Defeating DVTs With Prevention
Date: December 21, 2009
Trauma surgeon Elliott Haut is chasing a killer, one that causes much unnecessary loss of life despite being so easily prevented.
According to the federal Agency for Health Research and Quality (AHRQ), deep vein thromboses (DVTs)—and the often fatal pulmonary emboli (PE) they lead to—are the leading cause of preventable deaths in hospital admissions. Preventing DVTs and PEs and quantifying their place as a marker of quality of care are at the core of Haut’s research. It’s well known that giving prophylactic blood thinners such as heparin, using sequential compression devices or combining the two can eliminate nearly all DVTs. But, says Haut, “studies across a variety of services worldwide show that only about 50 percent of patients receive such prophylaxis. As a medical community, we’re pretty bad at that.”
Haut, an assistant professor of surgery and anesthesiology and critical care medicine, helped form a DVT collaborative to systemically attack the problem. Each patient admitted to Hopkins is now risk-assessed for DVT using the computer order entry system. “The way we constructed the decision support module,” he says, “forces people to think about prophylaxis by asking them a few simple questions as they place an order. If you try to skip that step, the computer will cancel the entire order set. To continue, you must answer the questions. This doesn’t allow you to deal with it later.” Preliminary results of the two-year-old system suggest that prophylaxis rates are rising and DVT occurrences are dropping.
The assumption—one used by both regulators and payment agencies such as Medicare—is that DVT levels alone can indicate whether a hospital provides proper quality of care. But that idea, Haut suggests, is too simplistic. For example, using DVT levels alone penalizes hospitals that aggressively use ultrasound to screen for DVTs. Furthermore, a small number of patients—2 percent to 3 percent—will still develop DVTs no matter what. “If I do ‘best practice’ and give you everything I can and you still develop a DVT,” asks Haut, “how is that poor quality of care on my part?”
He’s hoping the answers—and perhaps more accurate markers related to DVT and quality of care—will come from his latest research grant, supported by the AHRQ. Haut has begun the Graduate Training Program in Clinical Investigation at the Bloomberg School of Public Health. The grant will allow him to study for a Ph.D. in clinical investigation and receive training in research methodologies, biostatistics and epidemiology. It will also provide him time to work with Hopkins’ patient safety expert Peter Pronovost. For his patient-safety work, Pronovost already has a large, established collaborative in Michigan, which Haut plans to use in researching DVT education and prevention.
Haut wants to mimic the nationwide rollout and success of Pronovost’s ICU safety checklist (now credited with saving thousands of lives annually) to implement the DVT reduction efforts Haut leads here. “My goal is to take what we’ve put in place in our 1,000-bed hospital,” he says, “along with data that shows it’s beneficial, and disseminate it so it’s done