Patient Safety, 2010

Illinois Hospitals

May 2010

Between September 2008 and May 2009, AHRQ hosted a series of seven Web conferences about its toolkit, Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement. These events were part of an AHRQ Knowledge Transfer project. As a result of the Web conference series, two hospitals in Illinois changed or initiated protocols on caring for patients at risk for venous thromboembolism (VTE).

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, as well as forms that clinicians can use. The toolkit advises hospitals to establish VTE prevention protocols to assess patients' risk for hospital-acquired VTEs and select the best method for preventing the condition.

The toolkit encourages hospitals to discard commonly used protocols that assign points to risk factors for VTEs in order to determine the appropriate treatment option. Instead, the guide encourages hospitals to adopt protocols that group 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 VTEs.

St. James Hospital and Health Centers in Olympia Fields, Illinois, made changes to an existing VTE prevention protocol as a result of participating in the Web conferences. According to Jane Burnson, RN, a Quality Improvement Analyst at St. James, the hospital reduced the number of risk categories on the protocol from four to three and streamlined the form, making it easier to use. The revised protocol is now in effect throughout all units at both campuses.

St. Anthony's Health Center in Alton, Illinois, did not have a VTE prevention protocol before participating in the Web conference series. According to Crystal East, Quality Specialist, the hospital developed a VTE order set that was consistent with the principles described in the AHRQ toolkit. The order set was approved for use in the medical and surgical units and was implemented in the fall of 2009 following a training series. East reports that the tool was "very helpful in providing physicians the data that demonstrated the need to develop a protocol, helping secure buy-in to the new protocol."

The Web conferences were held in partnership with the Illinois Foundation for Quality Health Care. Gregory Maynard, MD, of the University of California, San Diego, developed the toolkit and presented information during the Web conferences.

Knowledge Transfer Case Study Identifier: KT-CQuIPS-37
AHRQ Products: Partnerships in Implementing Patient Safety
Topic(s): Hospital-Acquired Venous Thromboembolism
Scope: Illinois

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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