Process Improvement in VTE Prophylaxis
Cheryl D Richie, George Davis, Qiang He, Joseph Bobadilla, Eleftherios Xenos
University of Kentucky, Lexington, KY
BACKGROUND: Venous Thromboembolism (VTE) is associated with potentially preventable in-hospital morbidity and mortality. Although evidence‐based guidelines for the prevention of VTE are widely available, their application in clinical practice varies markedly. VTE prevention relies on correct risk stratification of the individual patient, ordering of the indicated chemical or mechanical prophylaxis and, finally, the delivery of this treatment throughout the continuum of the hospital stay. The aim of our study was to identify failure modes in VTE prophylaxis and use these as targets for intervention in order to reduce VTE incidence rates.
METHODS: Our institutional protocols require risk stratification for VTE at time of admission and subsequently provide guidance for appropriate chemical and mechanical prophylaxis. As part of quality improvement, all patients that fulfill the criteria for the Patient Safety Indicator (PSI)-12, as defined by the Agency for Healthcare Research and Quality( AHRQ), are prospectively entered into a database. PSI-12 is the rate of peri-procedure pulmonary embolism or proximal deep vein thrombosis per 1,000 discharges for patients ages 18 years and older excluding obstetric patients. A team of physicians, pharmacists and nurses performs weekly root cause analysis of all PSI-12 events at our institution to identify deficiencies. Based on these findings we design ongoing interventions to address these deficiencies following a Plan-Do-Study-Act cycle . The PSI-12 rate is monitored as part of continuous process improvement.
RESULTS: From review of eighty-two PSI-12 patients, only 10 had appropriate risk stratification and treatment. 72 had either incorrect risk stratification or a documented omission/inadequate application of appropriate prophylactic measures as shown in table . For several patients, more than one deficiency was identified. Based on these findings we implemented the following: a) modification of VTE prophylaxis computerized order sets using clinical decision support tools, b) periodic, reoccurring physician( including trainees), pharmacy, patient and nursing education c) monitoring of compliance with mechanical prophylaxis by nursing, d) elimination of "hold medication" orders and e) monitoring of heparin dosing by pharmacy. As these measures were instituted, the rate of PSI-12 at our institution has been declining as shown in figure .
CONCLUSIONS: VTE prophylaxis relies on a multi-step dynamic process that can fail at various points during the hospital stay. We have shown that a large percentage of patients who had a thromboembolic complication received inadequate prophylaxis and therefore this complication could have been prevented. We identified gaps in the delivery of VTE prophylaxis and designed system level measures to correct these. Using this process improvement approach we were able to reduce the periprocedural VTE rates at our institution.
|Wrong risk stratification||46|
|Incorrect treatment based on incorrect stratification||21|
|Interruption or delay of chemical VTE prophylaxis||32|
|Interruption of mechanical prophylaxis||37|
|Interruption or delay of both chemical and mechanical prophylaxis||14|
|Correct treatment despite incorrect risk stratification||25|
|Appropriate risk stratification and treatment||10|
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