Standardized Approach to Peri-Operative and Peri-Procedural Chemical Venous-Thromboembolism Prophylaxis

Introduction:

Appropriate chemical VTE (venous thromboembolism) prophylaxis is extremely effective in preventing most periprocedural/perioperative deep venous thrombosis (DVT) and pulmonary emboli (PE). Despite evidence-based guidelines, a significant proportion of patients do not receive VTE prophylaxis. This quality improvement initiative was to develop a standardized approach to periprocedural/perioperative VTE prophylaxis at a large, specialized complex care medical center.

Methods:

The study period was interval 2 (November 2023 to June 2024) compared with the data from interval 1 (November 2022 to October 2023) at Baptist Memorial Hospital-North Mississippi. Daily EPIC EHR (electronic health record) was reviewed for adequacy of VTE prophylaxis in all periprocedural/perioperative patients, patient refusals, provider hold orders, and identification of high-risk patients. Lower extremity ultrasound exams were suggested in search of occult DVT in these patients. Real-time HIPPA-compliant communications were made with the providers and the final decision-making was left to the provider. Pharmacy monitored VTE prophylaxis for adequate dosing and scheduling with respect to body weight and/or renal function. All perioperative/periprocedural patients with hospital-acquired VTE and VTE-related admissions were evaluated for any clinical care gaps for improvement. Data analysis with Vizient, Tableau, and REDCap reports was assessed every month to evaluate Patient Safety Indicator 12 (Perioperative PE/DVT), early VTE-related readmissions (1 to 14 days post-discharge), PE-associated mortality, and cost analysis.

Results:

From interval 1 to interval 2, the PSI (Patient Safety Indicator-12) rate O/E (Observed/expected) improved from 1.0 to 0.62, with a 38% reduction. Periprocedural/perioperative VTE related early readmissions decreased from 87.5% (n=7/8) to 33.3% (n=2/6) resulting in overall reduction of 54.2%. The incidence of occult DVT in asymptomatic high-risk patients was 7.4% (n=24/326). Overall VTE related early readmission rate decreased by 28% and the 30-day readmission rate decreased by 27%. The estimated net financial benefit from the project was $241,008.56.

Discussion:

This study demonstrated that a VTE prophylaxis treatment “standard” could be established and leveraged to reduce care variation at Baptist Memorial Hospital-North Mississippi. Despite strong evidence-based guidelines, some providers still failed to start appropriate chemical VTE prophylaxis for both medical and surgical patients. There also appeared to be some reluctance to restart chemical VTE prophylaxis on post-surgical patients. Our study demonstrated that daily, real-time communication with providers regarding these potential care gaps was, not only effective but, well received by most stakeholders. Additionally, Epic order set driven VTE prophylaxis decision-making appeared to be effective however surprisingly, the automated BPA (Best Practice Advisory) reminders did not eliminate all care gaps, as intended. Direct provider communication clearly had a bigger impact as indicated by reductions in PSI 12s and “early” readmissions—indicators of consistent chemical VTE prophylaxis.

The clinical value of identifying occult POA (present on admission) DVTs in high-risk hospitalized patients cannot be overstated. In our study, benefits included earlier DVT treatment thus limiting potential morbidity, reducing the incidence of subsequent PE and any potential associated morbidity/mortality, and also, served as an “exclusion” criteria for any PSI 12. Despite these potential benefits, providers were still reluctant to order ultrasound exams because of concerns over low yield and cost-effectiveness. This study has revealed the effectiveness of our approach—7.2% incidence of occult DVT—and should reinforce this practice. Additional study benefits were noted when we examined the impact of standardized VTE prophylaxis on mortality and patient care costs.

This quality improvement initiative underscored the importance of identifying clinical care gaps and adopting a standardized approach using real-time communication to prevent significant morbidity and mortality from VTE. Further studies are required to validate generalizability and bring effective innovations to bridge the clinical care gaps in VTE prevention.