Let's talk about missed doses of VTE prophylaxis. The real question is who cares and does it matter? We have for many years made a very big assumption. As physicians and specifically in the realm of quality and safety, we've driven our work to focus on the prescription of medications, specifically VTE prevention. And then we assume that, if we can write a medication order and if we can just get the doctors to write the right order, then everything would be perfect. If we write the order, then that medication will be consistently delivered every single time. But is that truly the case? Does prescription absolutely, always, every single time, equal administration? Hopefully, over the next few minutes, I'll show you that that may or may not be true. So what are the key steps to optimal pharmacologic VTE prophylaxis. The first as I've already mentioned is provider prescription. And we focused prior, for the first five years of our collaborative, on getting the doctors, nurse practitioners and physician assistants to write the right order. If we could just get that part done everything else would be fine. It turns out, however, that there are two other key components that are very important to think of, that are critical steps to make sure the patients receive perfect care. The nurse has to administer the dose to an accepting patient. So the nurse and the patient are absolutely involved, as you would expect. Does it really matter if patients miss a dose or two here and there? This is a small study of about 200 trauma and general surgery patients who had been ordered enoxaparin for VTE prophylaxis. And this study showed that the incidence of DVT is significant. It showed that a large number of patients missed at least one dose of prophylaxis and that DVT is significantly associated with missing doses of VTE prophylaxis. So this one study is showing us that missing doses matters. We published this paper a few years ago. We looked at one year's worth of data that we had to report from our hospital, Johns Hopkins Hospital, to the State of Maryland for our Maryland Hospital Acquired Conditions Program. This is a public reporting and quality improvement initiative where hospitals are financially rewarded for good care or penalized for bad care. We looked at all of our patients who had VTE, and we broke them into one of three categories. They were patients who had defect free care. So about half the patients had been prescribed perfect prophylaxis according to best practice based on their risk factors and contraindications. And they received every single dose of this medication while they were in the hospital. That's about half the patients. Now, as an aside, it turns out that we, as Johns Hopkins, are now financially penalized for those 50 percent of the patients who we gave perfect care to. But that's a story for another day. What I want to focus on is the other half of the patients. The patients who did not have perfect prophylaxis, and those are those other two bars. Fourteen percent of those patients were prescribed suboptimal prophylaxis. They either were prescribed nothing or not prescribed the appropriate care that they should be. The important thing to notice is that bar that says 39 percent. Thirty-nine percent of patients, or about three quarters of those that did not receive perfect care, had missed one or more doses of their VTE prophylaxis. And don't forget, these are all patients with a VTE event. This does not prove causation, but we can at least tell you that of the patients with an event, 39 percent had missed at least one dose. So it's another piece of the puzzle, another piece of data, that shows that missing doses matters. How frequent a problem is this? This is a small project we did that looked at about 100,000 doses of VTE prophylaxis at our hospital. Overall, 12 percent of all these doses were not administered to patients. Hopefully, you're shocked by that number. I know I was when I first saw it. Patient refusal is the most frequently documented reason. About 60 percent of the cases of missed doses are documented as patient refusal. This missed-doses problem is not randomly distributed throughout the hospital. Some floors are better than others. This is data from that same paper and some units missed five percent of doses. For example, the ICUs, and some of the surgical units, and some of the neurology units, are down at the far end with a relatively low proportion of missed doses. I don't know what the number should be. I don't know that we can always drive it down to zero. But there's a lot of units in that five to six, seven percent range. However, at the other end, are some of the units on the internal medicine service, and in particular, there are two that are in the vicinity of 25 percent missed doses. That's a lot of missed doses. One in four doses not given on those floors is a really big deal, especially when I've just told you that that's likely associated with higher risk of VTE events. More recently, we published this data, which looked at one full year across our whole entire health system. We looked at nearly half a million doses over the course of one year. And this is not just a problem at the Academic Medical Center. It's not just at Johns Hopkins Hospital where we're doing a worse job and you're doing great at your hospital. This is a problem everywhere. So this showed that the academic at our center Johns Hopkins, we were about 10.9 percent. And we've been doing a lot of work on this since that last first paper that showed about 12 percent. We've made a little bit of improvement. But, when you compare to the community hospitals, that's at about 13.5 percent. So the issue is, this is not just a community hospital problem, not just an academic problem, it's likely a problem everywhere. And if you don't know the number at your hospital, I would challenge you to go out there and find it out and do something to try to fix it. So what's the real story behind these missed doses? We actually went out and worked on this project. We had a pharmacy resident at the time, Stacy Elder, who did a mixed method study. So this is a combination of quantitative and qualitative work. The quantitative part was a survey of medical and surgical nurses, and the qualitative part was observations of nurse-patient interactions and focus groups with nurses. And they all knew exactly what Stacy was working on. She had a clipboard. She was writing down quotes. I'm going to give you some of that information. The first part is the quantitative. We had a a number of different survey items and questions. And I'll just give you one as an example. Here it is. I have the clinical knowledge and experience to determine if it is necessary to administer DVT/PE prophylaxis injections to patients. Eighty-seven percent of medicine nurses and 79 percent of surgical nurses agreed with that statement. This is for a standing order medication. This is not a PRN, an as needed, etc. This is for a standing order. So some of the quantitative data is showing that this might be part of the problem. Another thing we got from our qualitative part where some of these quotes. For example, one nurse said, "I'll push harder for my patients to accept heparin prophylaxis if they have like sickle cell disease as opposed to, say, pneumonia or something where they're just here for I.V. antibiotics." Another nurse said, "Sometimes, if it's the middle of the night and the heparin is the only medication I have to give a patient, I won't wake them up just to give VTE prophylaxis." It turns out nursing attitudes and beliefs might have a lot to do with the missed-doses problem, specifically, in the documentation of patient refusal. There's also the myth about ambulation. And this is one of my personal pet peeves. There really is no great data that ambulation prevents VTE. We certainly think that ambulation is good for overall clinical care but there's no data that ambulation alone is good for prevention. But, that being said, nurses told us that "we make the clinical decision all the time as to whether a patient needs VTE prophylaxis every day based on how much the patient's ambulating." Or this quote that the nurse said, "Hey, Ms. R. It's time for your heparin dose. But as long as I see up, high-fiving me in the hallways, we can hold off for now." This is clearly a myth that's pervasive amongst nurses, physicians, and patients because it's what we've been telling them, and patients that have started telling us the same thing. So are VTE meds any different than other medications? And the answer, I will tell you, is yes. Our group recently published this paper that looked at a small, single floor study. We did a chart review and looked at which meds are being missed. Overall, about 10 percent of medication doses are not administered. But look at the difference, VTE prophylaxis on this floor is missed 27 percent of the time. Twenty-seven percent of those doses are not administered. That is statistically significantly different than the other two columns over on the slide. For example, for infectious disease and cardiac prophylaxis, these are, for example, Aspirin or Bactrim prophylaxis for patients with HIV. Those medications are only missed about 7 percent of the time. And therapeutic medications are only missed about 9 percent of the time. Very, very different than VTE prophylaxis. So overall, in summary, missed doses of VTE prophylaxis are a really big deal. They are likely associated with VTE events. Missed VTE medications are very common. It's a multi-factorial problem. It's not just the patients' refusal. It's not just the nurses. It's not just the physicians. There's many different reasons for these missed doses. And it's probably more common for VTE medications than almost any other medication. Although there's very few studies on it, that's what we've been able to see.
