Strategies to Improve Safety and Outcomes Utilizing Systems-Based Hematologists in IVC Filter Placement and Management in an Academic Medical Center

In large academic institutions, there are multiple disciplines and clinical scenarios that may require placement of inferior vena cava filters (IVCF). Both the Society of Interventional Radiology (SIR) and the American College of Chest Physicians (ACCP) have released guidelines for IVCF use, with the ACCP guidelines being more stringent due to the lack of survival benefit supported by level I data. Several publications have reported high rates of retrievable IVCF complications. In response to these risks and low retrieval rates, the U.S. FDA issued an updated safety alert in 2014 recommending that implanting physicians and clinicians responsible for the ongoing care of patients with retrievable IVCF consider removing the filter as soon as protection from pulmonary embolism is no longer needed.

A systems-based hematologist (SBH) plays a vital role in navigating the health care system in the use of therapeutic and device agents that crosses multiple disciplines by implementing evidence-based strategies to improve safety and outcomes. Previously, we used our institution's electronic health record (EHR) system to assist in improving the quality of care and reducing the cost of heparin-induced thrombocytopenia management, blood product utilization in cardiac surgery and pre-procedure management of coagulopathy in chronic liver disease (Greenberg et al. Blood. Vol. 126, No. 23; Abstract 4467).

As a first step, the purpose of this study was to report our healthcare system use of IVCF to: a) define the scope of practice and b) to identify areas for improvement. We propose a practical plan that will assist in improving clinician performance, patient education, and acute and chronic management of IVCF in a large healthcare network based on our recent success utilizing EHR to manage complex medical care.

A retrospective review of all IVCF placement performed between July 2014 and December 2015 was conducted. A total of 181 IVCF were placed; 26 (14.4%) permanent IVCF, 143 (79.0%) retrievable IVCF, 12 (6.6%) unknown. Mean age at IVCF placement was 59.34 years (range: 19 - 85); 46.4% were male. Ninety-six (53.0%) patients had active cancer. Surgical Services and Medical Services requested IVCF placements in 112 (61.9%) patients and 69 (38.1%) patients, respectively. Only 13 (7.2%) patients had a SBH consultation prior to IVCF placement.

Per SIR guidelines, 60.2% (n=109) of IVCF were placed for absolute indications, 15.5% (n=28) for relative indications, 14.4% (n=26) prophylactically and 9.9% (n=18) with no clear indications.

Of the 143 retrievable IVCF, 21 patients died during their hospitalization or were discharged to hospice. Of the remaining 122 cases, documentation of the presence of an IVCF was present in 107 (87.7%) discharge summaries, and outlined instructions for filter retrieval were seen in 19 (15.6%) cases. Only 29 (23.8%) IVCF were retrieved at a mean interval of 159 days (range: 4-511 days). Of the 21 patients that had IVCF placed prophylactically, only 7 (33.3%) IVCF were retrieved.

While many of the retrievable filters were placed because of an absolute contraindication (n=64) or relative indication for high-risk of complication to anticoagulation (n=13), 37 (48.1%) patients were discharged on a regimen of anticoagulant therapy.

We performed a root cause analysis and identified that a lack of awareness of IVCF evidence-based indications could have played a role in filter use patterns and the lack of a structured system for IVCF tracking in some clinical services resulted in poor IVCF retrieval rates. We propose a practical plan requiring clinicians requesting for IVCF to check an evidence-based indication via EHR. When an IVCF is placed, the Anticoagulation and Bleeding Management Specialty Nurse maintains a log of these patients and provides them with an Information Sheet that lists the date, indication and type of IVCF, specific instructions on IVCF retrieval, and a follow-up appointment in the Benign Hematology clinic for anticoagulant management. The Information Sheet is uploaded onto EHR for documentation. In conclusion, we identified the scope of practice and areas that could be improved by the adoption of a centralized and coordinated approach to monitor patients with IVCF. This study demonstrates the potential impact that a SBH has on health care delivery in both the inpatient and outpatient settings.