This project is a landmark project in many ways.
Read Delfini commentary on the Kaiser Permanente Hawaii VTE Prevention Project.

Kaiser Permanente Hawaii (KPHI): Prevention of Venous Thromboemobolism (VTE) in Total Hip and Total Knee Replacement

Mission: Help advance evidence- and value-based medicine in an organization that has already proved a demonstrated commitment to evidence- and value-based care by dedicating resources to EBM training and support and that now seeks to progress to an even higher level in skill, depth, application and cultural transformation.

Success Stories:
Clinical Guideline & Quality Improvement Project
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Concept: Identify a clinical group that has ideas for a successful evidence-based clinical improvement project and provide them with training and support. Learnings will be applicable to other projects, plus team members will be able to facilitate similar projects with other clinical groups within the care system.

Delfini Role: Provide training, facilitation and support to the team to conduct the project and to effect both clinical and evidence-based process change.

Update: What’s New In Venous Thromboembolism (VTE) Prophylaxis For Total Hip and Total Knee Replacement Surgery 2009

In the summer of 2008, a group of KPHI clinicians and other stakeholders (orthopedists, hospitalists, pharmacists, nurses, facilitators, CME and EBM specialists) formed a working group—the KPHI VTE Prevention Guideline Team—along with Delfini to address the significant uncertainty about the following key questions:

1. What is the evidence that thromboembolism or deep vein thrombosis (DVT) prophylaxis with various agents reduces mortality and clinically significant morbidity in hip and knee replacement surgery?
2. What is the evidence regarding timing of anticoagulant prophylaxis for appropriate agents when used for prevention of thromboembolism in hip and knee replacement surgery?
   • What is the evidence regarding starting anticoagulant prophylaxis?
   • What is the evidence regarding duration of anticoagulant prophylaxis?
3. What is the evidence regarding bleeding from thromboembolism prophylaxis with the various appropriate agents?

What We Learned and Recommend To Others

• The risk of VTE in total hip replacement (THR) and total knee replacement (TKR) surgery without VTE prophylaxis is frighteningly high with reported figures from 41% to 85%.
• The level of evidence (LOE) is fair for reduction of overall DVT rates with mechanical compression devices used in conjunction with recommended pharmacological agents; LOE is inconclusive for reduction of symptomatic DVT, proximal DVT and PE rates.
• Current national guidelines are conflicting and include evidence with significant threats to validity.
• With mechanical compression and pharmacological prophylaxis some studies report incidence rates of 10% to 15%.
• Based on our evidence review and evidence synthesis the KPHI VTE Prevention Guideline Team recommends that —
  1. Mechanical compression devices be used in conjunction with recommended pharmacological agents (enoxaparin, warfarin, fondaparinux or aspirin).
  2. Both compression devices and recommended pharmacological agents be continued at least through discharge, to achieve the lowest possible DVT rates in THR and TKR surgery.
  3. Until further evidence is available, decisions regarding the extension of VTE prophylaxis beyond hospitalization be individualized following risk assessment.
  4. Aspirin alone not be used as VTE prophylaxis in THR and TKR surgery because there is fair evidence that aspirin alone is not effective in preventing VTE and in one study the DVT rate was 47%.

Details regarding specific mechanical devices, drugs, bleeding risks, the quality of the evidence, dosing, etc. are available immediately below.

Read the interview with medical leader, Karen Ching MD, about how to make such evidence-based quality improvement projects successful.

Venous Thromboembolism Guideline Materials are posted with permission from Kaiser Permanente Hawaii and Delfini Group. Selected components of guideline documentation are available from Sheri upon request at sstrite (at) delfini.org.

• VTE/DVT Prophylaxis for Total Knee/Hip Surgery Guideline Recommendations
• VTE/DVT Prophylaxis for Total Knee/Hip Surgery - Clinician 1-Pager
• VTE/DVT Prophylaxis for Total Knee/Hip Surgery - Patient Messaging Script

Also from the Agency for Healthcare Research & Quality, general information for patients about blood thinners.

Kaiser Permanente Hawaii: Prevention of Venous Thromboemobolism in Total Hip and Total Knee Replacement

At the beginning of the 2005, we were invited to work with Kaiser Permanente Hawaii to help advance EBM within their organization. KP Hawaii has a strong commitment to evidence- and value-based care. Their leaders are committed to supporting EBM. They frequently sponsor outstanding EBM conferences and retreats which are very well attended, and they have an impressive and active EBM working group. They were desirous of taking EBM to a new level and expanding and embedding evidence-based clinical improvement skills and techniques more solidly and more broadly into their culture. We came up with an idea for a working project that would provide just-in-time practical training, advance clinical care and help further "seed" cultural change. Our first project in 2005 was a Chronic Kidney Disease referral and management guideline. (Read about the CKD project here.) We facilitated a second project on management of elevated blood pressure. This VTE project is our third.

In the meantime, the two clinical leads of the CKD project were promoted into evidence-based leadership positions in their organization which we consider to be further evidence of the value of this approach. You can grow quality care through a clinical project and you can grow quality overall in your organization as well.

This VTE project was phenomenal. Some of the members were initially a little (or, admittedly, more than a little) skeptical. All members were challenged for time beyond what we usually experience. The combination of these two barrier forces meant that necessity required our extreme inventiveness so that the project would not fail.

We constructed a process that we now think is an incredible model for doing evidence-based quality improvements, utilizing just-in-time group activities. We had a series of initial short phone meetings with the group, did a lot of work behind-the-scenes, had a 2 day training and work-intensive in mid-November of 2008 and then followed that with another 2-day work-intensive in mid-January resulting in the completion of major work in record time and in a highly rigorous way.

At the completion of the work session on evidence synthesis and clinical recommendations on day 4, one of our most resistant and skeptical colleagues raved! "I was a little lost at first," he said, "but now I really get it, and this was great!" The team is energized and enthused. Major skills have been acquired. Change has occurred. People are having objective communications based on evidence (and lack thereof) where they have only minimally communicated before since there was so much uncertainty and lack of a centered focus due to the clinical controversies in this area and lack of clarity. Patients and clinicians will now get some needed help even if just to know how much of what might be done is not supported by science.

We are so happy and honored to do this work with some of the greatest minds we have ever encountered. We are thrilled we have helped them and their patients. We are ever learners — we are happy to have developed more solutions and honed more methods to help groups achieve success in clinical quality. If you have not already done so, we urge you to read the VTE Update and interview with Dr. Karen Ching on how to achieve project success.

Mahalo,
&

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