Wednesday, August 5, 2015

Some venous thromboembolic events can’t be prevented even with optimal care

I have written several posts about how I get things right before others see the light, but none better than one from three years ago pointing out that some of the Centers for Medicare and Medicaid Services (CMS) "never events" can't really be completely prevented and therefore should not be considered "never events."

One specific "never event" I questioned was hospital acquired venous thromboembolic (VTE) disease which encompasses deep venous thrombosis (DVT) and/or pulmonary embolism (PE). I wrote "I am unaware of any DVT study in which no patients in the experimental arm developed DVTs or PEs. Patients will develop DVT or PE even with the best evidence-based care."

Along comes a brief research letter published last month in JAMA Surgery by a group from Johns Hopkins led by surgeon Elliott R. Haut.

Of 92 patients in their institution who had VTEs in a single year, 43 (47%) had received defect-free care. That is, each of those patients received all doses of risk-appropriate pharmacological prophylaxis ordered for the entire hospitalization.

To put it another way, VTEs for those 43 patients were not preventable. There would be no way to do a quality improvement project for a group of patients who received the right prophylaxis throughout their hospital stays and still got VTEs.

The Joint Commission/CMS criterion states that a hospital is in compliance with VTE prophylaxis if a patient receives one dose of an appropriate drug within 24 hours of admission. The Hopkins study showed that of the 49 patients (53%) whose care was suboptimal, 36 (73%) missed at least one dose of prophylaxis that was correctly ordered. Other studies have shown that missing even one dose of prophylaxis at any time during a hospitalization increases the risk of VTE.

So about half of VTEs are not preventable even with perfect adherence to the prophylaxis protocol, and the standard for compliance established by the JC/CMS is inadequate to judge the quality of an institution's performance for VTE prevention.

The study shows that 1) a lot of good information can be delivered in a two-page paper, 2) JC/CMS criteria for compliance with VTE prophylaxis need to be revisited, and 3) VTE should be removed from the list of "never events.”


artiger said...

Scalpel, have you thought about coming out of retirement, and going to work for Joint Commission/CMS/[insert your favorite organization that lacks any common sense)?

Correct me if I'm wrong, but was iatrogenic pneumothorax (from CVL insertion) on the list initially? Or is it still there? What that told me was that complications were considered "never events". Have we finally accepted that we aren't perfect?

Skeptical Scalpel said...

Pneumothorax after central line wasn't one of the original list. Maybe it's there now. Infection of central line is on the list.

I don't think the Joint Commission would have me. I've trashed it a few times on this blog. Search "Joint Commission."

PGYx said...

Wait, you're saying we can't prevent bad things from happening to people 100% of the time?

I am glad that the Hopkins study has put actual numbers to what those of us who work with trauma and acute traumatic spinal cord injury patients know all too well: We can prevent many clots with VTE prophylaxis, but some folks with an acute hypercoagulable state will clot even when they are given standard prophylactic doses of low molecular weight heparin at the appropriate times. For acute SCI, subcutaneous heparin is actually inferior to Lovenox, although to my knowledge this has not been found for other studied conditions.

Anonymous said...

Assuming it's possible to get a 0% dvt rate disregards the spectrum of human variation when it comes to understanding hypercoagulability. Although a small percent, those with genetic hypercoagulable conditions are at increased rate for thrombotic complications even with prophylaxis after certain surgical procedures. People get dvts even without surgery (travel and immobility). Can't prevent it 100%. Just my 2 cents.

Skeptical Scalpel said...

PGYx and anon, I agree. That's why I wrote this post.

Anonymous said...

I was curious if you feel similarly about the impossibility of 100% never events with pressure ulcers. It takes only a few hours of ischemia to develop tissue necrosis and easily during a long case, particularly in a emergent case, perhaps with some intraop hemodynamic instability where vasopressors and blood products are needed will tissue injury occur. Add in diabetes, malnutrition, obesity and even a short post-op period (even overnight) need for ventilatory support and you've got a very high risk patient for pressure ulceration. "Frequent turning" is not going to prevent that.

artiger said...

Anon above, I think in the situation you described, it should not be considered a never event.

William Reichert said...

I think the concept of a "never event" is a clever device that will allow Medicare to cut the payment to doctors for the medical care they provide to seniors.
Recently I heard Medicare administrators on NPR say that the way they will decrease the cost of Medicare going forward was to rely on preventive medicine to prevent disease. By expanding the definition of the efficacy of preventive medicine, they can eventually deny payment for any disease process that occurs that they have
identified that should have been prevented

Anonymous said...

Anonymous Europe: Hi I am back!:) Sorry for not commenting this long, I just raked in a crazy amount of on-call hours... Anyway, this whole thrombosis thing smells a bit like big pharmaceuticals for me... Funny thing is, you even have to inject teenagers in Europe with Lovenox if they are to get a cast on a leg... And not just the overweight but the healthy, sporty kids too.... If someone is to get dvt, he or she will get it. If someone is not to get dvt they will not get it, not even when this person is sitting on a 12h long haul flight...

Skeptical Scalpel said...

I an ideal world, no patient should ever get a pressure ulcer, but we don't live in an ideal world. There are issues of staffing, other sick patients etc. Should pressure ulcers be never events? In theory, yes, but in reality no.

William, I agree that CMS is trying to save some money. Establishing never events that are impossible to prevent and penalizing hospitals that do not comply will certainly do that.

Anonymous Europe, I disagree. Some, but not all, DVT's can be prevented.

Elliott R. Haut, MD, PhD, FACS said...

Agree with you completely. Here is paper we wrote in JAMA on this exact topic. "The CMS Ruling on Venous Thromboembolism After Total Knee or Hip Arthroplasty: Weighing Risks and Benefits "

Skeptical Scalpel said...

In case you missed it, Dr. Haut is also the author of the paper that is the subject of the above post.

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