SummaryTo reduce hospital-acquired deep vein thrombosis, a nurse-led multidisciplinary team launched a program to identify and administer preventive treatment (prophylaxis) in a timely manner to at-risk surgical and medical patients. Providers use an established tool to classify patients into low-, moderate-, or high-risk categories, and then prescribe anticoagulant (blood thinner) medication and/or mechanical devices (e.g., elastic stockings) as appropriate based on the patient's risk. The program resulted in a significant increase in screening and use of appropriate prophylaxis for moderate- and high-risk patients, which is expected to lead to a reduction in deep vein thrombosis rates over time.Moderate: The program was evaluated using a quasi-experimental design with nonrandom assignment of patients and post-implementation comparison with a baseline. However, the strength of the evidence is limited somewhat by uncertainties about baseline data.
Developing OrganizationsBarnes Jewish Christian Hospital, St. Louis, MO; Memorial Medical Center, Springfield, IL
Date First Implemented2005
Problem AddressedDeep vein thrombosis (DVT) (characterized by the formation of one or more blood clots in one of the body's large veins, commonly in the lower limbs) is a common, costly, and often preventable condition that can lead to morbidity and death, particularly when the clot breaks free and travels through the bloodstream to the lungs (a condition known as pulmonary embolism or PE).1
- A frequent, devastating disease: Nationally, DVT and PE occur in 200,000 to 600,000 patients annually.2 Risk factors for hospital-acquired DVT include hormone use, major lower extremity surgery, multiple trauma, obesity, older age, pregnancy, and stroke. DVT is often a silent disease, with only about half of patients experiencing symptoms.1 The most serious potential problem for DVT sufferers is the potential for PE, which can result in organ damage and sudden death. DVT and PE, collectively referred to as venous thromboembolism (VTE), kill more people each year than acquired immunodeficiency syndrome, breast cancer, and highway fatalities combined.2
- Highly preventable: VTE is largely preventable through risk-based screening and appropriate preventive treatment.2 Standard prophylactic treatment for high-risk hospitalized patients has been shown to be highly effective in reducing the incidence of DVT and PE. However, providers today often do not provide this potentially life-saving treatment. Between 14 and 55 percent of surgeons fail to order appropriate DVT prophylaxis, while 5 to 12 percent of surgeons never order prophylaxis, and roughly 40 percent of moderate- to high-risk Medicaid patients do not receive appropriate preventive measures.1
- A critical safety issue: Based on evidence about the effectiveness of prophylactic treatment, the Agency for Healthcare Research and Quality (AHRQ) ranked prevention of DVT and PE as the number-one patient safety practice out of 79 ranked practices.1
Description of the Innovative ActivityThe DVT prevention program consists of a nurse conducting an initial assessment to identify at-risk patients followed by a physician review of the case and the administration of appropriate, evidence-based prophylactic treatment. The goal is to assess and treat (as necessary) patients within 48 hours of hospital admission. Key elements of the program are described below:
- Identifying at-risk patients: Nurses assess each patient's DVT risk factors within 48 hours of admission using an adapted version of the Thrombosis Risk Factor Assessment Tool, which is derived from American College of Chest Physicians guidelines. (After the initial pilot test, the protocol was changed to call for assessment within 24 hours of admission.) Stickers placed on all patient charts remind nurses to take this step. Nurses use the tool to triage patients into low-, moderate-, or high-risk categories based on their risk score, which is calculated from 28 risk-factor categories, each having a point value between 1 and 4. American College of Chest Physicians guidelines are posted in highly visible locations (e.g., entry/exit points, high traffic areas) to remind physicians and staff of the need to screen all patients.
- Ordering of prophylactic treatment: Physicians review the assessment and check off the appropriate therapy (e.g., anticoagulant medications to thin the blood and prevent clots, elastic stockings to prevent the pooling of blood) based on the nurses' classification of patient's risk level. The form includes a reminder for physicians to act in the best interest of the individual patient and to use their best judgment.
- Low-risk patients: These patients generally receive no drug or device treatment, but early ambulation is encouraged after surgery.
- Moderate- to high-risk patients: These patients typically receive an anticoagulant medication (blood thinner) and a pneumatic or sequential compression device to prevent blood pooling in legs. The appropriate drug dosage is indicated on the tool, based on the type of surgery and the patient's risk level.
- Contraindicated patients: Patients who have contraindications for anticoagulant medications are given only pneumatic or sequential compression device treatment. For patients for whom medications and compression device treatment are contraindicated, physicians are required to indicate the reason or reasons why by checking the appropriate box or filling in the information on the form.
- Nurse followup: Nursing staff follow up to ensure that appropriate treatment has been ordered, and they are empowered to initiate contact with physicians if prophylaxis has not been ordered for an eligible patient.
- Ongoing audit and performance feedback: Several steps are taken to monitor adherence with established protocols and provide timely feedback to clinicians as a way to stimulate continuous improvement.
- Daily rounds: A dedicated nurse from the quality management department initially made daily rounds to review all patient charts for documentation relating to DVT assessment and prophylaxis, and then contacted physicians to discuss audit results periodically. After the pilot and initial implementation across the hospital, the nurse audited a random sample of patients to track adherence and reported the results regularly to the director of clinical quality control. Adherence data is shared at departmental and nursing unit staff meetings and in newsletters from the chief medical officer.
- Weekly audit feedback: The hospital incorporated reliability theory, a proven scientific method of evaluating, calculating, and improving the overall reliability of a complex system,3 into its auditing protocol. The director of clinical resource management oversees the review and analysis of 10 charts each week, and provides feedback to the unit staff on adherence. If the target outcomes are missed, weekly random unit audit sampling is increased hospital-wide until the target is achieved. An administrative team, composed of the chief medical officer, director of clinical quality improvement, and an advanced practice nurse, attends unit-based governance meetings to share performance information directly with nurses, including the risk categorization profile of patients, the timeframe and appropriateness of prophylaxis orders, outliers, problem areas, and nursing contributions to these problems. The presence and commitment of the administrative team and the use of immediate feedback has been found to be an effective way to improve communication within and across the organization.
- Monthly improvement meetings: Each month the hospital’s Quality Improvement and Quality Practice Council meets with relevant staff and administration to discuss the program's outcomes and strategies for sustaining or improving its success.
- Refinement of protocol was made since its inception: Risk assessment process and order set now divides patient therapy for prophylaxis into two groups: surgical patient and medical patient groups. In addition, the pharmacy reviews all orders for anticoagulation therapy to adjust dosing for renal impairment.
References/Related ArticlesCrowther M, McCourt K. Venous thromboembolism: a guide to prevention and treatment. Nurse Pract. 2005;30(8):26-9, 32-4, 39-45. [PubMed]
Summerfield DL. Decreasing the incidence of deep vein thrombosis through the use of prophylaxis. AORN J. 2006;84(4):642-5. [PubMed]
More information about reliability theory can be found on the Institute for Healthcare Improvement Web site at http://www.ihi.org/offerings/VirtualPrograms/OnDemand/Reliability/Pages/default.aspx.
Contact the InnovatorTina Weitzel, MA, RN-BC
Memorial Medical Center
Springfield, IL 62781
Phone: (217) 757-7424
Fax: (217) 788-3903
ResultsSystematic evaluation of this program shows increased screening and better adherence to evidence-based prophylactic treatment.
Moderate: The program was evaluated using a quasi-experimental design with nonrandom assignment of patients and post-implementation comparison with a baseline. However, the strength of the evidence is limited somewhat by uncertainties about baseline data.
- Increase in screening rates: Before implementation of the program, screening rates for DVT risk varied from unit to unit, from a low of 10 percent to a high of 60 percent. After initial implementation of the program, more than 95 percent of all inpatients were assessed within the prescribed 48-hour time limit. After the pilot test was completed, the protocol was changed to provide screening within 24 hours of admission, and adherence rates remained at 92 percent or above.
- Increase in prescribing prophylaxis: The use of appropriate preventive treatment in moderate- and high-risk patients increased from less than 50 percent before the program to nearly 70 percent initially and after a 2009 chart audit, 98 percent adherence was attained.
- Temporary increase in DVT rates, but a decline expected: Data collection and chart reviews for inpatients revealed an increase in DVT rates compared with previous data that relied on discharge charts. The multidisciplinary team attributes the spike to improved data collection techniques and better reporting of specified outcome measures. Although hard data are not yet available, program leaders are convinced that the increased use of prophylaxis will reduce rates of DVT in the near future.
Context of the InnovationMemorial Medical Center is a 562-bed, acute care, nonprofit hospital offering comprehensive inpatient and outpatient services. The facility was named a magnet hospital by the American Nurses Credentialing Center in 2005, 1 of 225 U.S. hospitals to receive this status.
The chief medical officer at Memorial became aware of the need for preventive DVT treatment through a professional journal article. The officer assembled a multidisciplinary team to research the issue, and the team determined that the hospital's rate of DVT was unacceptably high, at a level close to the national average. Memorial's leadership believed the organization could do a better job of preventing DVT. A resident conducted a pilot study in the medical–surgical department to determine how many patients were at moderate or high risk of DVT, and to evaluate initial implementation of prophylaxis. The pilot program's success in increasing use of preventive treatment served as the impetus to spread the innovation throughout the hospital.
Planning and Development ProcessKey steps in the planning and development process include the following:
- Data collection and analysis: Audits of discharge documents were conducted to determine rates of DVT, type of surgery, length of stay, and treatment. These figures were compared with national averages. The accuracy of these data may have been somewhat limited due to incomplete information on discharge documents.
- Review and assessment of evidence-based practices: National guidelines from several sources and peer-reviewed journal articles were evaluated for their feasibility and adaptability.
- Consultation with American College of Chest Physicians experts: The hospital contacted the authors of literature on best practices in prophylactic care to assist in adapting and adopting treatment protocols. The American College of Chest Physicians Consensus Task Force consultants offered valuable insights into implementing the program.
- Collection of risk-assessment tools: Memorial Medical Center contacted partner hospitals to collect multiple risk assessment tools and to pool intellectual resources.
- Adaptation and adoption of a risk-assessment tool: The hospital selected the most effective tool and customized the order form to include information such as reminders for doctors to assess cases based on an individual patient's needs.
- Determination of measures for monitoring DVT outcomes: Outcomes chosen included the provision of pharmacologic prophylaxis, adverse events, and incidence of DVT.
- Pilot study: Initiated by a resident, the prophylaxis treatment was pilot-tested and analyzed for its impact on DVT and adverse effects. After the pilot proved successful, the program was expanded throughout the hospital.
- Physician and nursing staff champions: Physician and nurse champions were identified and recruited to promote the program among their peer groups throughout the hospital.
- Training materials and educational sessions: A multidisciplinary team developed training materials, including a curriculum for a brief inservice education, the reminder stickers to be placed on patient folders, and special forms for nurses and physicians to complete for assessing the patient and ordering medication and treatment. Information and expectations related to the program were shared through educational sessions with nurses and physicians. Experienced staff also attended all-unit governance council meetings to inform nursing staff about the program.
Resources Used and Skills NeededStaffing: The program initially required an additional 0.25 full-time equivalents (FTEs) for chart review, a figure that was later reduced to 0.13 FTEs. The bulk of the program's upfront planning and ongoing operations are conducted by a multidisciplinary team as a part of their regular duties. This team included the American College of Chest Physicians consultants, the chief medical officer, the director of quality care and infection control, physicians, the director of nursing, and the nursing staff. In addition, the director of clinical resource management and a nurse from the quality management department assist with ongoing monitoring, auditing, and performance feedback as a part of their regular duties.
Funding SourcesBarnes Jewish Christian Hospital, St. Louis, MO; Memorial Medical Center, Springfield, IL
Memorial Medical Center teamed with Barnes Jewish Christian Hospital in St. Louis, MO, to share expertise, resources, and funding.
Tools and Other ResourcesGeerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004 Sep;126(3 Suppl):338S-400S. [PubMed] [This guideline has been removed from the National Guideline Clearinghouse site. It has been replaced by an updated guideline, available at http://www.guideline.gov/content.aspx?id=34957&search=prevention+of+venous+thromboembolism. However, this innovation was based on the 7th ACCP Conference on Antithrombotic and Thrombolytic Therapy]
Hirsh J, Guyatt GH, Albers GW, et al. Antithrombotic and thrombolytic therapy: American College of Chest Physicians Evidence-Based Practice Guidelines, (8th ed). Chest. 2008;133(6 suppl):67s-968s. [PubMed] Available at: http://journal.publications.chestnet.org/article.aspx?articleid=1085921.
Interactive Venous Thromboembolism Safety Toolkit for Providers and Patients. An interactive safety toolkit contains multiple evidence-based tools for providers and patients to improve the safety of the process for the diagnosis and treatment of VTE, including: patient education materials, prevention guidelines, screening and assessment materials, treatment pathways. The toolkit is available at http://vte.son.washington.edu/.
Memorial Medical Center's updated physician order set for DVT Prophylaxis Risk Assessment may be obtained from the innovator at firstname.lastname@example.org.
Getting Started with This Innovation
- Conduct background research: Review the most recent evidence-based literature and guidelines. Gather baseline information on the incidence of DVT and PE in the hospital. Review and revise reporting systems related to DVT. Memorial Medical Center recognized that better data on outcomes were needed to accurately gauge the occurrence of DVT in patients in various departments. The only data available came from discharge papers, which were not always accurately filled out.
- Use a team approach: Create a multidisciplinary team to identify specific problems and to address the needs of the individual units and the entire hospital.
- Define outcomes: Establish clear definitions of expected patient outcomes from the program, including not only rates of DVT, but also the incidence of complications from treatment.
- Customize tools: Customize tools to incorporate up-to-date, evidence-based recommendations to simplify workflow.
- Conduct a pilot: Consider piloting the program in one department before implementing it across the hospital.
Sustaining This Innovation
- Conduct ongoing monitoring: Continually monitor trends in DVT assessment, treatment, and outcomes, including adverse events. Random sampling, conducted monthly in all units, can help to identify and address potential problems early.
- Provide feedback: Provide timely feedback on adherence rates using regular audits. At Memorial, reducing the frequency of audits from weekly to quarterly resulted in a decline in performance, which was later reversed after reverting back to weekly audits. Use hospital newsletters to report outcomes to physicians and staff and to reinforce the importance of the DVT prophylaxis program. Convene monthly meetings where quality improvement staff can meet with clinicians and administrators to discuss program outcomes and strategies for sustaining the innovation.
- Expect an initial rate increase: Be prepared for an initial increase in DVT rates due to better screening and reporting.
- Facilitate patient followup: Provide nurse managers with the names of moderate- and high-risk patients who do not receive appropriate preventive treatment so that they can follow up with the patients and their physicians.
- Monitor the evidence: Continue to review updates from the American College of Chest Physicians and make changes based on recommendations.
Service Delivery Innovation Profile
Original publication: December 12, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: August 22, 2012.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: April 12, 2011.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.