Two North Carolina 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, Carolina's Center for Medical Excellence, the QIO for North Carolina, 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.

Johnston Medical Center in Smithfield, North Carolina, revised a VTE protocol based on the toolkit. The protocol was widely accepted by the surgical staff and was implemented throughout the department. The general feedback from the surgery department was that the protocol was easy to use, and it made ordering appropriate VTE prophylaxis easier. There was increased support for the VTE protocol at the unit level with nursing staff and directors being more involved with concurrent review. The facility included the Obstetrics/Gynecology director on the team to address VTE risk and prophylaxis in the caesarean delivery population.

Lenoir Memorial Hospital in Kinston, North Carolina, had VTE prophylaxis orders in its standing post-surgical order sets without a standardized VTE assessment. Following participation in the collaborative, the facility implemented the physician-driven VTE protocol in the toolkit using a risk-stratified assessment. Following implementation of the protocol, 91 percent of patients received VTE prophylaxis. According to Teresa Sumner, RN, Quality Coordinator, "The greatest influence for participating in this project was the almost one-on-one work with the New York and North Carolina QIOs. Having live question and answer sessions enabled our questions to be answered on the spot."

Learning Network session activities were held in partnership with Carolina's Center for Medical Excellence. 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: North Carolina
Implementer: North Carolina
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