What is Venous Thromboembolism?  Venous thromboembolism, or VTE, is a term used to describe the blocking of a blood vessel by a blood clot.  VTE can be a deep vein thrombosis (DVT) or a pulmonary embolism (PE).  DVT occurs when a blood clot blocks a deep vein, usually in the leg.  PE is a potentially life-threatening complication and occurs when the blood clot escapes into the circulation and becomes lodged in the lungs.  Both of these events are commonly associated with surgery, but can also occur in hospitalized medical patients due to prolonged immobility or as a result of their underlying illnesses.

Most hospitalized patients have one or more risk factors for the development of DVT or PE. Risk factors are generally cumulative and are determined by preexisting comorbidities, age, activity, and the patient's present condition, and patients fall into any of the following risk groups - low, moderate, high, or very high risk.  In many patients, VTE is the most serious complication they will experience.  Without prophylaxis, the incidence of hospital-acquired DVT is approximately 10-40% among medical or general surgical patients and 40-60% following major orthopedic surgery.  One-quarter to one-third of DVTs involve the proximal deep veins which are more likely to produce symptoms and progress to PE, which has been found to be the cause of approximately 10% of hospital deaths.  Despite this commonly known information, under-use of appropriate prophylaxis continues to occur; some studies indicate that prophylaxis occurs in only 44% of patients.  Because of these issues, BMC chartered a team to work on prevention and reduction of hospital-acquired VTE related events.  The team developed and implemented several interventions to ensure that appropriate prophylaxis therapy is in place for all appropriate patients.

• Use of performance improvement methods such as rapid cycle PDSA (plan-do-study-act) and multiple small tests of change were used to ensure timely risk assessment and intervention.  This work resulted in adding DVT prophylaxis orders to all admission order sets in our computerized physician order entry system (CIS), building a “SMART” rule to check DVT prophylaxis orders prior to entering initial orders in CIS, and using a daily screening of all patients as a safety net to evaluate risk and adjust if needed to ensure appropriate prophylaxis.
• Multi-modal education was provided to all clinical staff through web-based/online training, Grand Rounds, mailings, noon conferences, and electronic media.
• The Division of Healthcare Quality’s nurse reviewers work closely with coding compliance analysts to validate clinical documentation of DVT/PE, especially those that may be hospital-acquired.
• Clinical review of all DVT/PE events for “potential preventability” is in place.   Any omissions in care provide learning opportunities and direct future improvement efforts.
• All patients undergoing surgery have mechanical prophylaxis applied as the minimal standard of prophylaxis, and therapy is intensified based on post-operative risk per BMC and national guidelines. 

Highlights

Baystate Medical Center 

• Despite the need for additional data, there is sufficient evidence to recommend routine thromboprophylaxis for the majority of hospitalized patients, therefore all patients are screened and treated based on risk.
• Focus on this important issue has brought our overall rate of prophylaxis to 100% for all patients, well above the National Quality Forum and Centers for Medicare and Medicaid Services reported rates. 
• Our VTE rate is consistently lower than the Leapfrog hospitals comparative rate.

Baystate Mary Lane Hospital 

• The current post-procedure VTE rate is zero. Compliance in the application of VTE prophylaxis is currently at 77% and will be an area of focus going forward.

Baystate Franklin Medical Center 

• New processes have been effectively implemented in the medical-surgical units and intensive care unit (ICU) to ensure that patients receive proper measures to prevent VTE all the time.  The current VTE prophylaxis rate is 93%, with a zero post-operative VTE rate.

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