Hospital-associated venous thromboembolism (HA-VTE) is a serious condition with controversy regarding ideal risk assessment and VTE prophylaxis (VTEP), especially in medical patients. We conducted a collaborative VTE quality improvement project, supported by a charitable grant from the Gordon and Betty Moore Foundation, in 35 hospitals across three states and assessed the impact on HA-VTE rates.
Methods:
Data management, order set design, and hosted webinar support were provided centrally. All hospitals formed multi-disciplinary teams to drive local educational efforts and address lapses in VTEP. Interventions included:
- A standardized, 3-bucket risk assessment module linked to a protocol of pharmacologic and mechanical VTEP, embedded in order sets
- 9 “pilot” sites received mentored implementation modeled after SHM collaboratives; 26 “spread” sites did not
- Measure-vention (measurement and real-time correction of defects) was funded in pilot sites and encouraged in spread sites
HA-VTE events (during hospitalization or present on admission within 30 days of prior discharge) were collected from coding data. 2011 was considered the baseline year, 2012-13 intervention years, and 2014 the mature period for comparison. Data collection for VTEP did not begin until 2012-2013. All sites monitored compliance with TJC VTE measures 1&2 (“any” VTEP). Measure-vention sites also determined whether VTEP was adequate according to the protocol.
Results:
5370 HA-VTE occurred during 1.16 million admissions during the study period. TJC VTE-1 and 2 performance and protocol appropriate VTEP rates both reached 97% in 2014, up from 2012-13 performance of 78-87%. Across all 35 sites, 428 fewer HA-VTE occurred in 2014 than in 2011 (RR 0.78, 95% CI [0.73 – 0.85]). Pilot sites enjoyed a more robust reduction in HA-VTE than Spread sites (26% vs 20%). Heparin induced thrombocytopenia and adverse effects from anticoagulants were reduced or unchanged (Table). The average annual HA-VTE rate over the study was higher in surgical patients [5.7 (pilot) and 7.3 (spread)/1000] than medical patients (3.3 and 3.6 /1000). In medical patients, most HA-VTE occurred post-discharge (2740 of 3416; 80%); in surgical patients, most occurred during the index admission (1611 of 2630, 61%)(Figure).
Conclusions:
Our collaborative QI project was associated with a reduction in HA-VTE across a broad medical-surgical inpatient population. Interventions proved easy to disseminate across multiple hospitals. HA-VTE rates can be improved, even when already low (~0.5%).