Patient Safety, 2012

New York Hospitals Use AHRQ Toolkit to Revise Protocol for Preventing Hospital-Acquired Venous Thromboembolism (VTE)

May 2012

Seven New York hospitals revised their protocol for preventing venous thromboembolism (VTE) after their State Quality Improvement Organization (QIO), IPRO, participated in a series of onsite learning sessions and technical assistance calls for implementing the AHRQ toolkit Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement.

AHRQ's QIO Learning Network hosted the onsite sessions and calls between January and September 2011. Gregory Maynard, MD, of the University of California, San Diego, whose AHRQ-funded research provided the basis for the VTE prevention toolkit, presented information during the learning sessions and provided expert support during technical assistance calls.

The AHRQ toolkit is a comprehensive guide to help hospitals and clinicians implement processes to prevent dangerous blood clots. The 60-page guide details how to start, implement, evaluate, and sustain a quality improvement strategy. It includes case studies and forms that clinicians can use. The toolkit advises hospitals to establish a VTE prevention protocol for assessment of patients' risk for hospital-acquired VTEs and selection of the best method for preventing the condition.

The toolkit also encourages hospitals to discard a commonly used protocol that assigns points to risk factors for VTEs in order to determine the appropriate treatment option. Instead, the guide encourages hospitals to adopt a protocol that groups patients into three risk categories. Each category is associated with a clear set of recommendations about the most appropriate measures to prevent VTEs. The guide also advises hospitals to provide drug therapy to prevent clots to all patients at moderate or high risk of developing VTEs.

John T. Mather Memorial Hospital in Port Jefferson, New York, developed a VTE protocol using the AHRQ toolkit, and after a successful 30-day pilot with the hospitalist group, the 248-bed acute care facility implemented the protocol throughout the hospital. As a result, VTE risk assessments increased from 10 to 80 percent, and VTE prophylaxis increased from 90 to 100 percent. At the request of subspecialty surgeons, the hospital created separate assessment and order forms for medical and surgical patients and inpatient surgical subspecialty patients.

"The VTE project made it easy to do the right thing for our patients across the board," says Jacob Sokol, MD, Director of Hospital Medicine.

A multidisciplinary team, including the information systems department, at Westchester Medical Center, a teaching hospital in Valhalla, New York, developed an electronic format of the VTE protocol that was incorporated into the 635-bed hospital's electronic medical record (EMR) to make assessment, treatment choices, and physician ordering a complete electronic process.

"We believe that this ongoing multidisciplinary project has helped to improve our process of care for patients at risk of VTE," says Renee Garrick, MD, Chief Medical Officer. "The process also allowed us to develop a framework for improving the delivery of care by incorporating and applying our technology infrastructure to bedside care."

Mount Sinai Hospital in New York City implemented a robust VTE clinical pathway in its EMR. The EMR order set defines a low-risk population that does not require prophylaxis other than early ambulation. For patients identified at moderate or high risk for acquiring a VTE, the EMR order set triggers the provider to select the appropriate option for pharmacologic or mechanical prophylaxis, or both. The 1,171-bed academic hospital also implemented concurrent review of VTE prophylaxis to identify and intervene with patients who are not receiving appropriate VTE prophylaxis. The facility developed a new policy for patient assessment and use of sequential compression devices for patients transferring from the post-anesthesia care unit and surgical unit to the inpatient floors. The hospital increased staff awareness of VTE prophylaxis through a continuous education process that encourages "just-in-time" feedback. In addition, all hospital-acquired VTEs that the health information management department identifies are referred to Andrew Dunn, MD, Chair, VTE Prophylaxis Committee, to ensure coding accuracy. As a result, prevalence of appropriate VTE prophylaxis increased from 85 to 100 percent from March through June 2011.

"It's gratifying to work on an initiative that targets and measures an important clinical outcome rather than only assessing compliance with steps in the process. The process is crucial, but improving patient outcomes is the main goal," says Dr. Dunn.

Additional New York hospitals that improved VTE prophylaxis after participating in onsite learning sessions and technical assistance calls include:

• Claxton-Hepburn Medical Center in Ogdensburg.
• Lawrence Hospital Center in Bronxville.
• St. Luke's–Roosevelt Hospital in New York City.
• Massena Memorial Hospital in Massena.

Knowledge Transfer Case Study Identifier: KT-CQuIPS-99
AHRQ Products: Partnerships in Implementing Patient Safety, QIO Learning Network
Topic(s): Hospital-Acquired Venous Thromboembolism
Scope: New York

Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/vtguide/

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