- and post-intervention VTE events.

The other Champion was Intermountain Healthcare in Utah. Across their hospitals, an electronic VTE Risk Assessment Module was integrated into the EHR system and generated a risk score for each hospitalized patient. The tool also searched the medical administration record for the best chemoprophylaxis or therapeutic anticoagulation.

Large Single Hospital, Large Reach

The first Champion in this category is Northwestern Memorial Hospital in Illinois. The hospital implemented a new VTE prevention program and a hospital-wide VTE prophylaxis QI project from 2013 to 2015.

The prevention process included an early ambulation component that required daily ambulation checks, a mechanical prophylaxis component that monitored the use of sequential compression devices, and a chemoprophylaxis component that required customized regimes of anticoagulants in every postoperative patient.

Additionally, the Johns Hopkins Hospital in Maryland was acknowledged for creating a decision support tool that linked to the hospital’s order entry system and an engagement program for patients and nurses.

Medium Reach, Single Hospital

Harborview Medical Center in Washington was recognized for using a clinical leadership program that engaged all care teams. The hospital also implemented a decision support tool in the EHR, quality improvement analytics, and retrospective and prospective reporting.

The hospital formed a VTE Task Force consisting of physicians across services. They met once a month to review performance of VTE prevention practices and create improvement projects.

An electronic tool was integrated into the EHR system to provide real-time information about risks of VTE in hospitalized patients. It also created a data snapshot in the patient’s chart that allowed multidisciplinary communication for prevention treatments.

The Hutchinson Regional Medical Center in Kansas was also distinguished as a Champion for its efforts to reduce HA-VTE rates by establishing a prevention task force, attaching a VTE prophylaxis section in the EHR system that transmitted the risk of VTE on the vitals screen, and adding more mechanical prophylaxis equipment to the hospital.

Most programs aimed to emphasize VTE assessment data through EHR systems. By providing accessible information, HA-VTE Prevention Champions made it easier for healthcare providers to monitor and implement patient safety best practices. 

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