ROSEMONT, ILL. — A multifaceted intervention enabled a large health system to increase compliance with evidence-based guidelines for venous thromboembolism prophylaxis, according to Dr. Valerie Allusson, director of inpatient medicine services at Atlantic Health, Morristown, N.J.
Although the health system has not yet reached all of its quality benchmarks, compliance has risen substantially as the result of measures such as the creation of a physician order set and daily monitoring of compliance, Dr. Allusson reported at the Joint Commission national conference on quality and patient safety.
Atlantic Health's 504-bed Overlook Hospital was one of 41 hospitals that completed a 6-month pilot study of VTE quality measures sponsored by the Joint Commission in 2006–2007. Since then, Atlantic Health has spent 2 years focusing on improving VTE prophylaxis for medical and surgical patients at Overlook Hospital and the 629-bed Morristown Memorial Hospital.
In a baseline study of 100 randomly selected charts in one of Atlantic Health's medical units, only 39% of patients received VTE prophylaxis. The system implemented a quality improvement initiative based on recommendations from the American College of Chest Physicians (Chest 2004;126:338S–400S) and the National Consensus Standards for the Prevention and Care of Deep Vein Thrombosis developed by the National Quality Forum and the Joint Commission.
Areas of particular focus were VTE risk assessment/prophylaxis within 24 hours of hospital admission and VTE written discharge instructions for patients on warfarin addressing follow-up monitoring, compliance issues, dietary restrictions, and potential drug reactions or interactions.
The system set a 6-month goal to conduct a VTE risk assessment and provide appropriate prophylaxis within 24 hours of hospital admission or surgery end time for 95% of all patients. A second 6-month goal was to reach 95% of patients who had “fallen through the cracks” and had been admitted without prophylaxis.
A multidisciplinary steering committee developed a VTE prophylaxis order set addressing risk assessment, contraindications, and management options. A prototype daily VTE prophylaxis outlier list tracked patients who were and were not receiving acceptable medications (including argatroban, fondaparinux, heparin, and low-molecular-weight heparin, and warfarin). A sticker at the front of outlier charts alerted physicians about patients not receiving prophylaxis.
As of June 2009, the system had surpassed its target of 75% for prophylaxis in ICU patients (90%) and overlap therapy (82%), and was continuing to work on the remaining target of 95% for prophylaxis in medical/surgical patients (68%) and discharge instructions (79%).
In an interview, Dr. Allusson called the 95% target for prophylaxis in medical/surgical patients ambitious, considering the 39% baseline rate. Reaching 68% within 6 months represented significant progress, she said.
The system also achieved a 5%–7.5% reduction in in-hospital mortality due to VTE during this time, but whether the decline was due to the VTE quality improvement project is not known.
Dr. Allusson attributed the progress to date in part to the frequent and routine sharing of data at every level of the organization, and to the multidisciplinary collaboration. Efforts to systematize and streamline procedures related to VTE prophylaxis also helped. The new VTE prophylaxis order set, for example, allows physicians to document medications administered simply by checking the appropriate box. In addition, collaboration with information technology helped reduce the likelihood of human error.
VTE is 100 times more common in hospitalized patients than in the general population (Mayo Clin. Proc. 2001;76:1102), Dr. Allusson noted. Up to 2 million Americans experience VTE each year, and of these, 800,000 develop pulmonary thromboembolic syndrome (PTS), 600,000 develop pulmonary embolism (PE), and 300,000 die from PE (Lancet 1999;353:1386–9).
In the future, the health system aims to develop a business plan for inpatient and outpatient anticoagulation management, include pharmacists in rounds to discuss anticoagulation and discharge instructions, create a unit performance tracking system, and establish mandatory prophylaxis order forms for all admissions.