Idaho Hospitals Use AHRQ Toolkit to Revise Protocols for Preventing Blood Clots

Patient Safety
November 2011

Between January and September 2010, AHRQ partnered with seven Quality Improvement Organizations (QIOs) to deliver a series of onsite learning sessions and provider support calls for implementing the AHRQ-funded toolkit, Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement. These events were part of a QIO Learning Network established through an AHRQ Knowledge Transfer project. As a result of this project, Qualis Health, the QIO for Idaho, worked with two hospitals in the State to revise their VTE protocols.

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 developing VTEs.

Portneuf Medical Center in Pocatello, Idaho, discarded a points-based VTE assessment and adopted the toolkit protocol. The facility reported an increase in the use of the VTE protocol—from 33 to 68 percent from January to September 2010 in the medical services unit where it was piloted. According to Marilyn Hilby, LPN, CPHQ, Quality Manager Coordinator, "The involvement of a physician champion at the medical executive level and in grand rounds has validated the project and increased awareness of the importance of preventing hospital-acquired VTE."

Madison Memorial Hospital (MMH) in Rexburg, Idaho, developed and implemented a standardized VTE protocol for all hospital admissions based on the recommendations presented in the toolkit. The facility reported that the incidence of hospital-associated VTE per 1,000 patient days decreased from a rate of 1.30 to 0.18, an 86 percent relative improvement over 9 months. According to team leader, Nolan Bybee, RRT, Performance Improvement Director, "There was also significant qualitative impact to the hospital culture and quality performance as a result of the changes made to the VTE protocol. We implemented the first standardized best practice protocol ever in the institution. MMH now has a new, highly functional Quality Board Committee promoting, prioritizing, and resourcing quality initiatives. Administrative support for quality has grown, physician engagement in quality improvement efforts is increasing, and additional resources are being committed to care process improvement."

Learning Network session activities were held in partnership with Qualis Health. Gregory Maynard, MD, of the University of California, San Diego, developed the toolkit, and presented information during onsite learning sessions. He also provided expert support during technical assistance calls.

Impact Case Study Identifier: 
AHRQ Product(s): Partnerships in Implementing Patient Safety (PIPS), QIO Learning Network
Topics(s): Blood Clots
Geographic Location: Idaho
Implementer: Idaho
Date: 11/01/2011

Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement. Agency for Healthcare Research and Quality, Rockville, MD.

Page last reviewed October 2014