RE-AIMING PROCESS IMPROVEMENT: IMPLEMENTATION OF PREOPERATIVE VTE PROPHYLAXIS
Adam Lucy*, Melanie S. Morris, Jayme Locke
Surgery, UAB, Birmingham, AL
Background
Venous thromboembolism (VTE) is a common preventable cause of morbidity and mortality in surgical patients. VTE prophylaxis processes are often not standardized and our institution had an above-average VTE incidence. The aim of this study was to implement and evaluate the outcomes of a standardized VTE prophylaxis protocol at a single institution.
Methods
Our preop heparin (PH) initiative was conducted at a single tertiary academic medical center over two years. Our multidisciplinary team began with observation of current VTE prophylaxis processes in clinic and perioperative areas. Literature review and expert opinion were used to develop institutional practice guidelines. We used the RE-AIM model of implementation to design interventions to increase PH administration including appropriate patient selection, standardized administration, improving perioperative communication and documentation, and creating and disseminating patient and staff education. A new electronic VTE risk assessment tool was also embedded into all admission order sets.
We examined rates of PH administration and VTE for patients admitted after elective surgery from Oct 2019 to Jul 2021 and stratified by pre (Oct 2019-Aug 2020) and post-implementation (Sep 2020-Jul 2021). We used Statistical Process Control charts to track variation over time. VTE was defined by Patient Safety Indicator (PSI) 12 (postop DVT or PE) and bleeding by PSI 9 (postop hemorrhage or hematoma) using institutional Vizient data. We monitored balancing measures with rates of OR first-case start delays due to PH administration. T-tests were used to compare average rates.
Results
From Oct 2019 to Jul 2021 there were 14,559 patients admitted after elective surgery across all specialties, 7,191 pre (Oct 2019-Aug 2020) and 7,358 post-implementation (Sep 2020-Jul 2021). Our initiatives began in Sep 2020 and increased the average monthly rate of PH administration from 9.9 to 21.2% (p<0.05) and decreased the average monthly rate of VTE from 0.59% to 0.56% (p<0.05). On average, 4.7 first-case surgeries per month were directly delayed due to PH. Average total delay was 12.1 minutes (range 9-24 minutes) with the most common delay caused by lack of appropriate PH order. There was no increase in perioperative bleeding across all surgical services with initiation of PH.
Conclusion
VTE remains a substantial risk for surgical patients. Process improvement initiatives to administer PH create standard work to help decrease the incidence of VTE. However, this VTE rate reduction is marginal and can cause unintended OR delays. There remains the need for continued practice re-evaluation and service-specific protocols. Future work is ongoing to correlate Vizient PSI data with institutional risk-adjusted data for VTE and bleeding.
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