Seven Kentucky Hospitals Use AHRQ Guide to Revise Protocols for Preventing Blood Clots
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, Health Care Excel, the QIO for Kentucky, worked with seven 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.
Jewish Hospital and St. Mary's Health Care in Louisville, Kentucky, represented four hospitals in the collaborative. All four hospitals changed their points-based VTE risk assessments to the risk-stratified assessment recommended in the VTE toolkit. The systemwide implementation of the revised protocol resulted in a decrease in hospital-acquired VTE rates from 1.39 to 1.02 per 100 days. In addition, compliance improved from 2009 to the first quarter of 2010 in the following areas: ordering appropriate VTE prophylaxis improved from 87 to 93 percent, and the percentage of patients receiving appropriate VTE prophylaxis increased from 74 to 90 percent. According to Jennifer Robards, Director of Quality, "By participating in the AHRQ initiative, our individual facilities, as well as our system, were able to collaborate and be included with other facilities in the Commonwealth and across the country. While we took some comfort from realizing VTE is a national issue, we quickly realized that by participation in this project, we could benefit by allowing us to learn from other's mistakes, trials, and triumphs."
Jennie Stuart Medical Center in Hopkinsville, Kentucky, entered the collaborative without a VTE protocol for its medical patient population. As a result, medical patients received VTE prophylaxis only 58 percent of the time, compared with surgical patients, who received prophylaxis at a rate of 80 percent. Following participation in the collaborative, a standardized VTE protocol was implemented hospitalwide to include both surgical and medical patients. The revised protocol was pilot tested on the medical floor, with hospitalists consistently ordering VTE prophylaxis. Beth McCraw, A.RNP., A.C.N.S.-B.C., O.C.N., says, "I believe the deficits between VTE risk identification upon admission and the continued daily monitoring of VTE risk assessment became amazingly clear. This generated much-needed discussion, education, and awareness among our multidisciplinary staff."
Owensboro Medical Health Systems in Owensboro, Kentucky, entered the collaborative with a VTE protocol that had a nurse-driven assessment with physicians doing the ordering. While assessments were completed 100 percent of the time, only 10 percent of the physicians used the protocol for ordering. As a result of participating in the collaborative, the facility combined the moderate and high levels of VTE risk assessment. As a result, compliance with physician use of the VTE protocol increased to 37 percent. Hospitalists now assess all inpatients daily to ensure that those who are identified as at risk have been ordered pharmacologic prophylaxis. Marcella Henderson, RN, Manager of Quality Support Services, says, "Participation in this learning network opened our eyes to really look at our data, look for areas of improvement, and make the data transparent to the organization in order to improve patient outcomes."
Western Baptist Hospital in Paducah, Kentucky, revised its VTE protocol to separate the assessment from the order set. It also implemented a risk-stratified assessment to include low, medium, and high categories. The changes to the protocol-coupled with heightened awareness regarding the importance of VTE prophylaxis-led to an increase in VTE prophylaxis orders. Kristin Reid, A.RNP., A.C.N.S.-B.C., VTE Team Leader, says, "I now have a better understanding of how to work through processes within the hospital to facilitate change and awareness."
Learning Network session activities were held in partnership with Health Care Excel. 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.