New Mexico Hospitals Use AHRQ Toolkit to Revise Protocol for Preventing Blood Clots

Patient Safety
May 2012

Five New Mexico hospitals revised their protocol for preventing venous thromboembolism (VTE) after their State Quality Improvement Organization (QIO), the New Mexico Medical Review Association, participated in a series of onsite learning sessions and technical assistance calls for implementing the AHRQ toolkit Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement.

AHRQ's QIO Learning Network hosted the onsite sessions and calls between January and September 2011. Gregory Maynard, MD, of the University of California, San Diego, whose AHRQ-funded research provided the basis for the VTE prevention toolkit, presented information during the learning sessions and provided expert support during technical assistance calls.

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 and forms that clinicians can use. The toolkit advises hospitals to establish a VTE prevention protocol for assessment of patients' risk for hospital-acquired VTEs and selection of the best method for preventing the condition.

The toolkit encourages hospitals to discard a commonly used protocol that assigns points to risk factors for VTEs in order to determine the appropriate treatment option. Instead, the guide encourages hospitals to adopt a protocol that groups 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.

U.S. Public Health Service-Indian Health Service-Gallup Indian Medical Center in Gallup, New Mexico, entered the project with no VTE protocol but created one based on the toolkit's guidance. The 99-bed hospital's multidisciplinary team aggressively pursued improvement by developing, approving, and implementing the new VTE protocol less than 1 month after attending the first learning session. As a result, compliance with physician use of the protocol was nearly 90 percent, and appropriate VTE prophylaxis increased from 33 to 90 percent from March through September 2011.

"Our hospital has been successful in increasing VTE prophylaxis rates in our hospital thanks to the framework provided by AHRQ, QIO, and VTE experts who helped guide us in not only individualized clinical decisions but also hospitalwide policy, procedure, and protocol implementation," says Christina Andrade, PharmD, Lieutenant, U.S. Public Health Service.

Gerald Champion Regional Medical Center, a 95-bed acute care hospital in Alamogordo, New Mexico, had no formal VTE protocol prior to participating in the project but created one based on the toolkit's guidance. The hospitalist group uses the new risk assessment in paper format, and when admitting patients, clinicians are prompted by an electronic medical record dashboard to address treatment options based on best practices for VTE prophylaxis and therapeutic treatment.

As a result, prevalence of appropriate VTE prophylaxis increased from 55 to 100 percent for surgical prophylaxis and 100 percent for patients admitted to the hospitalist service between March and August 2011.

"Participation in the learning network has been instrumental in improving the level of knowledge of VTE prophylaxis for all disciplines in the hospital and has helped drive our improvement process," says Mary Ellen Esser, RN, Interim Director of Quality.

Miners' Colfax Medical Center, a critical access hospital in Raton, New Mexico, entered the project with a points-based risk assessment and VTE protocol that were used inconsistently and only for surgical patients. A protocol based on the toolkit was implemented in early October 2011 for medical and surgical patients, and within 2 weeks, prevalence of appropriate VTE prophylaxis increased from 30 to 70 percent. Because the 25-bed facility implemented a quality indicator to track success, the care management department monitors new admissions daily to check if staff members have completed assessments and implemented orders.

When U.S. Public Health Service-Indian Health Service-Shiprock Service Unit-Northern Navajo Medical Center in Shiprock, New Mexico, entered the project, it had a complicated points-based VTE assessment protocol that was used inconsistently. The 55-bed hospital used the toolkit to revise its protocol, which is included in the physicians' admission packet. The facility's Clinical Practices Committee, which includes nurses, physicians, and risk management and compliance staff, developed and approved a new policy for VTE risk assessment for all admissions, and a new multidisciplinary subcommittee was formed to review and monitor the new process. As a result of these interventions, appropriate VTE prophylaxis increased from 0 to 100 percent, and incidence of hospital-acquired VTE per 1,000 patient days declined from a rate of 0.99 to 0 from January through August 2011.

University of New Mexico Hospital, an academic medical center in Albuquerque, New Mexico, revised its protocol under Maynard's guidance in 2007, and in July 2011, the 428-bed facility implemented a "VTE Dashboard" in its computerized physician order entry system that allows them to view by unit, location, provider, or other category which patients are on VTE prophylaxis. The dashboard appears in green if the patient is on pharmacological prophylaxis, in yellow if the patient is on sequential compression devices or if a contraindication is documented, and in red if VTE prophylaxis has not been addressed so the staff can quickly evaluate risk and implement prophylaxis for those patients if needed.

"Participation helped us to reexamine our practices and see how they compared to the efforts of other facilities, identify new strategies to improve our performance, and most importantly, rejuvenated our enthusiasm for this initiative providing momentum to tackle problems that had stalled our progress in reaching our goals," says Allison Burnett, PharmD, an anticoagulation pharmacist at the hospital. "These actions collectively have led our facility to adopt VTE as a set of core measures on which we will now report. Additionally, we are undergoing a large-scale implementation of new software to help us track our performance and progress on all core measures, including VTE."

Impact Case Study Identifier: 
AHRQ Product(s): Partnerships in Implementing Patient Safety (PIPS), QIO Learning Network
Topics(s): Blood Clots
Geographic Location: New Mexico
Implementer: New Mexico Hospitals
Date: 05/01/2012

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

Page last reviewed October 2014
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