Six New York 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, Island Peer Review Organization (IPRO), the QIO for New York, worked with six 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.
Peninsula Hospital Center in Far Rockaway, New York, revised a VTE protocol from a two-level, risk-adjusted protocol to a three-level protocol consistent with the tools presented during the learning sessions. The facility reported that while physicians were ordering appropriate prophylaxis, compliance with the use of the risk assessment was low. To improve physician compliance, a physician champion implemented the protocol on the surgical unit, followed by the medical unit. As a result of the interventions, compliance related to using the form improved from 7 to 90 percent and from 85 to 97 percent in the ordering of appropriate prophylaxis. According to Carol Clark, RN, Director of Quality Management, "This has been a great learning experience and opportunity for improvements in the quality of care given here at Peninsula Hospital."
Richmond University Medical Center in Staten Island, New York, entered the collaborative with a points-based VTE risk assessment, which they revised to be consistent with the AHRQ toolkit. The protocol was implemented in the behavioral health unit. According to Lora Giacomoni, RN, MSN., Vice President, Quality and Care Coordination, "The Medical Center reviewed two cases of hospital-acquired VTE or pulmonary emboli in which both patients were admitted to the behavioral health unit. Case studies revealed that one patient would have benefited from VTE prophylaxis." Psychiatrists and internists now ensure that behavioral health patients at risk for VTE receive the proper assessment and care.
Southampton Hospital in Southampton, New York, revised its points-based VTE risk assessment to match the VTE toolkit. The revised VTE assessment-completed upon admission and whenever there is a significant change in condition-was implemented in October 2010. Irene Caulfield, RN, Director of Performance Improvement, says, "The presentations offered an evidence-based framework for rapid improvement. I found the meetings informative and supportive."
St. John's Riverside Hospital-Andrus Pavilion and Dobbs Ferry Pavilion, affiliated hospitals located in Yonkers and Dobbs Ferry, New York, respectively, revised an existing VTE protocol to be consistent with the VTE toolkit. The change in the assessment, and the strong support of the oncology unit nursing director champion, led to an increase in compliance in using the assessment from 80 percent in January 2010 to 100 percent in June 2010 in the oncology pilot unit. According to Judith Sapione, MS, RN, Director of Performance Improvement and Risk Management at St. John's Riverside Hospital, "Participation in this project allowed us to reassess and align our VTE protocol with nationally recognized best practice."
Saratoga Hospital in Saratoga Springs, New York, revised its VTE protocol and order sets to reflect the approach recommended by AHRQ experts. Pharmacologic prophylaxis is now indicated as the first choice for patients at moderate risk. As a result of changes made, compliance with ordering appropriate VTE prophylaxis improved from 60.0 to 84.6 percent. Maria Griswold, RPh, PharmD, Clinical Coordinator in the Department of Pharmacy, says, "After receiving input from the toolkit developers, the committee recognized that our original protocol offered too many choices, did not offer physicians enough guidance in choosing VTE prophylaxis, and, where choices were offered, they were presented as though they were equal."
Learning Network session activities were held in partnership with IPRO. 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.