Impact of a Multicenter, Mentored Quality Collaborative on Hospital-Associated Venous Thromboembolism
BACKGROUND: Reliable prophylaxis of hospital-associated venous thromboembolism (HA-VTE) is not achieved in many hospitals. Efforts to improve prophylaxis have had uneven results.
OBJECTIVE: To reduce HA-VTE with a scalable quality improvement collaborative.
DESIGN: A prospective, unblinded, open-intervention study with historical controls.
PARTICIPANTS AND SETTING: All adult inpatients at 35 community hospitals in California, Arizona, and Nevada.
INTERVENTIONS: A centrally supported collaborative implementing standardized VTE risk assessment and prophylaxis. Protocols were developed with 9 “pilot” sites, which received individualized mentoring. Finished protocols were disseminated to 26 “spread” sites, which received improvement webinars without mentoring. Active surveillance for real-time correction of suboptimal prophylaxis was funded in pilot sites and encouraged in spread sites. Planning and minimal improvement work began in 2011; most implementation occurred in 2012 and 2013.
MEASUREMENTS: Rates of per-protocol prophylaxis (at pilot sites), and compliance with The Joint Commission VTE measures (all sites), were monitored starting in January 2012. The International Classification of Diseases, 9th Edition-Clinical Modification codes were used to determine the rates of HA-VTE within 30 days of discharge, heparin-induced thrombocytopenia, and anticoagulation adverse events; preimplementation (2011) rates were compared with postimplementation (2014) rates.
RESULTS: Protocol-appropriate prophylaxis rates and The Joint Commission measure compliance both reached 97% in 2014, up from 70% to 89% in 2012 and 2013. Five thousand three hundred and seventy HA-VTEs occurred during 1.16 million admissions. Four hundred twenty-eight fewer HA-VTEs occurred in 2014 than in 2011 (relative risk 0.78; 95% confidence interval, 0.73-0.85). HA-VTEs fell more in pilot sites than spread sites (26% vs 20%). The rates of adverse events were reduced or unchanged.
CONCLUSIONS: Collaborative efforts were associated with improved prophylaxis rates and fewer HA-VTEs.
© 2018 Society of Hospital Medicine
Deep venous thrombosis and pulmonary embolism, collectively known as venous thromboembolism (VTE), affect up to 600,000 Americans a year.1 Most of these are hospital-associated venous thromboembolisms (HA-VTE).1,2 VTE poses a substantial risk of mortality and long-term morbidity, and its treatment poses a risk of major bleeding.1 As appropriate VTE prophylaxis (“prophylaxis”) can reduce the risk of VTE by 40% to 80% depending on the patient population,3 VTE risk assessment and prophylaxis is endorsed by multiple guidelines4-7 and supported by regulatory agencies.8-10
However, despite extensive study, consensus about the impact of prophylaxis4,11 and the optimal method of risk assessment4,5,7,12 is lacking. Meanwhile, implementation of prophylaxis in real-world settings is poor; only 40% to 60% of at-risk patients receive prophylaxis,13 and as few as <20% receive optimal prophylaxis.14 Both systematic reviews15,16 and experience with VTE prevention collaboratives17,18 found that multifaceted interventions and alerts may be most effective in improving prophylaxis rates, but without proof of improved VTE rates.15 There is limited experience with large-scale VTE prevention. Organizations like The Joint Commission (TJC)8 and the Surgical Care Improvement Project have promoted quality measures but without clear evidence of improvement.19 In addition, an analysis of over 20,000 medical patients at 35 hospitals found no difference in VTE rates between high- and low-performing hospitals,20 suggesting that aggressive prophylaxis efforts may not reduce VTE, at least among medical patients.21 However, a 5-hospital University of California collaborative was associated with improved VTE rates, chiefly among surgical patients.22
In 2011, Dignity Health targeted VTE for improvement after investigations of potentially preventable HA-VTE revealed variable patterns of prophylaxis. In addition, improvement seemed feasible because there is a proven framework for VTE quality improvement (QI) projects17,18 and a record of success with the following 3 specific strategies: quality mentorship,23 use of a simple VTE risk assessment method, and active surveillance (real-time monitoring targeting suboptimal prophylaxis with concurrent intervention). This active surveillance technique has been used successfully in prior improvement efforts, often termed measure-vention.17,18,22,24
METHODS
Setting and Participants
The QI collaborative was performed at 35 Dignity Health community hospitals in California, Arizona, and Nevada. Facilities ranged from 25 to 571 beds in size with a mixture of teaching and nonteaching hospitals. Prior to the initiative, prophylaxis improvement efforts were incomplete and inconsistent at study facilities. All adult acute care inpatients at all facilities were included except rehabilitation, behavioral health, skilled nursing, hospice, other nonacute care, and inpatient deliveries.
Design Overview
We performed a prospective, unblinded, open-intervention study of a QI collaborative in 35 community hospitals and studied the effect on prophylaxis and VTE rates with historical controls. The 35 hospitals were organized into 2 cohorts. In the “pilot” cohort, 9 hospitals (chosen to be representative of the various settings, size, and teaching status within the Dignity system) received funding from the Gordon and Betty Moore Foundation (GBMF) for intensive, individualized QI mentorship from experts as well as active surveillance (see “Interventions”). The pilot sites led the development of the VTE risk assessment and prophylaxis protocol (“VTE protocol”), measures, order sets, implementation tactics, and lessons learned, assisted by the mentor experts. Dissemination to the 26-hospital “spread” cohort was facilitated by the Dignity Health Hospital Engagement Network (HEN) infrastructure.
Timeline
Two of the pilot sites, acting as leads on the development of protocol and order set tools, formed improvement teams in March 2011, 6 to 12 months earlier than other Dignity sites. Planning and design work occurred from March 2011 to September 2012. Most implementation at the 35 hospitals occurred in a staggered fashion during calendar year (CY) 2012 and 2013 (see Figure 1). As few changes were made until mid-2012, we considered CY 2011 the baseline for comparison, CY 2012 to 2013 the implementation years, and CY 2014 the postimplementation period.
The project was reviewed by the Institutional Review Board (IRB) of Dignity Health and determined to be an IRB-exempt QI project.
