 Thank you for joining us today. The Patient Safety Movement Foundation posted the Imbolic Events Actionable Patient Safety Solution in September. Brandon and I, along with Michael Becker, are co-chairs of that Actionable Patient Safety Solution. And today, I get to interview Brandon Lao about some of the details that you'll find in that apps. I come to this with a personal reason. In 2012, my husband, Yogi Raj Charles Bates, died from a hospital-associated venous thromboembolism. So although you might just see me as a regular interviewer in many cases, today this interview is very personal for me. Brandon, thank you for joining me. Brandon is the faculty in the Armstrong Institute for Patient Safety and Quality. And he is the assistant professor of radiology and health sciences informatics with Johns Hopkins School of Medicine. And Brandon and I are going to address a few questions today that we think might be helpful for both clinicians as well as patients and family members. Brandon, welcome, and thank you for joining us today. Thanks for the invitation. Glad to be here. So let's just start by describing what a venous thromboembolism is. Give us a clinical definition of what we're talking about today. A venous thromboembolism, or VTE, is a blood clot that occurs in the leg as a deep vein thrombosis, or DVT, or in the lung, pulmonary embolism, or PE. Oftentimes, clots start in the legs as a DVT and can break off and travel to the lungs, where it can cut off your ability to breathe effectively. Yeah. And as I know, all too well and very personally, it can be fatal. And even if it's not fatal, it can create lifelong complications. So it's a very, very important topic. And let's dive a little bit more into a few more questions. So let's just start by looking at a typical organizational protocol. What is typically required in the inpatient setting with formal risk assessments? Is there a standard protocol? There isn't really a standard protocol that has been universally adopted by all hospitals, which I think is very unfortunate, because we do have pretty clear guidance of what it takes to effectively prevent blood clots in the hospital setting. And it requires a series of actions to be taken. First, patients need to be risk assessed to determine what their risk level is for developing VTE. Based on that risk assessment, the appropriate prophylaxis, which could be medication or sequential compression devices, boots that squeeze the leg, based on the risk assessment, appropriate prophylaxis should be prescribed for the patients. Nurses should be communicating the harms of VTE and the importance of prophylaxis to prevent blood clots. And then patients would then make an informed decision to accept and have the prophylaxis applied or administered to them. And then we need to be mindful of our surveillance practices to look at when events occur and really use that entire loop to look for opportunities to improve practice within hospitals. That goes into what I was going to ask as the next question, Brandon. And that is, what can change in a patient setting that would require a reassessment after an initial formal assessment has been given? That's a really important question. And it's one that is also frequently overlooked. Patients' clinical conditions change dramatically over the course of hospitalization. Risk factors can develop changes in whether or not patients are eligible to get medication to prevent blood clots change dramatically. One example of that, when we think about medications to prevent blood clots, we're talking about anticoagulants or blood thinners. And a patient could come into the hospital and have lab values that would make it inappropriate to give anticoagulants to them. Perhaps their INR is too high or their PTT is too long or they're actively bleeding if they're coming in for surgery. And these are things that can resolve or change over the course of hospitalization. So if you have somebody who's at very high risk of clotting and they don't get prescribed medication because they have one of these bleeding risk factors which is entirely appropriate, if that bleeding risk factor changes over the course of hospitalization, maybe we need to rethink about what the prophylaxis or prevention strategies are to make sure the patients are protected. So there should be some level of reassessment periodically through the hospital, particularly for patients who might need stronger preventive measures that they just weren't eligible for on admission. You know, just yesterday I was with a friend who had to stop her eloquence for just a day or two in preparation for procedure and then she would go back on that. So it is that fine balance between clotting and bleeding and it's very important to sort of manage both of those dynamics that our bodies, you know, naturally try to resolve for ourselves but sometimes need a little help in doing so. Let's talk a little bit about something you and I talk about I think frequently is this notion of with regard to blood clotting and DVT development, there's quite a lot of beliefs that aren't necessarily evidence-based. Sort of the way that we think about it is sort of like attitude and evidence. And because clinicians are very evidence-based, it often surprises me that a lot, many clinicians I've spoken with operate a little bit more on the attitude side when it comes to DVT. What are some of those common areas where attitude might be a little bit more heavily weighted than evidence with regard to DVT and VTE? Yeah, it's really interesting and I think VTE prevention is definitely one of those areas where there are a lot of misconceptions. Misconceptions that we prescribe prophylaxis for every patient, that we prescribe medication for every patient who's coming into the hospital. And I think that that underscores the importance of a formal risk assessment. I've never advocated that every patient who comes into the hospital should be prescribed in anti-coagulant because you're potentially exposing patients to harm, risks of bleeding. And the goal is really to prescribe appropriate prophylaxis to patients. Pretty much every professional organization in healthcare has standardized evidence-based guidelines for what their patient population should be prescribed for different levels of risk. And I think that it's important that as we consider what prophylaxis should be prescribed, we give greater weight to the evidence rather than the intuition or experience that people may think that they possess when it comes to VTE prevention. So there is some disconnect, at least on the prescribing side, but there is very strong rigorous evidence to support appropriate decision-making. The other end, we've actually seen that a lot of doses of prescribed medication aren't being administered to patients. We've actually published at our own institution that between 10 and 15% of prescribed doses of anti-coagulants to prevent blood clots aren't being administered to patients. And we've done some deeper digging into the reasons for this non-administration. And we've seen that many nurses have a belief that prophylaxis is overprescribed for patients. And we've also seen a belief that if patients are ambulatory up walking around that pharmacologic prophylaxis becomes optional, that ambulation is in itself effective VTE prevention. And I mentioned that we've just had a systematic review accepted for publication that we'll be sure to share with you that shows that there actually has never been a rigorous study to look at the effectiveness of ambulation for blood clot prevention in hospitalized patients. In fact, the idea of ambulation started with a single author editorial in JAMA in 1951 where the author wrote that there may be some benefit to ambulation for blood clot prevention. And now we hear very often in hospital settings that if patients are up walking around, their risk for getting a blood clot is not there. And I can tell you that we have seen patients who are ambulatory who still develop blood clots and the evidence just isn't there for it. It confuses me because when I hear it said I've attended appointments with friends and family members sometimes in hospitals often as well. And I have heard nurses say, oh, if you can just get up and walk around we can avoid having you give that shot in the belly and everybody of course says, well, great, get me up. But what I can tell you is that my husband, Yogi Raj was one of those cases where he couldn't have walked more. He was up and walking so much that he thought that the leg calf pain that he had was a result of walking so much when in fact that calf pain was actually a DVT developing but it was completely off the radar of his care providers. So I think I can't underscore enough what you're saying there that the science just simply doesn't support that mobility is a replacement for a risk assessment and prophylaxis, whether it's compression devices if it's contraindicated to have a pharmaceutical option but it really, really, it sickens me sometimes to hear that that myth has prevailed. And it's just amazing to me how something somebody says so many years ago could have taken hold to such an extent and it's certainly my hope that we can course correct that belief. Of course we want people up and mobile if it's safe to do so as much as possible so many benefits from that but as a replacement for prophylactic for DVT development it's just simply not there and in evidence at this time. Did I say accurately? You're the doctor. You're the medical professional, not me. I think that that is completely accurate and I do wanna say that I don't think that in saying this, I don't believe that nurses are wanting to cause harm to patients. Oh, goodness me. I think that there is a misconception about the importance of prophylaxis, what the evidence says about proven pharmacologic or mechanical prophylaxis. And I think that in doing this in offering patients an opportunity to walk around while there is no evidence to support that that is effective VT prevention they are trying to reduce discomfort for patients. I mean, getting a shot is not necessarily a pleasant experience. And if I didn't necessarily know that there was no evidence for it if somebody presented to me the option of walking around or getting a shot, I would certainly walk around too. But I think that it definitely underscores the importance of where the myths change people's priorities. And it's important to keep in mind that every year more people die from pulmonary embolism, clot in the lungs than from AIDS, breast cancer and motor vehicle collisions combined. And that's a staggering number. And the idea that I would bet anyone who has experienced breast cancer would say if somebody came and presented me an opportunity to get rid of it with a shot or reduce my risk with a shot I would absolutely take it. And I think that we definitely need to give blood clots the level of priority that they deserve in providing evidence-based preventive care for it. Thank you, that's very well put. And because of our personal experience obviously I'm a strong advocate for that communication. Let's dive into that a little bit further. And I should have started this by just having you describe what that is but I think you just did a good job of, the difference between a DVT, a PE and a VTE or a deep vein thrombosis, pulmonary embolism and venous thromboembolism. Let's talk about what information can be shared between patients and clinicians and also between healthcare settings to improve VTE prevention. What would you recommend in terms of communications that would help us really get to address VTE at the level that it needs to be? Well, I think there are several areas of communication at different levels with different types of clinicians between patients and physicians, patients and nurses. First of all is VTE risk. There are a number of risk factors that will never appear on a scan, will never appear as a lab value. One of those, and one of the biggest predictors of developing blood clots is if you've had a personal history of a blood clot or if a family member has had blood clot. I have personally had multiple members of my family who have had blood clots in the past. And one of the things that I will tell my doctors both in primary care and if I am in the hospital is that I have a family history of blood clots. I know that I'm at elevated risk for that. And it will change decision-making processes around preventive practices. Another thing to know is what the signs and symptoms are. Most patients who are going into the hospital aren't necessarily going in to have a blood clot prevented. They're going in for some other condition, but it is a complication that can develop. And I think that we need to be very proactive in telling patients what the signs and symptoms are to make sure that they're aware of what could be. And I will tell you that a patient knows their body better than anyone else. And if they start to see leg swelling, if they start to feel shortness of breath, they are going to know this before anyone else. And that information will certainly empower them to speak up to their nurses or to their doctors about what it is that they're experiencing. So I think that there's a lot of communication back and forth of sharing what potential risk factors exist. But then also making sure that patients are informed about this condition, which unfortunately doesn't get nearly as much attention as it should, what they should be looking for and when they really need to ring the bell and sound the alarm that something is wrong. I often harken back to our experience in the hospital where my husband went into the hospital for traumatic brain injury and had a craniotomy and that was successfully resolved. If somebody had handed me a pamphlet that just said, these are some common hospital associated conditions that can happen after surgery and hospitalization and VTE would have certainly been on that list because we know it's about the third leading cause of hospital associated deaths in the United States. I would have read that pamphlet and then the symptoms, which were very evident for my husband, I would have been able to point to them and say, hey, do you think it could have been such and such? No, not everybody would be able to do that or even have somebody by their side like my husband did all those 13 days, but that education and that communication process needs to be in place as a standard protocol just to make sure that we are doing the very, very best that we can to educate across the board. Even those PT and OT people who also saw the signs and symptoms were not making the correlation between the evidence symptoms and the development of that blood clot in my husband's leg. Brandon, I wanna just move to our final question here and that's really about going global. Like how do we really help prevent this? And one of the ways that we can help prevent is really, really good reporting. So what are some of the barriers to objective reporting and reporting this all-to-common VTE event post-discharge when somebody actually is in their home setting post-care in Pennsylvania? That's such an important question and the majority of VTE events happen outside of the hospital and we know that VTE is associated not just while you're in the hospital, risk isn't just when you're in the hospital and then when you're discharged, your risk magically disappears. You still have risk associated with your overall health, whatever it is that you were treated, as well as what prevention strategies were taken or not taken while you were in the hospital. So your risk for developing a blood clot still extends after discharge. And one of the challenges that we run into because so many events develop outside of the hospital, we don't necessarily get feedback that a patient has experienced those events. And I think that that's a really important component when you think about continuous quality improvement. We look at within the hospital where patients risk assessed, where they prescribed the right thing, where they administered everything that was prescribed, did they develop an event? And then when a patient is discharged, we don't really know if an event developed thereafter. So we assume at that point that they did not develop an event. They could have gotten suboptimal VTE prevention during hospitalization, but then developed an event after discharge that we wouldn't know about, but we would still consider that prevention practice successful because they didn't happen to develop that event while they were in the hospital. So I think one of the great unknowns that there is fantastic opportunity to improve upon is sharing that information, that post discharge information back with hospitals. And I know that it can be somewhat of a challenge that hospitals don't necessarily want to report adverse events, but I think that it's critical for quality and safety purposes and continuous improvement that we really have that full picture to know what we can do better. And I think that that's the main takeaway that we always have opportunities to improve. There are hospitals that do wonderful jobs at ensuring the prophylaxis is administered, but do they actually ensure that it's the right prophylaxis? Similarly, there are hospitals that might make risk assessment mandatory for all patients, but are they ensuring that all patients are getting every single dose or having their prophylaxis applied as it's written? Are they ensuring the full continuum of VTE prevention to ensure that we're providing defect-free care? And I think that that's really the goal that we should be striving for. Well, let's just give an applause to those administrators who and clinicians who are making sure that those precautions are taken for their inpatient settings as well as their clinical settings. And also just a recommendation to patients and family members to report back and to be in communication to ask questions about the risk for DVT during hospitalization or procedures, clinical and surgical procedures. The communication and the learning from the experiences are what will help us get to the state where this is not the problem that it is today. So, Brandon, thank you again for taking time for this particular recording today. I know it will bring value to a lot of people. And I hope that you have a really, really good rest of the year and thank you very much for your continued research in this important area. Thanks for this invitation. It's always wonderful chatting with you. I hope you stay safe as well. Thank you.