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Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a serious and growing public health problem. In the United States an estimated 900,000 people are affected and more than 100,000 die from VTE or related complications each year. More than half of VTE events occur in association with hospitalization or major surgery; many are thought to be preventable.[1, 2, 3, 4, 5] The Centers for Medicare and Medicaid Services (CMS), Centers for Disease Control and Prevention (CDC), and the Agency for Healthcare Research and Quality (AHRQ),[6, 7, 8, 9] among other organizations, have identified VTE as a potentially preventable never event. Evidence‐based guidelines and resources exist to help support hospital‐acquired venous thromboembolism (HA‐VTE) prevention.[1, 2, 3, 4, 5, 6, 7, 8, 9, 10] Harborview Medical Center, a tertiary referral center with more than 17,000 patients hospitalized annually, many requiring surgery, serves one of the highest‐risk populations for HA‐VTE development. Despite high rates of VTE prophylaxis in accordance with an established institutional guideline,[11, 12] VTE remains the most common hospital‐acquired condition in our institution.

OBJECTIVES

To improve the safety and care of all patients in our medical center and eliminate preventable HA‐VTE events, we set out to: (1) incorporate evidence‐based best practices in VTE prevention and treatment into current practice in alignment with institutional guidelines, (2) standardize the review process for all HA‐VTE events to identify opportunities for improvement, (3) utilize quality improvement (QI) analytics and information technology (IT) to actively improve our processes at the point of care, and (4) share process and outcome performance relating to VTE prevention transparently across our institution

METHODS

To prevent HA‐VTE, we employ a multifactorial strategy that includes designated clinical leadership, active engagement of all care team members, decision support tools embedded in the electronic health record (EHR), QI analytics, and retrospective and prospective reporting that provides ongoing measurement and analysis of the effectiveness of implemented interventions.

Intervention

In 2010, at the request of the Harborview Medical Executive Board and Medical Director, we formed the Harborview VTE Task Force to assess VTE prevention practices across services and identify improvement opportunities for all hospitalized patients. This multidisciplinary team, co‐chaired by a hospitalist and trauma surgeon, includes representatives from trauma/general surgery, orthopedic surgery, hospital medicine, nursing, pharmacy, and QI. Task force members represent critical and acute care as well as the ambulatory setting. Additional stakeholders and local experts including IT directors and analysts, continuity of care nurses, and other clinical service representatives participate on an ad hoc basis.

Since its inception, the VTE Task Force has met monthly to review performance data and develop improvement initiatives. Initially we collaborated with experts across our health system to update an existing institutional VTE prophylaxis guideline to reflect current evidence‐based standards.[1, 3, 4, 5, 12] We met with all clinical services to ensure that the guidelines incorporated departmental best practices. These guidelines were integrated into our Cerner‐based (Cerner Corp., North Kansas City, MO) computerized provider order entry (CPOE) system to support accurate VTE risk assessment and appropriate ordering of prophylaxis.

The VTE Task Force collaborated with QI programmers to develop an electronic tool, the Harborview VTE Tool (Figure 1),[13] that allows for efficient, standardized review of all HA‐VTE at monthly meetings. The tool uses word and phrase search capabilities to identify PEs and DVTs from imaging and vascular studies and links those events with pertinent demographic and clinical data from the EHR in a timeline. Information about VTE risk assigned by physicians in the CPOE system is extracted as well as specific VTE prophylaxis and treatment (drug, dose, timing of administration of medications, reason for doses being held, and orders for and application of mechanical prophylaxis). Using the VTE tool, the task force reviews each VTE event to assess the accuracy of VTE risk assignment, the appropriateness of prophylaxis received relative to guidelines, and the adequacy of VTE treatment and follow‐up. This tool has facilitated our review process, decreasing time from >30 minutes of manual chart review per event to several minutes. In recent months, a quality analyst has prescreened all VTEs prior to task force discussion to further improve efficiency. The tool allows the team to assess the case together and reach consensus regarding VTE prevention.

Figure 1

Prompt event reviews allow the task force to provide timely feedback about specific VTE events to physicians, nurses, and pharmacists. Cases with potential opportunities for improvement are referred to a medical center‐wide QI committee for secondary review. Areas of opportunity identified are tracked and trended to direct ongoing system improvement cycles. In 2014, as a result of reviewing patient cases with VTE diagnosed after discharge, we began a similar review process to assess current practice and standardize prophylaxis across care transitions.

In response to opportunities identified from reviews, the VTE Task Force developed multiple reporting tools that provide real‐time, actionable information to clinicians at the bedside. Daily electronic lists highlight patients who have not received chemical or mechanical prophylaxis in 24 hours and are utilized by nursing, pharmacy, and physician groups. Patients receiving new start vitamin K antagonists or direct oral anticoagulants are identified for pharmacists and discharge care coordinators to support early patient/family education and ensure appropriate follow‐up. Based on input from frontline providers, tools are continually refined to improve their clinical utility. A timeline of initiatives that the Harborview VTE Task Force has championed is outlined in Figure 2.

Figure 2

To bring HA‐VTE prevention information to the point of care, we developed a VTE Prevention/Treatment Summary within the EHR (Figure 3). Information about VTE risk assigned by the physician based on guidelines, current prophylaxis orders (pharmacologic/nonpharmacologic) and administration status, therapeutic anticoagulation and pertinent laboratory values are imported into a summary snapshot that can be accessed on demand by any member of the care team from within the patient's chart. The same data elements are being imbedded in resident physician and nursing handoff tools to highlight VTE prevention for all hospitalized patients and ensure optimal prophylaxis at transitions of care.

Figure 3

To emphasize Harborview's commitment to VTE prevention and ensure that care providers across the institution are aware of and engaged in this effort, we utilize our intranet to disseminate information in a fully transparent manner. Both process and outcome measures are available to all physicians and staff at service and unit levels on a Web‐based institutional dashboard. Data are updated monthly by QI analysts and improvement opportunities are highlighted in multiple fora. Descriptions of the quality metrics that are tracked are summarized in Table 1.

Table 1.Quality Metrics

Quality Metric	Description
NOTE: Abbreviations: AHRQ, Agency for Healthcare Research and Quality; CMS, Centers for Medicare and Medicaid Services; PSI, Patient Safety Indicator; VTE, venous thromboembolism.
AHRQ PSI 12	Cases of VTE not present on admission per 1000 surgical discharges with select operating room procedures
CMS Core Measure VTE‐1	Percent of patients without VTE who received VTE prophylaxis on day of or day after arrival to an acute care area, random sample
CMS Core Measure VTE‐2	Percent of patients without VTE who received VTE prophylaxis on day of or day after arrival to an intensive care unit or surgery date, random sample
CMS Core Measure VTE 5	Percent of patients with hospital acquired VTE discharged to home on warfarin who received education and written discharge instructions
CMS Core Measure VTE‐6	Percent of patients with hospital‐acquired VTE who received VTE prophylaxis prior to the event diagnosis

MEASUREMENTS

RESULTS

Our VTE prevention initiatives have resulted in improved compliance with our institutional guideline‐directed VTE prophylaxis and a decrease in HA‐VTE at our institution.

Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a serious and growing public health problem. In the United States an estimated 900,000 people are affected and more than 100,000 die from VTE or related complications each year. More than half of VTE events occur in association with hospitalization or major surgery; many are thought to be preventable.[1, 2, 3, 4, 5] The Centers for Medicare and Medicaid Services (CMS), Centers for Disease Control and Prevention (CDC), and the Agency for Healthcare Research and Quality (AHRQ),[6, 7, 8, 9] among other organizations, have identified VTE as a potentially preventable never event. Evidence‐based guidelines and resources exist to help support hospital‐acquired venous thromboembolism (HA‐VTE) prevention.[1, 2, 3, 4, 5, 6, 7, 8, 9, 10] Harborview Medical Center, a tertiary referral center with more than 17,000 patients hospitalized annually, many requiring surgery, serves one of the highest‐risk populations for HA‐VTE development. Despite high rates of VTE prophylaxis in accordance with an established institutional guideline,[11, 12] VTE remains the most common hospital‐acquired condition in our institution.

OBJECTIVES

To improve the safety and care of all patients in our medical center and eliminate preventable HA‐VTE events, we set out to: (1) incorporate evidence‐based best practices in VTE prevention and treatment into current practice in alignment with institutional guidelines, (2) standardize the review process for all HA‐VTE events to identify opportunities for improvement, (3) utilize quality improvement (QI) analytics and information technology (IT) to actively improve our processes at the point of care, and (4) share process and outcome performance relating to VTE prevention transparently across our institution

METHODS

To prevent HA‐VTE, we employ a multifactorial strategy that includes designated clinical leadership, active engagement of all care team members, decision support tools embedded in the electronic health record (EHR), QI analytics, and retrospective and prospective reporting that provides ongoing measurement and analysis of the effectiveness of implemented interventions.

Intervention

In 2010, at the request of the Harborview Medical Executive Board and Medical Director, we formed the Harborview VTE Task Force to assess VTE prevention practices across services and identify improvement opportunities for all hospitalized patients. This multidisciplinary team, co‐chaired by a hospitalist and trauma surgeon, includes representatives from trauma/general surgery, orthopedic surgery, hospital medicine, nursing, pharmacy, and QI. Task force members represent critical and acute care as well as the ambulatory setting. Additional stakeholders and local experts including IT directors and analysts, continuity of care nurses, and other clinical service representatives participate on an ad hoc basis.

Since its inception, the VTE Task Force has met monthly to review performance data and develop improvement initiatives. Initially we collaborated with experts across our health system to update an existing institutional VTE prophylaxis guideline to reflect current evidence‐based standards.[1, 3, 4, 5, 12] We met with all clinical services to ensure that the guidelines incorporated departmental best practices. These guidelines were integrated into our Cerner‐based (Cerner Corp., North Kansas City, MO) computerized provider order entry (CPOE) system to support accurate VTE risk assessment and appropriate ordering of prophylaxis.

The VTE Task Force collaborated with QI programmers to develop an electronic tool, the Harborview VTE Tool (Figure 1),[13] that allows for efficient, standardized review of all HA‐VTE at monthly meetings. The tool uses word and phrase search capabilities to identify PEs and DVTs from imaging and vascular studies and links those events with pertinent demographic and clinical data from the EHR in a timeline. Information about VTE risk assigned by physicians in the CPOE system is extracted as well as specific VTE prophylaxis and treatment (drug, dose, timing of administration of medications, reason for doses being held, and orders for and application of mechanical prophylaxis). Using the VTE tool, the task force reviews each VTE event to assess the accuracy of VTE risk assignment, the appropriateness of prophylaxis received relative to guidelines, and the adequacy of VTE treatment and follow‐up. This tool has facilitated our review process, decreasing time from >30 minutes of manual chart review per event to several minutes. In recent months, a quality analyst has prescreened all VTEs prior to task force discussion to further improve efficiency. The tool allows the team to assess the case together and reach consensus regarding VTE prevention.

Figure 1

Prompt event reviews allow the task force to provide timely feedback about specific VTE events to physicians, nurses, and pharmacists. Cases with potential opportunities for improvement are referred to a medical center‐wide QI committee for secondary review. Areas of opportunity identified are tracked and trended to direct ongoing system improvement cycles. In 2014, as a result of reviewing patient cases with VTE diagnosed after discharge, we began a similar review process to assess current practice and standardize prophylaxis across care transitions.

In response to opportunities identified from reviews, the VTE Task Force developed multiple reporting tools that provide real‐time, actionable information to clinicians at the bedside. Daily electronic lists highlight patients who have not received chemical or mechanical prophylaxis in 24 hours and are utilized by nursing, pharmacy, and physician groups. Patients receiving new start vitamin K antagonists or direct oral anticoagulants are identified for pharmacists and discharge care coordinators to support early patient/family education and ensure appropriate follow‐up. Based on input from frontline providers, tools are continually refined to improve their clinical utility. A timeline of initiatives that the Harborview VTE Task Force has championed is outlined in Figure 2.

Figure 2

To bring HA‐VTE prevention information to the point of care, we developed a VTE Prevention/Treatment Summary within the EHR (Figure 3). Information about VTE risk assigned by the physician based on guidelines, current prophylaxis orders (pharmacologic/nonpharmacologic) and administration status, therapeutic anticoagulation and pertinent laboratory values are imported into a summary snapshot that can be accessed on demand by any member of the care team from within the patient's chart. The same data elements are being imbedded in resident physician and nursing handoff tools to highlight VTE prevention for all hospitalized patients and ensure optimal prophylaxis at transitions of care.

Figure 3

To emphasize Harborview's commitment to VTE prevention and ensure that care providers across the institution are aware of and engaged in this effort, we utilize our intranet to disseminate information in a fully transparent manner. Both process and outcome measures are available to all physicians and staff at service and unit levels on a Web‐based institutional dashboard. Data are updated monthly by QI analysts and improvement opportunities are highlighted in multiple fora. Descriptions of the quality metrics that are tracked are summarized in Table 1.

Table 1.Quality Metrics

Quality Metric	Description
NOTE: Abbreviations: AHRQ, Agency for Healthcare Research and Quality; CMS, Centers for Medicare and Medicaid Services; PSI, Patient Safety Indicator; VTE, venous thromboembolism.
AHRQ PSI 12	Cases of VTE not present on admission per 1000 surgical discharges with select operating room procedures
CMS Core Measure VTE‐1	Percent of patients without VTE who received VTE prophylaxis on day of or day after arrival to an acute care area, random sample
CMS Core Measure VTE‐2	Percent of patients without VTE who received VTE prophylaxis on day of or day after arrival to an intensive care unit or surgery date, random sample
CMS Core Measure VTE 5	Percent of patients with hospital acquired VTE discharged to home on warfarin who received education and written discharge instructions
CMS Core Measure VTE‐6	Percent of patients with hospital‐acquired VTE who received VTE prophylaxis prior to the event diagnosis

MEASUREMENTS

RESULTS

Our VTE prevention initiatives have resulted in improved compliance with our institutional guideline‐directed VTE prophylaxis and a decrease in HA‐VTE at our institution.

Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a serious and growing public health problem. In the United States an estimated 900,000 people are affected and more than 100,000 die from VTE or related complications each year. More than half of VTE events occur in association with hospitalization or major surgery; many are thought to be preventable.[1, 2, 3, 4, 5] The Centers for Medicare and Medicaid Services (CMS), Centers for Disease Control and Prevention (CDC), and the Agency for Healthcare Research and Quality (AHRQ),[6, 7, 8, 9] among other organizations, have identified VTE as a potentially preventable never event. Evidence‐based guidelines and resources exist to help support hospital‐acquired venous thromboembolism (HA‐VTE) prevention.[1, 2, 3, 4, 5, 6, 7, 8, 9, 10] Harborview Medical Center, a tertiary referral center with more than 17,000 patients hospitalized annually, many requiring surgery, serves one of the highest‐risk populations for HA‐VTE development. Despite high rates of VTE prophylaxis in accordance with an established institutional guideline,[11, 12] VTE remains the most common hospital‐acquired condition in our institution.

OBJECTIVES

To improve the safety and care of all patients in our medical center and eliminate preventable HA‐VTE events, we set out to: (1) incorporate evidence‐based best practices in VTE prevention and treatment into current practice in alignment with institutional guidelines, (2) standardize the review process for all HA‐VTE events to identify opportunities for improvement, (3) utilize quality improvement (QI) analytics and information technology (IT) to actively improve our processes at the point of care, and (4) share process and outcome performance relating to VTE prevention transparently across our institution

METHODS

To prevent HA‐VTE, we employ a multifactorial strategy that includes designated clinical leadership, active engagement of all care team members, decision support tools embedded in the electronic health record (EHR), QI analytics, and retrospective and prospective reporting that provides ongoing measurement and analysis of the effectiveness of implemented interventions.

Intervention

In 2010, at the request of the Harborview Medical Executive Board and Medical Director, we formed the Harborview VTE Task Force to assess VTE prevention practices across services and identify improvement opportunities for all hospitalized patients. This multidisciplinary team, co‐chaired by a hospitalist and trauma surgeon, includes representatives from trauma/general surgery, orthopedic surgery, hospital medicine, nursing, pharmacy, and QI. Task force members represent critical and acute care as well as the ambulatory setting. Additional stakeholders and local experts including IT directors and analysts, continuity of care nurses, and other clinical service representatives participate on an ad hoc basis.

Since its inception, the VTE Task Force has met monthly to review performance data and develop improvement initiatives. Initially we collaborated with experts across our health system to update an existing institutional VTE prophylaxis guideline to reflect current evidence‐based standards.[1, 3, 4, 5, 12] We met with all clinical services to ensure that the guidelines incorporated departmental best practices. These guidelines were integrated into our Cerner‐based (Cerner Corp., North Kansas City, MO) computerized provider order entry (CPOE) system to support accurate VTE risk assessment and appropriate ordering of prophylaxis.

The VTE Task Force collaborated with QI programmers to develop an electronic tool, the Harborview VTE Tool (Figure 1),[13] that allows for efficient, standardized review of all HA‐VTE at monthly meetings. The tool uses word and phrase search capabilities to identify PEs and DVTs from imaging and vascular studies and links those events with pertinent demographic and clinical data from the EHR in a timeline. Information about VTE risk assigned by physicians in the CPOE system is extracted as well as specific VTE prophylaxis and treatment (drug, dose, timing of administration of medications, reason for doses being held, and orders for and application of mechanical prophylaxis). Using the VTE tool, the task force reviews each VTE event to assess the accuracy of VTE risk assignment, the appropriateness of prophylaxis received relative to guidelines, and the adequacy of VTE treatment and follow‐up. This tool has facilitated our review process, decreasing time from >30 minutes of manual chart review per event to several minutes. In recent months, a quality analyst has prescreened all VTEs prior to task force discussion to further improve efficiency. The tool allows the team to assess the case together and reach consensus regarding VTE prevention.

Figure 1

Prompt event reviews allow the task force to provide timely feedback about specific VTE events to physicians, nurses, and pharmacists. Cases with potential opportunities for improvement are referred to a medical center‐wide QI committee for secondary review. Areas of opportunity identified are tracked and trended to direct ongoing system improvement cycles. In 2014, as a result of reviewing patient cases with VTE diagnosed after discharge, we began a similar review process to assess current practice and standardize prophylaxis across care transitions.

In response to opportunities identified from reviews, the VTE Task Force developed multiple reporting tools that provide real‐time, actionable information to clinicians at the bedside. Daily electronic lists highlight patients who have not received chemical or mechanical prophylaxis in 24 hours and are utilized by nursing, pharmacy, and physician groups. Patients receiving new start vitamin K antagonists or direct oral anticoagulants are identified for pharmacists and discharge care coordinators to support early patient/family education and ensure appropriate follow‐up. Based on input from frontline providers, tools are continually refined to improve their clinical utility. A timeline of initiatives that the Harborview VTE Task Force has championed is outlined in Figure 2.

Figure 2

To bring HA‐VTE prevention information to the point of care, we developed a VTE Prevention/Treatment Summary within the EHR (Figure 3). Information about VTE risk assigned by the physician based on guidelines, current prophylaxis orders (pharmacologic/nonpharmacologic) and administration status, therapeutic anticoagulation and pertinent laboratory values are imported into a summary snapshot that can be accessed on demand by any member of the care team from within the patient's chart. The same data elements are being imbedded in resident physician and nursing handoff tools to highlight VTE prevention for all hospitalized patients and ensure optimal prophylaxis at transitions of care.

Figure 3

To emphasize Harborview's commitment to VTE prevention and ensure that care providers across the institution are aware of and engaged in this effort, we utilize our intranet to disseminate information in a fully transparent manner. Both process and outcome measures are available to all physicians and staff at service and unit levels on a Web‐based institutional dashboard. Data are updated monthly by QI analysts and improvement opportunities are highlighted in multiple fora. Descriptions of the quality metrics that are tracked are summarized in Table 1.

Table 1.Quality Metrics

Quality Metric	Description
NOTE: Abbreviations: AHRQ, Agency for Healthcare Research and Quality; CMS, Centers for Medicare and Medicaid Services; PSI, Patient Safety Indicator; VTE, venous thromboembolism.
AHRQ PSI 12	Cases of VTE not present on admission per 1000 surgical discharges with select operating room procedures
CMS Core Measure VTE‐1	Percent of patients without VTE who received VTE prophylaxis on day of or day after arrival to an acute care area, random sample
CMS Core Measure VTE‐2	Percent of patients without VTE who received VTE prophylaxis on day of or day after arrival to an intensive care unit or surgery date, random sample
CMS Core Measure VTE 5	Percent of patients with hospital acquired VTE discharged to home on warfarin who received education and written discharge instructions
CMS Core Measure VTE‐6	Percent of patients with hospital‐acquired VTE who received VTE prophylaxis prior to the event diagnosis

MEASUREMENTS

RESULTS

Our VTE prevention initiatives have resulted in improved compliance with our institutional guideline‐directed VTE prophylaxis and a decrease in HA‐VTE at our institution.

Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism, is a significant cause of morbidity and mortality in the United States among hospitalized patients.[1, 2, 3, 4, 5, 6] Although it may not be possible to completely eradicate VTE events,[7] chemical and/or mechanical prophylaxis can reduce VTE rates by up to 74% to 86%,[8, 9, 10] and meta‐analyses have demonstrated the benefit of VTE prophylaxis in the inpatient population.[11, 12] Despite evidence‐based guidelines regarding the appropriate type, duration, and dosing of prophylaxis, thromboprophylaxis has been found to be underutilized in the inpatient setting.[13, 14, 15]

Northwestern Memorial Hospital (NMH) historically performed poorly on VTE outcome measures. VTE in the surgical patient population was an especially glaring problem, as NMH was persistently found to be a risk‐adjusted poor performer in the American College of Surgeons National Surgical Quality Improvement Project (ACS‐NSQIP).

However, VTE outcome measures have been shown to be problematic due to their susceptibility to surveillance bias; that is, variation in the ordering of screening or diagnostic VTE imaging studies between hospitals leads to variable VTE rates (the more you look, the more you find).[16, 17, 18, 19] More vigilant hospitals that have a lower threshold to order an imaging study may find higher occurrences of VTE, and paradoxically be deemed a poor performer. Surveillance bias and the lack of validity of the VTE outcome measurement highlighted the importance of utilizing process‐of‐care measures in assessing hospital VTE prevention efforts.[20, 21] Thus, when the Joint Commission enacted 6 new VTE core process‐of‐care measures on January 1, 2013 to monitor hospital performance on VTE prophylaxis administration and VTE treatment (Table 1), NMH undertook a hospital‐wide quality‐improvement (QI) project utilizing the define‐measure‐analyze‐improve‐control (DMAIC) process improvement (PI) methodology to optimize their performance on these core measures as well as the Surgical Care Improvement Project (SCIP) SCIP‐VTE‐2 measure. In this article, we describe the QI effort undertaken at NMH to improve hospital‐level measure performance and the outcomes of this effort.

METHODS

The Intervention

Review of baseline performance on the core measures began in January 2013. Common failure points were identified first by electronic medical record (EMR) evaluation. Subsequently, focus groups with front‐line staff, close examination of EMR ordering logic for chemical and mechanical prophylaxis with the IT department, hospital floor observations, and evaluation of the patient education process during discharge were performed to further define the reasons for common failure points.

Fifteen data‐driven, focused interventions were then designed, pilot tested, and implemented throughout the hospital in May 2013, with iterative improvement of each component over the next 18 months (Table 1). This project utilized DMAIC PI methodology, and was carried out by a multidisciplinary team with representatives from the departments of surgery, internal medicine, anesthesia, gynecology, PI, clinical quality, pharmacy, analytics, information technology (IT), and nursing. Broadly, the 15 interventions consisted of (1) EMR alerts, (2) education initiatives, (3) new EMR order sets, and (4) other EMR changes.

EMR Alerts

Novel provider alerts were built into NMH's inpatient EMR platform (Cerner PowerChart; Cerner Corp., North Kansas City, MO) to address common mistakes contributing to failures on VTE‐1 (chemoprophylaxis) and VTE‐3 (overlap therapy). Although VTE‐1 failures were often multifactorial, missing documentation regarding reasons for no chemoprophylaxis given and failures to order chemoprophylaxis were 2 common drivers of failures. To address these 2 problems, a logic‐driven alert to force patient‐specific ordering of appropriate VTE prophylaxis was developed (Figure 1). VTE‐3 (overlap therapy) failures occurred due to clinician failure to order a full 5 days of overlap therapy when switching from parenteral anticoagulation to warfarin therapy; hence, to target VTE‐3 performance, new alerts reminding clinicians to meticulously order and document the overlap of parenteral VTE therapy and warfarin were developed. As part of the logic‐driven alert to improve patient‐specific ordering of appropriate VTE prophylaxis, we allowed for the inclusion of documentation of a contraindication to explain why VTE prophylaxis was not ordered.

Figure 1

Educational Initiatives

After consulting with attending physicians, residents, nurses, and practice managers at NMH to understand the potential drivers of VTE‐1 (chemoprophylaxis) failures, a team of clinicians and PI experts held 2‐part interactive educational sessions with nurses to address knowledge deficits. The first part focused on general VTE education (eg, the significance of the problem nationwide as well as at NMH, general signs and symptoms of VTE, risk factors for VTE, and NMH‐specific failure rates for mechanical and chemoprophylaxis). The second portion used a myth‐busting approach, in which common misunderstandings that frequently impede VTE prophylaxis (eg, a patient capable of ambulating does not need sequential compression devices (SCDs), or SCDs cannot be applied to a patient with acute or chronic DVT) were discussed. Educational efforts also addressed VTE‐5 (warfarin discharge instructions) performance; although nurses provided patient education with regard to home warfarin use, the timing was inconsistent. The VTE‐5 education provided nurses with a standardized method and time for educating patients about postdischarge warfarin use. EMR changes ensured that when warfarin was ordered, warfarin education automatically populated the nurse's task list, reminding them to educate their patients prior to discharge.

New EMR Order Sets

Previously existing order sets often made it difficult for physicians to order the correct dosing and timing of VTE prophylaxis, document contraindications to prophylaxis, and lacked the appropriate laboratory orders with therapy orders. New order sets were designed to facilitate compliance with VTE‐1 (chemoprophylaxis), VTE‐4 (platelet monitoring), VTE‐5 (warfarin discharge instructions), and SCIP‐VTE‐2 (perioperative prophylaxis) by updating lab and medication order listings, dosing choices, prophylaxis contraindications, reminders to monitor platelet counts per nomogram, and physician follow‐up reasons. When we considered our hospital's specific local factors, we came to the conclusion that risk stratification would be a difficult strategy to apply effectively as a component of the new order sets, mainly due to barriers related to buy‐in from physicians and nurses.

Other EMR Changes

Other interventions targeted at specific issues were programmed into the EMR. For example, a shortcut (known as a dotphrase in Cerner PowerChart) for inserting warfarin instructions into patient care documentation was available to physicians, but was misaligned to the standard warfarin instructions. In addition, the physician responsible for following up on a patient's first outpatient international normalized ratio was often omitted from the discharge instructions, potentially leaving patients without a physician to adjust their dosing appropriately. Adding this physician information, as well as aligning and updating all discharge instructions, allowed for clear, consistent patient instructions for home warfarin use. Moreover, EMR forms used by physicians and forms used by nurses to check for VTE prophylaxis were inconsistent, thus leading to potential confusion between physicians and nurses. Accordingly, regularly used EMR forms (eg, the interdisciplinary plan of care, and the unit summary page or unit snapshot) were updated and standardized.

Control Mechanisms

Concurrent with the implementation of the 15 interventions was the development of several control mechanisms to ensure sustained improvement. These mechanisms consisted of (1) an electronic proxy measure for VTE‐1 (chemoprophylaxis) and (2) monitoring of clinician (including physicians, nurses, and midlevel providers) responses to the EMR alerts, and (3) a comprehensive EMR unit report (Figure 2).

Figure 2

Proxy Measure

Because the Joint Commission core measures are abstracted from only a sample of cases, and a time lag existed between each failure on VTE‐1 (chemoprophylaxis) to the time the QI team learned of the failure, a proxy measure was created. This proxy measure is used as a stand‐in for actual VTE‐1 measure performance, but is generated in real time and reflects performance throughout the entire hospital instead of a random sample of cases. Using the Northwestern Electronic Data Warehouse (EDW), the NMH analytics team created a report reflecting thromboprophylaxis administration on each hospital unit currently and over time. Performance could also be examined for each individual hospital service line. Being able to track longitudinal performance by unit and by service line enabled the QI team to understand trends in performance. Having the ability to examine patients who missed doses over the preceding few hours allowed unit leadership to proactively act upon the failures in a timely fashion, instead of waiting to receive their performance on the Joint Commission core measures.

Physician Alert Response Monitoring

Monitoring of clinical responses to EMR alerts was embedded as standard practice. Because alert fatigue is a documented unintended consequence of heavy reliance on EMR alerts,[24, 25] physicians and nurses who failed to respond to alerts regarding VTE prophylaxis were identified. Interventions targeted toward this group of nonresponders are currently being developed and tested.

EDW Unit Report

This report allows unit managers to track potential failures real time and act prior to a failure occurring (eg, missed chemoprophylaxis dose) through the NMH EDW (Figure 2). These reports contained detailed order and administration data at the individual patient, nurse, and physician levels. Missed doses of VTE chemoprophylaxis were immediately fed back to unit nursing managers who utilized the report to perform a rapid drilldown to identify the root cause(s) of the failure, and then rectify the failure while the patient was still hospitalized.

RESULTS

A total of 1679 cases were abstracted to obtain core measure performance in the time period before the DMAIC intervention phase (January 1, 2013May 1, 2013), and 1424 cases were abstracted to obtain core measure performance in the time period after the DMAIC intervention phase (October 1, 2014April 1, 2015).

Overall NMH performance on measures VTE‐1 (chemoprophylaxis) and VTE36 (overlap therapy, platelet monitoring, warfarin discharge instructions, hospital‐acquired [HA]‐VTE) improved significantly (P < 0.05) (Table 1). No improvement was seen on VTE‐2 (intensive care unit chemoprophylaxis) given that pre‐ and postintervention performance was 100%, which likely reflects previous hospital efforts to improve adherence to this measure. The percentage of patients who failed measure VTE‐6 (number of patients with HA‐VTE who did not have VTE prophylaxis ordered prior to diagnosis of their VTE) decreased from 8% to 2.4%, demonstrating improved VTE prevention prescribing habits in NMH providers rather than a change in VTE event rates (ie, if more patients receive prophylaxis, they cannot be included in the numerator). Performance on SCIP‐VTE‐2 (perioperative chemoprophylaxis) increased from 99.5% to 100% as well but did not reach significance given the baseline high performance.

Measure performance on the general surgery services was comparable to the general medical services, with 1 exception. VTE‐1 (chemoprophylaxis) performance was lower both prior to and following the QI intervention on general medicine services (medicine: 82.5% to 90.2% vs surgery: 94.4% to 97.6%). Recent performance on the VTE‐1 proxy measure has proven to be stable between 95% and 97% on surgery services. Physician response to alerts has increased slightly among the NMH general medicine practitioners (15.2%19.1%) but has been stable among NMH general surgery providers.

DISCUSSION

Our study demonstrates that a formal DMAIC QI project taken on by a multidisciplinary team (including clinicians from multiple specialties as well as personnel from IT, nursing, analytics, and PI) can be successfully implemented and can result in marked improvement in VTE core process measure performance. We used a multifaceted approach undertaken by the NMH VTE QI team, utilizing 15 data‐driven interventions including EMR alerts, education initiatives, and new EMR order sets. These were combined with strong control mechanisms to sustain gains.

Previously published studies on VTE prophylaxis practices found that projects combining both passive (ie, helping clinicians to remember to risk‐assess their patients' for VTE) and active (ie, assisting clinicians in appropriate prescribing practices) strategies are the most successful.[26] Our improvement on VTE‐1 can be compared to previous studies examining changes in ordering rates of VTE prophylaxis. Other QI projects that featured a combination of interventions observed similar significant increases in prophylaxis ordering.[27, 28] Our improvement on VTE‐1 (chemoprophylaxis) was significant, although the difference between pre‐ and postintervention performance varied by service type (general surgery vs general medicine vs other). The small increment of improvement on surgical services was likely attributable to a high baseline performance. Prior to 2013, surgically focused VTE prophylaxis QI efforts spurred by poor ACS‐NSQIP performance proved to be successful, thus resulting in high surgical prophylaxis rates at the outset of the hospital‐wide VTE DMAIC project.

One of the most significant unanticipated barriers to improving performance on VTE‐1 (chemoprophylaxis) included the different hospital subcultures on the medical floors as compared to the surgical floors. The surgical floors had higher rates of compliance with VTE‐1 than the general medicine floors both before and after the QI interventions. When the root causes were explored, the medical floors were found to have different ordering and administration patterns. These, in part, stemmed from differing guidelines[29] and standards in the literature regarding VTE prophylaxis for medical and surgical patients. Multiple discussions within the multidisciplinary QI team and with each involved department were held, focusing on the data regarding safe care in medical patients at low risk for a VTE. Subsequent EMR alerts alterations reflected the internal medicine VTE prophylaxis recommendations for medical patients, allowing that low‐risk patients could be assessed by the provider and given as a reason for foregoing VTE prophylaxis.

Barriers to VTE prophylaxis administration were encountered on the nursing front as well. Floor observations illustrated that chemoprophylaxis injections were often offered as an optional medication. Patients, when given the choice of receiving an injection or not, would understandably choose to forgo their heparin or enoxaparin shot. This missed dose was then documented as a patient refusal. This may not be a problem unique to NMH; 1 study demonstrated that almost 12% of chemoprophylaxis doses may not be administered, and a frequent reason may be due to patient refusal.[30] The lack of patient education regarding the importance of receiving chemical prophylaxis was an improvement opportunity at both the nursing and physician level. Not only did physicians and nurses take the responsibility to educate patients on the importance of receiving the proper prophylaxis, but nursing managers were made responsible for acting on missed doses that were listed on the real‐time performance reports for their units. Missed prophylaxis doses thus became an actionable item instead of an acceptable occurrence.

Culture change in an organization is difficult and necessitates sustained efforts. An important component of our project is our control mechanism, in which a real‐time, continuously updated unit report leverages data from our EDW to generate ongoing performance reports that are regularly reviewed by hospital leadership, clinical process owners, and, most importantly, frontline nurse managers. The unit‐specific reports allow nurse managers and clinical project owners to review prophylaxis failures on a case‐by‐case basis daily and to address and rectify the cause. In addition, the QI team tracks individual physician action taken in response to EMR alerts. As performance feedback to surgical trainees has been demonstrated to have a positive effect on ordering practices,[31] efforts to improve resident alert response rates by means of feedback and education are underway.

CONCLUSION

This institutional project was a large, multidisciplinary, and sustained undertaking that improved our performance on the VTE core measures. We believe that our bundle of EMR modifications, alerts (particularly the underlying alert logics), order sets, and standardization of summary EMR view can be adopted in other settings with appropriate adaptations to each hospital's specific local environment. Our focused educational interventions can also be easily adapted to other hospital settings. Perhaps the most important part of the project was the construction of novel control mechanisms that allow for tracking of physical alert response and for real‐time evaluation, audit, and feedback of prophylaxis ordering and administration practices at NMH. Taken as a whole, this bundle of resources to improve adherence to optimal VTE prophylaxis will facilitate future interventions targeted at reaching defect‐free care.

Disclosures: Nothing to report.

Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism, is a significant cause of morbidity and mortality in the United States among hospitalized patients.[1, 2, 3, 4, 5, 6] Although it may not be possible to completely eradicate VTE events,[7] chemical and/or mechanical prophylaxis can reduce VTE rates by up to 74% to 86%,[8, 9, 10] and meta‐analyses have demonstrated the benefit of VTE prophylaxis in the inpatient population.[11, 12] Despite evidence‐based guidelines regarding the appropriate type, duration, and dosing of prophylaxis, thromboprophylaxis has been found to be underutilized in the inpatient setting.[13, 14, 15]

Northwestern Memorial Hospital (NMH) historically performed poorly on VTE outcome measures. VTE in the surgical patient population was an especially glaring problem, as NMH was persistently found to be a risk‐adjusted poor performer in the American College of Surgeons National Surgical Quality Improvement Project (ACS‐NSQIP).

However, VTE outcome measures have been shown to be problematic due to their susceptibility to surveillance bias; that is, variation in the ordering of screening or diagnostic VTE imaging studies between hospitals leads to variable VTE rates (the more you look, the more you find).[16, 17, 18, 19] More vigilant hospitals that have a lower threshold to order an imaging study may find higher occurrences of VTE, and paradoxically be deemed a poor performer. Surveillance bias and the lack of validity of the VTE outcome measurement highlighted the importance of utilizing process‐of‐care measures in assessing hospital VTE prevention efforts.[20, 21] Thus, when the Joint Commission enacted 6 new VTE core process‐of‐care measures on January 1, 2013 to monitor hospital performance on VTE prophylaxis administration and VTE treatment (Table 1), NMH undertook a hospital‐wide quality‐improvement (QI) project utilizing the define‐measure‐analyze‐improve‐control (DMAIC) process improvement (PI) methodology to optimize their performance on these core measures as well as the Surgical Care Improvement Project (SCIP) SCIP‐VTE‐2 measure. In this article, we describe the QI effort undertaken at NMH to improve hospital‐level measure performance and the outcomes of this effort.

METHODS

The Intervention

Review of baseline performance on the core measures began in January 2013. Common failure points were identified first by electronic medical record (EMR) evaluation. Subsequently, focus groups with front‐line staff, close examination of EMR ordering logic for chemical and mechanical prophylaxis with the IT department, hospital floor observations, and evaluation of the patient education process during discharge were performed to further define the reasons for common failure points.

Fifteen data‐driven, focused interventions were then designed, pilot tested, and implemented throughout the hospital in May 2013, with iterative improvement of each component over the next 18 months (Table 1). This project utilized DMAIC PI methodology, and was carried out by a multidisciplinary team with representatives from the departments of surgery, internal medicine, anesthesia, gynecology, PI, clinical quality, pharmacy, analytics, information technology (IT), and nursing. Broadly, the 15 interventions consisted of (1) EMR alerts, (2) education initiatives, (3) new EMR order sets, and (4) other EMR changes.

EMR Alerts

Novel provider alerts were built into NMH's inpatient EMR platform (Cerner PowerChart; Cerner Corp., North Kansas City, MO) to address common mistakes contributing to failures on VTE‐1 (chemoprophylaxis) and VTE‐3 (overlap therapy). Although VTE‐1 failures were often multifactorial, missing documentation regarding reasons for no chemoprophylaxis given and failures to order chemoprophylaxis were 2 common drivers of failures. To address these 2 problems, a logic‐driven alert to force patient‐specific ordering of appropriate VTE prophylaxis was developed (Figure 1). VTE‐3 (overlap therapy) failures occurred due to clinician failure to order a full 5 days of overlap therapy when switching from parenteral anticoagulation to warfarin therapy; hence, to target VTE‐3 performance, new alerts reminding clinicians to meticulously order and document the overlap of parenteral VTE therapy and warfarin were developed. As part of the logic‐driven alert to improve patient‐specific ordering of appropriate VTE prophylaxis, we allowed for the inclusion of documentation of a contraindication to explain why VTE prophylaxis was not ordered.

Figure 1

Educational Initiatives

After consulting with attending physicians, residents, nurses, and practice managers at NMH to understand the potential drivers of VTE‐1 (chemoprophylaxis) failures, a team of clinicians and PI experts held 2‐part interactive educational sessions with nurses to address knowledge deficits. The first part focused on general VTE education (eg, the significance of the problem nationwide as well as at NMH, general signs and symptoms of VTE, risk factors for VTE, and NMH‐specific failure rates for mechanical and chemoprophylaxis). The second portion used a myth‐busting approach, in which common misunderstandings that frequently impede VTE prophylaxis (eg, a patient capable of ambulating does not need sequential compression devices (SCDs), or SCDs cannot be applied to a patient with acute or chronic DVT) were discussed. Educational efforts also addressed VTE‐5 (warfarin discharge instructions) performance; although nurses provided patient education with regard to home warfarin use, the timing was inconsistent. The VTE‐5 education provided nurses with a standardized method and time for educating patients about postdischarge warfarin use. EMR changes ensured that when warfarin was ordered, warfarin education automatically populated the nurse's task list, reminding them to educate their patients prior to discharge.

New EMR Order Sets

Previously existing order sets often made it difficult for physicians to order the correct dosing and timing of VTE prophylaxis, document contraindications to prophylaxis, and lacked the appropriate laboratory orders with therapy orders. New order sets were designed to facilitate compliance with VTE‐1 (chemoprophylaxis), VTE‐4 (platelet monitoring), VTE‐5 (warfarin discharge instructions), and SCIP‐VTE‐2 (perioperative prophylaxis) by updating lab and medication order listings, dosing choices, prophylaxis contraindications, reminders to monitor platelet counts per nomogram, and physician follow‐up reasons. When we considered our hospital's specific local factors, we came to the conclusion that risk stratification would be a difficult strategy to apply effectively as a component of the new order sets, mainly due to barriers related to buy‐in from physicians and nurses.

Other EMR Changes

Other interventions targeted at specific issues were programmed into the EMR. For example, a shortcut (known as a dotphrase in Cerner PowerChart) for inserting warfarin instructions into patient care documentation was available to physicians, but was misaligned to the standard warfarin instructions. In addition, the physician responsible for following up on a patient's first outpatient international normalized ratio was often omitted from the discharge instructions, potentially leaving patients without a physician to adjust their dosing appropriately. Adding this physician information, as well as aligning and updating all discharge instructions, allowed for clear, consistent patient instructions for home warfarin use. Moreover, EMR forms used by physicians and forms used by nurses to check for VTE prophylaxis were inconsistent, thus leading to potential confusion between physicians and nurses. Accordingly, regularly used EMR forms (eg, the interdisciplinary plan of care, and the unit summary page or unit snapshot) were updated and standardized.

Control Mechanisms

Concurrent with the implementation of the 15 interventions was the development of several control mechanisms to ensure sustained improvement. These mechanisms consisted of (1) an electronic proxy measure for VTE‐1 (chemoprophylaxis) and (2) monitoring of clinician (including physicians, nurses, and midlevel providers) responses to the EMR alerts, and (3) a comprehensive EMR unit report (Figure 2).

Figure 2

Proxy Measure

Because the Joint Commission core measures are abstracted from only a sample of cases, and a time lag existed between each failure on VTE‐1 (chemoprophylaxis) to the time the QI team learned of the failure, a proxy measure was created. This proxy measure is used as a stand‐in for actual VTE‐1 measure performance, but is generated in real time and reflects performance throughout the entire hospital instead of a random sample of cases. Using the Northwestern Electronic Data Warehouse (EDW), the NMH analytics team created a report reflecting thromboprophylaxis administration on each hospital unit currently and over time. Performance could also be examined for each individual hospital service line. Being able to track longitudinal performance by unit and by service line enabled the QI team to understand trends in performance. Having the ability to examine patients who missed doses over the preceding few hours allowed unit leadership to proactively act upon the failures in a timely fashion, instead of waiting to receive their performance on the Joint Commission core measures.

Physician Alert Response Monitoring

Monitoring of clinical responses to EMR alerts was embedded as standard practice. Because alert fatigue is a documented unintended consequence of heavy reliance on EMR alerts,[24, 25] physicians and nurses who failed to respond to alerts regarding VTE prophylaxis were identified. Interventions targeted toward this group of nonresponders are currently being developed and tested.

EDW Unit Report

This report allows unit managers to track potential failures real time and act prior to a failure occurring (eg, missed chemoprophylaxis dose) through the NMH EDW (Figure 2). These reports contained detailed order and administration data at the individual patient, nurse, and physician levels. Missed doses of VTE chemoprophylaxis were immediately fed back to unit nursing managers who utilized the report to perform a rapid drilldown to identify the root cause(s) of the failure, and then rectify the failure while the patient was still hospitalized.

RESULTS

A total of 1679 cases were abstracted to obtain core measure performance in the time period before the DMAIC intervention phase (January 1, 2013May 1, 2013), and 1424 cases were abstracted to obtain core measure performance in the time period after the DMAIC intervention phase (October 1, 2014April 1, 2015).

Overall NMH performance on measures VTE‐1 (chemoprophylaxis) and VTE36 (overlap therapy, platelet monitoring, warfarin discharge instructions, hospital‐acquired [HA]‐VTE) improved significantly (P < 0.05) (Table 1). No improvement was seen on VTE‐2 (intensive care unit chemoprophylaxis) given that pre‐ and postintervention performance was 100%, which likely reflects previous hospital efforts to improve adherence to this measure. The percentage of patients who failed measure VTE‐6 (number of patients with HA‐VTE who did not have VTE prophylaxis ordered prior to diagnosis of their VTE) decreased from 8% to 2.4%, demonstrating improved VTE prevention prescribing habits in NMH providers rather than a change in VTE event rates (ie, if more patients receive prophylaxis, they cannot be included in the numerator). Performance on SCIP‐VTE‐2 (perioperative chemoprophylaxis) increased from 99.5% to 100% as well but did not reach significance given the baseline high performance.

Measure performance on the general surgery services was comparable to the general medical services, with 1 exception. VTE‐1 (chemoprophylaxis) performance was lower both prior to and following the QI intervention on general medicine services (medicine: 82.5% to 90.2% vs surgery: 94.4% to 97.6%). Recent performance on the VTE‐1 proxy measure has proven to be stable between 95% and 97% on surgery services. Physician response to alerts has increased slightly among the NMH general medicine practitioners (15.2%19.1%) but has been stable among NMH general surgery providers.

DISCUSSION

Our study demonstrates that a formal DMAIC QI project taken on by a multidisciplinary team (including clinicians from multiple specialties as well as personnel from IT, nursing, analytics, and PI) can be successfully implemented and can result in marked improvement in VTE core process measure performance. We used a multifaceted approach undertaken by the NMH VTE QI team, utilizing 15 data‐driven interventions including EMR alerts, education initiatives, and new EMR order sets. These were combined with strong control mechanisms to sustain gains.

Previously published studies on VTE prophylaxis practices found that projects combining both passive (ie, helping clinicians to remember to risk‐assess their patients' for VTE) and active (ie, assisting clinicians in appropriate prescribing practices) strategies are the most successful.[26] Our improvement on VTE‐1 can be compared to previous studies examining changes in ordering rates of VTE prophylaxis. Other QI projects that featured a combination of interventions observed similar significant increases in prophylaxis ordering.[27, 28] Our improvement on VTE‐1 (chemoprophylaxis) was significant, although the difference between pre‐ and postintervention performance varied by service type (general surgery vs general medicine vs other). The small increment of improvement on surgical services was likely attributable to a high baseline performance. Prior to 2013, surgically focused VTE prophylaxis QI efforts spurred by poor ACS‐NSQIP performance proved to be successful, thus resulting in high surgical prophylaxis rates at the outset of the hospital‐wide VTE DMAIC project.

One of the most significant unanticipated barriers to improving performance on VTE‐1 (chemoprophylaxis) included the different hospital subcultures on the medical floors as compared to the surgical floors. The surgical floors had higher rates of compliance with VTE‐1 than the general medicine floors both before and after the QI interventions. When the root causes were explored, the medical floors were found to have different ordering and administration patterns. These, in part, stemmed from differing guidelines[29] and standards in the literature regarding VTE prophylaxis for medical and surgical patients. Multiple discussions within the multidisciplinary QI team and with each involved department were held, focusing on the data regarding safe care in medical patients at low risk for a VTE. Subsequent EMR alerts alterations reflected the internal medicine VTE prophylaxis recommendations for medical patients, allowing that low‐risk patients could be assessed by the provider and given as a reason for foregoing VTE prophylaxis.

Barriers to VTE prophylaxis administration were encountered on the nursing front as well. Floor observations illustrated that chemoprophylaxis injections were often offered as an optional medication. Patients, when given the choice of receiving an injection or not, would understandably choose to forgo their heparin or enoxaparin shot. This missed dose was then documented as a patient refusal. This may not be a problem unique to NMH; 1 study demonstrated that almost 12% of chemoprophylaxis doses may not be administered, and a frequent reason may be due to patient refusal.[30] The lack of patient education regarding the importance of receiving chemical prophylaxis was an improvement opportunity at both the nursing and physician level. Not only did physicians and nurses take the responsibility to educate patients on the importance of receiving the proper prophylaxis, but nursing managers were made responsible for acting on missed doses that were listed on the real‐time performance reports for their units. Missed prophylaxis doses thus became an actionable item instead of an acceptable occurrence.

Culture change in an organization is difficult and necessitates sustained efforts. An important component of our project is our control mechanism, in which a real‐time, continuously updated unit report leverages data from our EDW to generate ongoing performance reports that are regularly reviewed by hospital leadership, clinical process owners, and, most importantly, frontline nurse managers. The unit‐specific reports allow nurse managers and clinical project owners to review prophylaxis failures on a case‐by‐case basis daily and to address and rectify the cause. In addition, the QI team tracks individual physician action taken in response to EMR alerts. As performance feedback to surgical trainees has been demonstrated to have a positive effect on ordering practices,[31] efforts to improve resident alert response rates by means of feedback and education are underway.

CONCLUSION

This institutional project was a large, multidisciplinary, and sustained undertaking that improved our performance on the VTE core measures. We believe that our bundle of EMR modifications, alerts (particularly the underlying alert logics), order sets, and standardization of summary EMR view can be adopted in other settings with appropriate adaptations to each hospital's specific local environment. Our focused educational interventions can also be easily adapted to other hospital settings. Perhaps the most important part of the project was the construction of novel control mechanisms that allow for tracking of physical alert response and for real‐time evaluation, audit, and feedback of prophylaxis ordering and administration practices at NMH. Taken as a whole, this bundle of resources to improve adherence to optimal VTE prophylaxis will facilitate future interventions targeted at reaching defect‐free care.

Disclosures: Nothing to report.

Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism, is a significant cause of morbidity and mortality in the United States among hospitalized patients.[1, 2, 3, 4, 5, 6] Although it may not be possible to completely eradicate VTE events,[7] chemical and/or mechanical prophylaxis can reduce VTE rates by up to 74% to 86%,[8, 9, 10] and meta‐analyses have demonstrated the benefit of VTE prophylaxis in the inpatient population.[11, 12] Despite evidence‐based guidelines regarding the appropriate type, duration, and dosing of prophylaxis, thromboprophylaxis has been found to be underutilized in the inpatient setting.[13, 14, 15]

Northwestern Memorial Hospital (NMH) historically performed poorly on VTE outcome measures. VTE in the surgical patient population was an especially glaring problem, as NMH was persistently found to be a risk‐adjusted poor performer in the American College of Surgeons National Surgical Quality Improvement Project (ACS‐NSQIP).

However, VTE outcome measures have been shown to be problematic due to their susceptibility to surveillance bias; that is, variation in the ordering of screening or diagnostic VTE imaging studies between hospitals leads to variable VTE rates (the more you look, the more you find).[16, 17, 18, 19] More vigilant hospitals that have a lower threshold to order an imaging study may find higher occurrences of VTE, and paradoxically be deemed a poor performer. Surveillance bias and the lack of validity of the VTE outcome measurement highlighted the importance of utilizing process‐of‐care measures in assessing hospital VTE prevention efforts.[20, 21] Thus, when the Joint Commission enacted 6 new VTE core process‐of‐care measures on January 1, 2013 to monitor hospital performance on VTE prophylaxis administration and VTE treatment (Table 1), NMH undertook a hospital‐wide quality‐improvement (QI) project utilizing the define‐measure‐analyze‐improve‐control (DMAIC) process improvement (PI) methodology to optimize their performance on these core measures as well as the Surgical Care Improvement Project (SCIP) SCIP‐VTE‐2 measure. In this article, we describe the QI effort undertaken at NMH to improve hospital‐level measure performance and the outcomes of this effort.

METHODS

The Intervention

Review of baseline performance on the core measures began in January 2013. Common failure points were identified first by electronic medical record (EMR) evaluation. Subsequently, focus groups with front‐line staff, close examination of EMR ordering logic for chemical and mechanical prophylaxis with the IT department, hospital floor observations, and evaluation of the patient education process during discharge were performed to further define the reasons for common failure points.

Fifteen data‐driven, focused interventions were then designed, pilot tested, and implemented throughout the hospital in May 2013, with iterative improvement of each component over the next 18 months (Table 1). This project utilized DMAIC PI methodology, and was carried out by a multidisciplinary team with representatives from the departments of surgery, internal medicine, anesthesia, gynecology, PI, clinical quality, pharmacy, analytics, information technology (IT), and nursing. Broadly, the 15 interventions consisted of (1) EMR alerts, (2) education initiatives, (3) new EMR order sets, and (4) other EMR changes.

EMR Alerts

Novel provider alerts were built into NMH's inpatient EMR platform (Cerner PowerChart; Cerner Corp., North Kansas City, MO) to address common mistakes contributing to failures on VTE‐1 (chemoprophylaxis) and VTE‐3 (overlap therapy). Although VTE‐1 failures were often multifactorial, missing documentation regarding reasons for no chemoprophylaxis given and failures to order chemoprophylaxis were 2 common drivers of failures. To address these 2 problems, a logic‐driven alert to force patient‐specific ordering of appropriate VTE prophylaxis was developed (Figure 1). VTE‐3 (overlap therapy) failures occurred due to clinician failure to order a full 5 days of overlap therapy when switching from parenteral anticoagulation to warfarin therapy; hence, to target VTE‐3 performance, new alerts reminding clinicians to meticulously order and document the overlap of parenteral VTE therapy and warfarin were developed. As part of the logic‐driven alert to improve patient‐specific ordering of appropriate VTE prophylaxis, we allowed for the inclusion of documentation of a contraindication to explain why VTE prophylaxis was not ordered.

Figure 1

Educational Initiatives

After consulting with attending physicians, residents, nurses, and practice managers at NMH to understand the potential drivers of VTE‐1 (chemoprophylaxis) failures, a team of clinicians and PI experts held 2‐part interactive educational sessions with nurses to address knowledge deficits. The first part focused on general VTE education (eg, the significance of the problem nationwide as well as at NMH, general signs and symptoms of VTE, risk factors for VTE, and NMH‐specific failure rates for mechanical and chemoprophylaxis). The second portion used a myth‐busting approach, in which common misunderstandings that frequently impede VTE prophylaxis (eg, a patient capable of ambulating does not need sequential compression devices (SCDs), or SCDs cannot be applied to a patient with acute or chronic DVT) were discussed. Educational efforts also addressed VTE‐5 (warfarin discharge instructions) performance; although nurses provided patient education with regard to home warfarin use, the timing was inconsistent. The VTE‐5 education provided nurses with a standardized method and time for educating patients about postdischarge warfarin use. EMR changes ensured that when warfarin was ordered, warfarin education automatically populated the nurse's task list, reminding them to educate their patients prior to discharge.

New EMR Order Sets

Previously existing order sets often made it difficult for physicians to order the correct dosing and timing of VTE prophylaxis, document contraindications to prophylaxis, and lacked the appropriate laboratory orders with therapy orders. New order sets were designed to facilitate compliance with VTE‐1 (chemoprophylaxis), VTE‐4 (platelet monitoring), VTE‐5 (warfarin discharge instructions), and SCIP‐VTE‐2 (perioperative prophylaxis) by updating lab and medication order listings, dosing choices, prophylaxis contraindications, reminders to monitor platelet counts per nomogram, and physician follow‐up reasons. When we considered our hospital's specific local factors, we came to the conclusion that risk stratification would be a difficult strategy to apply effectively as a component of the new order sets, mainly due to barriers related to buy‐in from physicians and nurses.

Other EMR Changes

Other interventions targeted at specific issues were programmed into the EMR. For example, a shortcut (known as a dotphrase in Cerner PowerChart) for inserting warfarin instructions into patient care documentation was available to physicians, but was misaligned to the standard warfarin instructions. In addition, the physician responsible for following up on a patient's first outpatient international normalized ratio was often omitted from the discharge instructions, potentially leaving patients without a physician to adjust their dosing appropriately. Adding this physician information, as well as aligning and updating all discharge instructions, allowed for clear, consistent patient instructions for home warfarin use. Moreover, EMR forms used by physicians and forms used by nurses to check for VTE prophylaxis were inconsistent, thus leading to potential confusion between physicians and nurses. Accordingly, regularly used EMR forms (eg, the interdisciplinary plan of care, and the unit summary page or unit snapshot) were updated and standardized.

Control Mechanisms

Concurrent with the implementation of the 15 interventions was the development of several control mechanisms to ensure sustained improvement. These mechanisms consisted of (1) an electronic proxy measure for VTE‐1 (chemoprophylaxis) and (2) monitoring of clinician (including physicians, nurses, and midlevel providers) responses to the EMR alerts, and (3) a comprehensive EMR unit report (Figure 2).

Figure 2

Proxy Measure

Because the Joint Commission core measures are abstracted from only a sample of cases, and a time lag existed between each failure on VTE‐1 (chemoprophylaxis) to the time the QI team learned of the failure, a proxy measure was created. This proxy measure is used as a stand‐in for actual VTE‐1 measure performance, but is generated in real time and reflects performance throughout the entire hospital instead of a random sample of cases. Using the Northwestern Electronic Data Warehouse (EDW), the NMH analytics team created a report reflecting thromboprophylaxis administration on each hospital unit currently and over time. Performance could also be examined for each individual hospital service line. Being able to track longitudinal performance by unit and by service line enabled the QI team to understand trends in performance. Having the ability to examine patients who missed doses over the preceding few hours allowed unit leadership to proactively act upon the failures in a timely fashion, instead of waiting to receive their performance on the Joint Commission core measures.

Physician Alert Response Monitoring

Monitoring of clinical responses to EMR alerts was embedded as standard practice. Because alert fatigue is a documented unintended consequence of heavy reliance on EMR alerts,[24, 25] physicians and nurses who failed to respond to alerts regarding VTE prophylaxis were identified. Interventions targeted toward this group of nonresponders are currently being developed and tested.

EDW Unit Report

This report allows unit managers to track potential failures real time and act prior to a failure occurring (eg, missed chemoprophylaxis dose) through the NMH EDW (Figure 2). These reports contained detailed order and administration data at the individual patient, nurse, and physician levels. Missed doses of VTE chemoprophylaxis were immediately fed back to unit nursing managers who utilized the report to perform a rapid drilldown to identify the root cause(s) of the failure, and then rectify the failure while the patient was still hospitalized.

RESULTS

A total of 1679 cases were abstracted to obtain core measure performance in the time period before the DMAIC intervention phase (January 1, 2013May 1, 2013), and 1424 cases were abstracted to obtain core measure performance in the time period after the DMAIC intervention phase (October 1, 2014April 1, 2015).

Overall NMH performance on measures VTE‐1 (chemoprophylaxis) and VTE36 (overlap therapy, platelet monitoring, warfarin discharge instructions, hospital‐acquired [HA]‐VTE) improved significantly (P < 0.05) (Table 1). No improvement was seen on VTE‐2 (intensive care unit chemoprophylaxis) given that pre‐ and postintervention performance was 100%, which likely reflects previous hospital efforts to improve adherence to this measure. The percentage of patients who failed measure VTE‐6 (number of patients with HA‐VTE who did not have VTE prophylaxis ordered prior to diagnosis of their VTE) decreased from 8% to 2.4%, demonstrating improved VTE prevention prescribing habits in NMH providers rather than a change in VTE event rates (ie, if more patients receive prophylaxis, they cannot be included in the numerator). Performance on SCIP‐VTE‐2 (perioperative chemoprophylaxis) increased from 99.5% to 100% as well but did not reach significance given the baseline high performance.

Measure performance on the general surgery services was comparable to the general medical services, with 1 exception. VTE‐1 (chemoprophylaxis) performance was lower both prior to and following the QI intervention on general medicine services (medicine: 82.5% to 90.2% vs surgery: 94.4% to 97.6%). Recent performance on the VTE‐1 proxy measure has proven to be stable between 95% and 97% on surgery services. Physician response to alerts has increased slightly among the NMH general medicine practitioners (15.2%19.1%) but has been stable among NMH general surgery providers.

DISCUSSION

Our study demonstrates that a formal DMAIC QI project taken on by a multidisciplinary team (including clinicians from multiple specialties as well as personnel from IT, nursing, analytics, and PI) can be successfully implemented and can result in marked improvement in VTE core process measure performance. We used a multifaceted approach undertaken by the NMH VTE QI team, utilizing 15 data‐driven interventions including EMR alerts, education initiatives, and new EMR order sets. These were combined with strong control mechanisms to sustain gains.

Previously published studies on VTE prophylaxis practices found that projects combining both passive (ie, helping clinicians to remember to risk‐assess their patients' for VTE) and active (ie, assisting clinicians in appropriate prescribing practices) strategies are the most successful.[26] Our improvement on VTE‐1 can be compared to previous studies examining changes in ordering rates of VTE prophylaxis. Other QI projects that featured a combination of interventions observed similar significant increases in prophylaxis ordering.[27, 28] Our improvement on VTE‐1 (chemoprophylaxis) was significant, although the difference between pre‐ and postintervention performance varied by service type (general surgery vs general medicine vs other). The small increment of improvement on surgical services was likely attributable to a high baseline performance. Prior to 2013, surgically focused VTE prophylaxis QI efforts spurred by poor ACS‐NSQIP performance proved to be successful, thus resulting in high surgical prophylaxis rates at the outset of the hospital‐wide VTE DMAIC project.

One of the most significant unanticipated barriers to improving performance on VTE‐1 (chemoprophylaxis) included the different hospital subcultures on the medical floors as compared to the surgical floors. The surgical floors had higher rates of compliance with VTE‐1 than the general medicine floors both before and after the QI interventions. When the root causes were explored, the medical floors were found to have different ordering and administration patterns. These, in part, stemmed from differing guidelines[29] and standards in the literature regarding VTE prophylaxis for medical and surgical patients. Multiple discussions within the multidisciplinary QI team and with each involved department were held, focusing on the data regarding safe care in medical patients at low risk for a VTE. Subsequent EMR alerts alterations reflected the internal medicine VTE prophylaxis recommendations for medical patients, allowing that low‐risk patients could be assessed by the provider and given as a reason for foregoing VTE prophylaxis.

Barriers to VTE prophylaxis administration were encountered on the nursing front as well. Floor observations illustrated that chemoprophylaxis injections were often offered as an optional medication. Patients, when given the choice of receiving an injection or not, would understandably choose to forgo their heparin or enoxaparin shot. This missed dose was then documented as a patient refusal. This may not be a problem unique to NMH; 1 study demonstrated that almost 12% of chemoprophylaxis doses may not be administered, and a frequent reason may be due to patient refusal.[30] The lack of patient education regarding the importance of receiving chemical prophylaxis was an improvement opportunity at both the nursing and physician level. Not only did physicians and nurses take the responsibility to educate patients on the importance of receiving the proper prophylaxis, but nursing managers were made responsible for acting on missed doses that were listed on the real‐time performance reports for their units. Missed prophylaxis doses thus became an actionable item instead of an acceptable occurrence.

Culture change in an organization is difficult and necessitates sustained efforts. An important component of our project is our control mechanism, in which a real‐time, continuously updated unit report leverages data from our EDW to generate ongoing performance reports that are regularly reviewed by hospital leadership, clinical process owners, and, most importantly, frontline nurse managers. The unit‐specific reports allow nurse managers and clinical project owners to review prophylaxis failures on a case‐by‐case basis daily and to address and rectify the cause. In addition, the QI team tracks individual physician action taken in response to EMR alerts. As performance feedback to surgical trainees has been demonstrated to have a positive effect on ordering practices,[31] efforts to improve resident alert response rates by means of feedback and education are underway.

CONCLUSION

This institutional project was a large, multidisciplinary, and sustained undertaking that improved our performance on the VTE core measures. We believe that our bundle of EMR modifications, alerts (particularly the underlying alert logics), order sets, and standardization of summary EMR view can be adopted in other settings with appropriate adaptations to each hospital's specific local environment. Our focused educational interventions can also be easily adapted to other hospital settings. Perhaps the most important part of the project was the construction of novel control mechanisms that allow for tracking of physical alert response and for real‐time evaluation, audit, and feedback of prophylaxis ordering and administration practices at NMH. Taken as a whole, this bundle of resources to improve adherence to optimal VTE prophylaxis will facilitate future interventions targeted at reaching defect‐free care.

Disclosures: Nothing to report.

Venous thromboembolism (VTE), comprised of pulmonary embolism (PE) and deep vein thrombosis (DVT), impacts hundreds of thousands of Americans annually.[1] The complications of VTE can be severe, including the post‐thrombotic syndrome, pulmonary hypertension, and complications of anticoagulation. VTE is often a complication of hospitalization, and PE is a common preventable cause of hospital mortality.[2, 3] Pharmacologic VTE prophylaxis (VTEP) in at‐risk patients is effective and endorsed by prominent guidelines.[4, 5, 6] However, VTEP is underutilized, with only 30% to 50% of eligible patients receiving the right drug, dose, and duration.[7, 8]

Public reporting and reimbursement policies reflect the magnitude of VTE as a public health concern. The Centers for Medicare and Medicaid Services (CMS) withholds incremental payment for VTE complications.[9] The rate of hospital‐associated VTE (HA‐VTE) is used by benchmarking organizations as a quality indicator.[10, 11]

The University of California (UC) has 5 major academic medical centers, located in Irvine (UCI), Los Angeles (UCLA), Sacramento (UC Davis [UCD]), San Diego (UCSD), and San Francisco (UCSF). In both 2010 and 2011, almost 700 UC patients suffered from HA‐VTE annually. Barriers to optimal VTEP included the absence of standardized VTE risk assessment, lack of consensus on appropriate VTEP options for various inpatient populations, and a lack of collaborative infrastructure. Other barriers included poor adherence to mechanical prophylaxis and suboptimal measurement of prophylaxis and HA‐VTE outcomes.

In late 2011, leaders from the 5 medical centers, supported by an internal competitive grant from the UC Office of the President and the Center for Health Quality and Innovation, formed a collaborative to address barriers, optimize VTEP in inpatients, and reduce HA‐VTE across the system. Prior efforts at UCSD illustrated single‐center improvement, with an increase in adequate VTEP from 50% to over 95%, and a nearly 40% reduction in the incidence of HA‐VTE.[12] We set out to scale this success across all 5 sites as a coordinated collaborative.

METHODS

This was a prospective, unblinded, open‐intervention study with historical controls that assessed prespecified outcomes before, during, and after institution of multiple VTEP strategies in 5 independent, but cooperating, academic hospitals. All adult medical and surgical inpatients were included; psychiatric, obstetricsgynecology, rehabilitation, observation status, and pediatric populations were excluded. The study period was July 1, 2012 through June 30, 2015. Calendar year (CY) 2011 was the baseline year for comparison; interventions were initiated in CY 2012 to CY 2014, and CY 2014 was considered the mature postintervention period.

RESULTS

Robust sampling (421 to 728 patients at each site) revealed attainment of high rates of adequate VTE prophylaxis (82% to 96% at all sites, collectively 89%) by early 2014. Common measures for adequate VTEP were not finalized and collected by all sites until early 2013, so we did not capture baseline VTEP rates, and could not compare baseline to mature prophylaxis rates. Reliable administration of mechanical and anticoagulant prophylaxis was monitored and targeted by each institution, albeit not in an identical fashion at each site. Adherence to mechanical prophylaxis was reported as improved at the sites, but these data were not collated and analyzed centrally.

Hospital‐Associated VTE

There were 2431 HA‐VTE events observed in 306,906 adult inpatients across CY 2011 to 2014 (Table 1). The baseline incidence of HA‐VTE was 0.90% (667 events in 73,941 hospitalizations in 2011). The incidence of HA‐VTE in the postintervention period was 0.69% (546 HA‐VTE events in 79,565 hospitalizations in 2014, P < 0.001), an overall reduction of 24%. The absolute risk for PE decreased from 0.49% to 0.39% (RR: 0.79, 95% CI: 0.68‐0.92), a reduction of 21%, and the absolute risk of leg DVT fell from 0.41% to 0.30% (RR: 0.73, 95% CI: 0.61‐0.86), a reduction of 27%. Both proximal and distal DVT were reduced significantly. Proximal DVT was much more commonly diagnosed than distal DVT. Proximal DVT incidence decreased from 0.32% to 0.25% (RR: 0.77, 95% CI: 0.64‐0.93), whereas distal DVT incidence decreased from 0.09% to 0.05% (RR: 0.58, 95% CI: 0.39‐0.86). The lower overall VTE rate in the postimplementation period compared with the baseline period corresponds to an estimated 170 fewer cases of VTE per year (89 DVT, 81 PE).

Table 1.Pulmonary and Deep Vein Thrombosis Rates Calendar Years 2011 to 2014

	2011 (Baseline), No./%	2012, No./%	2013, No./%	2014 (Mature), No./%	2014 Versus 2011 Relative Risk (95% CI)	2014 Versus 2011 Estimated Averted Events (95% CI)
NOTE: All adult Inpatients (with and without cancer diagnosis), discharged from all University of California Hospitals are included. The impact of improvement efforts was highest in the surgical population. See text for additional detail on proximal versus distal DVT. Abbreviations: CI, confidence interval; DVT, deep vein thrombosis; PE, pulmonary embolism.
Total discharges (medical and surgical)	73,941	76,100	77,300	79,565
Total PE + leg DVT	667/0.90%	650/0.85%	568/0.73%	546/0.69%	0.761 (0.680‐0.852)	170 (103‐247)
Total PE	363/0.49%	359/0.47%	340/0.44%	309/0.39%	0.791 (0.680‐0.920)	81 (32‐135)
Total leg DVT	304/0.41%	291/0.38%	228/0.29%	237/0.3%	0.725 (0.612‐0.858)	89(40‐135)
Medical discharges	31,219	32,597	33,805	34,875
Total PE + leg DVT	178/0.57%	168/0.52%	164/0.49%	179/0.51%	0.900 (0.732‐1.1071)
PE	110/0.35%	94/0.29%	106/0.31%	104/0.30%	0.846 (0.648‐1.106)
Leg DVT	68/0.22%	74/0.23%	58/0.17%	75/0.22%	0.987 (0.711‐1.371)
Surgical discharges	42,722	43,503	43,495	44,690
Total PE + leg DVT	489/1.14%	482/1.11%	404/0.93%	367/0.82%	0.718 (0.627‐0.821)
PE	253/0.59%	265/0.61%	234/0.54%	205/0.46%	0.775 (0.645‐0.931)
Leg DVT	236/0.55%	217/0.50%	180/0.41%	162/0.36%	0.656 (0.538‐0.801)

The baseline rate of HA‐VTE and degree of improvement varied between institutions (Figure 1). UCI and UCD began the study with significantly higher VTE rates, and enjoyed the largest improvements. UCLA's VTE rate decreased to a lesser extent, whereas UCSD and UCSF rates remained relatively flat or were marginally higher. In contrast to the highly variable 2011 baseline rate of HA‐VTE (0.60%1.36%), all 5 sites had HA‐VTE rates within a very narrow range (0.65%0.73%) at maturity in 2014.

Figure 1

Cancer Versus Noncancer Patients

The incidence of HA‐VTE was higher in cancer patients than in noncancer patients. In 2011, 227 of 18,487 (1.23%) cancer patients developed VTE, versus 440 of 55,454 (0.79%) noncancer patients (Figure 2). After implementation of the VTE prevention initiative, the incidence of VTE in cancer patients fell by 0.21% (210 events in 20,544 patients in 2014, 1.02%), and the incidence of VTE in noncancer patients fell by 0.22% (336 events in 59,021 patients, 0.57%). The relative risk of HA‐VTE after the VTE interventions was reduced by 17% (RR: 0.83, 95% CI: 0.69‐1.00) in cancer patients and 28% (RR: 0.72, 95% CI: 0.62‐0.83) in noncancer patients.

Figure 2

DISCUSSION

Our initiative, comprised of a collaborative infrastructure, a proven quality‐improvement framework, and a bundle of interventions, was associated with a 24% reduction in the risk of HA‐VTE across our 5 academic medical centers. This represents avoidance of significant clinical morbidity (an estimated 81 PEs and 89 DVTs per year) and significant cost. Assuming costs of $9250 per DVT and $13,050 per PE,[17] the estimated short‐term cost savings are almost $1.9 million per year (minus expenditures on VTEP). Further savings might be expected over a longer time horizon because of the avoidance of recurrent VTE, post‐thrombotic syndrome, and the costs and complications of long‐term anticoagulation.

We believe the highly variable degree of improvement seen across our 5 sites was due to the relatively mature VTEP efforts at the onset of this collaborative improvement effort at UCSD and UCSF. As we noted earlier, the interventional bundle and methods were derived from earlier work at UCSD that had already demonstrated published marked improvement in prophylaxis and a 40% decrease in HA‐VTE.[14] The narrow range of low HA‐VTE rates in 2014 (the mature intervention time period) suggests there may be some HA‐VTE rate beyond which further prevention efforts are less productive.

Our study has several limitations. As a longitudinal collaborative improvement effort introducing a bundle of interventions, we cannot ascribe improved outcomes to individual components in the bundle; for example, we did not record the number of measure‐vention calls or resulting prophylaxis changes. We also did not measure adverse events due to VTEP, believing benefits to be greater than risks, but some adverse events likely did occur and attenuated benefits and cost savings. Although we had rigorous measures to assess the prevalence of appropriate prophylaxis, we failed to capture the baseline rate of VTEP, which means we cannot show that improved HA‐VTE rates corresponded to improvements in VTEP rates. The bundle of interventions was not implemented uniformly. Some metrics, like adherence to mechanical prophylaxis, were monitored in a decentralized fashion, without collation or collective analysis.

Were improved VTE rates due to decreases in HA‐VTE detection? We could not detect postdischarge HA‐VTE that presented to other hospitals, but we have no reason to think the proportion of missed HA‐VTE changed over the study. We discouraged the practice of routinely extending duplex ultrasound testing below the knee, and also discouraged surveillance of asymptomatic patients with Doppler ultrasound. This raises the question of ascertainment bias. Did we have fewer HA‐VTE in 2014 because our interventions worked, or did we reduce how aggressively we looked for HA‐VTE? Higher frequencies of ultrasound testing are correlated with higher rates of DVT because of surveillance bias.[18] Although some reduction in DVT was due to changes in ultrasound practices, several factors suggest the majority of improvement resulted from our interventions. First, only 1 of our 5 sites (UCD) routinely extended ultrasound testing below the knee in the baseline period. Second, we distinguished distal DVT from proximal/unspecified DVT, and the rates of both showed significant improvement. Screening asymptomatic patients with ultrasounds for DVT was limited to a few services in special circumstances (for example, the trauma service at UCSD screened patients at highest risk who could not be prophylaxed with anticoagulation). We did not have the capability to formally track which patients were being diagnosed with screening exams versus for symptoms, but screen‐detected patients were a small minority. We did not successfully dissuade these few services from stopping this approach, but we did head off some services that were considering this strategy, and think it likely that at best, we kept screening from spreading. Third, PE was reduced by over 20%, in addition to reductions in DVT, even though several of our sites acquired computed tomography scanners more sensitive for small thrombi/emncidental PE. Finally, the aggressiveness of ultrasound testing often goes up with aggressive prevention efforts, which would have led to surveillance bias with increasedrather than decreasedrates of HA‐VTE.

Our study has a number of strengths. Our effort encompassed a large and inclusive adult inpatient population over a long period of observation, with a relatively large reduction in HA‐VTE. These reductions occurred even though the proportion of patients with cancer (our most powerful predictor of VTE risk) was 34.8% in 2014 versus 33.3% in 2011. Our metrics captured patients readmitted to the hospital within 30 days of a prior VTE‐free admission as well as patients suffering VTE during the hospital stay, with the limitation that we captured only patients readmitted back to our own institutions. Our metrics for VTEP scrutinized prophylaxis rates at different points during hospitalizations, and risk‐appropriate prophylaxis was assessed, in contrast to some common regulatory measures that monitor only whether any prophylaxis is in place on the first day of admission or transfer.[11]

Our study should be instructive in terms of focusing improvement efforts. The rate of HA‐VTE was much higher in cancer and surgical patients than in medical patients, and we only achieved a nonsignificant 10% reduction in risk among medical patients (RR: 0.90, 95% CI: 0.73‐1.11). This is consistent with literature demonstrating a more limited benefit of prophylaxis in medical inpatients.[19] Although we continue to recommend prophylaxis in high‐risk medical inpatients, efforts targeting cancer and surgical populations are likely to yield greater results.

Our collaborative used methods that are portable, sustainable, and provide an excellent platform for spread of improvement across a system. The portability of these strategies is underlined by the variable baseline performance and the different stages of electronic health record development at our unique sites. Toolkits that describe the interventions (such as order sets, educational tools, measures, measure‐vention) are freely available, and reflect established guidelines.[1] Our collaborative model is consistent with successful models published in the literature.[1, 14, 20] In these models, clinical experts distill the evidence down into key best practices, and design processes that need to occur with the lowest barriers to use. Metrics, expert advice, and toolkits are assembled centrally, while each hospital identifies local barriers to implementation, educates and engages staff, executes implementation, and continually evaluates performance, modifying interventions accordingly. Embedding clinical decision and risk‐assessment into VTE prevention modules within commonly used order sets and documentation tools helps to hard‐wire the interventions, tightly linking risk assessment to appropriate prophylaxis options. The approach to standardization allows for flexibility for special populations and special needs of unique patients, while minimizing needless variation based on the ordering providers. Program management tools and regular webinars keeps sites on track, coordinate interventions, sustain enthusiasm, and provide a venue for sharing tools and lessons learned. Multiple active interventions are utilized rather than relying on passive educational techniques or order sets alone. Active surveillance (i.e., measure‐vention) deserves special attention. Measure‐vention has demonstrated utility in inpatient glycemic control and a variety of hospital‐associated infections in addition to VTE prevention, and some systems now uses measure‐ventionists as the lynchpin for a whole host of successful improvement programs.[12, 14, 21, 22] We believe high‐quality metrics, standardized protocol‐driven order sets, and measure‐vention are the crucial elements for success.

CONCLUSIONS

Hospital systems can reduce HA‐VTE by implementing a bundle of active interventions including standardized VTEP orders with embedded risk assessment and measure‐vention. Good measurement of HA‐VTE, appropriate VTEP that exceeds minimum regulatory standards, and a robust collaborative infrastructure inform and accelerate improvement. Surgical and cancer populations are at higher risk for HA‐VTE and should be a prime focus of improvement efforts.

Venous thromboembolism (VTE), comprised of pulmonary embolism (PE) and deep vein thrombosis (DVT), impacts hundreds of thousands of Americans annually.[1] The complications of VTE can be severe, including the post‐thrombotic syndrome, pulmonary hypertension, and complications of anticoagulation. VTE is often a complication of hospitalization, and PE is a common preventable cause of hospital mortality.[2, 3] Pharmacologic VTE prophylaxis (VTEP) in at‐risk patients is effective and endorsed by prominent guidelines.[4, 5, 6] However, VTEP is underutilized, with only 30% to 50% of eligible patients receiving the right drug, dose, and duration.[7, 8]

Public reporting and reimbursement policies reflect the magnitude of VTE as a public health concern. The Centers for Medicare and Medicaid Services (CMS) withholds incremental payment for VTE complications.[9] The rate of hospital‐associated VTE (HA‐VTE) is used by benchmarking organizations as a quality indicator.[10, 11]

The University of California (UC) has 5 major academic medical centers, located in Irvine (UCI), Los Angeles (UCLA), Sacramento (UC Davis [UCD]), San Diego (UCSD), and San Francisco (UCSF). In both 2010 and 2011, almost 700 UC patients suffered from HA‐VTE annually. Barriers to optimal VTEP included the absence of standardized VTE risk assessment, lack of consensus on appropriate VTEP options for various inpatient populations, and a lack of collaborative infrastructure. Other barriers included poor adherence to mechanical prophylaxis and suboptimal measurement of prophylaxis and HA‐VTE outcomes.

In late 2011, leaders from the 5 medical centers, supported by an internal competitive grant from the UC Office of the President and the Center for Health Quality and Innovation, formed a collaborative to address barriers, optimize VTEP in inpatients, and reduce HA‐VTE across the system. Prior efforts at UCSD illustrated single‐center improvement, with an increase in adequate VTEP from 50% to over 95%, and a nearly 40% reduction in the incidence of HA‐VTE.[12] We set out to scale this success across all 5 sites as a coordinated collaborative.

METHODS

This was a prospective, unblinded, open‐intervention study with historical controls that assessed prespecified outcomes before, during, and after institution of multiple VTEP strategies in 5 independent, but cooperating, academic hospitals. All adult medical and surgical inpatients were included; psychiatric, obstetricsgynecology, rehabilitation, observation status, and pediatric populations were excluded. The study period was July 1, 2012 through June 30, 2015. Calendar year (CY) 2011 was the baseline year for comparison; interventions were initiated in CY 2012 to CY 2014, and CY 2014 was considered the mature postintervention period.

RESULTS

Robust sampling (421 to 728 patients at each site) revealed attainment of high rates of adequate VTE prophylaxis (82% to 96% at all sites, collectively 89%) by early 2014. Common measures for adequate VTEP were not finalized and collected by all sites until early 2013, so we did not capture baseline VTEP rates, and could not compare baseline to mature prophylaxis rates. Reliable administration of mechanical and anticoagulant prophylaxis was monitored and targeted by each institution, albeit not in an identical fashion at each site. Adherence to mechanical prophylaxis was reported as improved at the sites, but these data were not collated and analyzed centrally.

Hospital‐Associated VTE

There were 2431 HA‐VTE events observed in 306,906 adult inpatients across CY 2011 to 2014 (Table 1). The baseline incidence of HA‐VTE was 0.90% (667 events in 73,941 hospitalizations in 2011). The incidence of HA‐VTE in the postintervention period was 0.69% (546 HA‐VTE events in 79,565 hospitalizations in 2014, P < 0.001), an overall reduction of 24%. The absolute risk for PE decreased from 0.49% to 0.39% (RR: 0.79, 95% CI: 0.68‐0.92), a reduction of 21%, and the absolute risk of leg DVT fell from 0.41% to 0.30% (RR: 0.73, 95% CI: 0.61‐0.86), a reduction of 27%. Both proximal and distal DVT were reduced significantly. Proximal DVT was much more commonly diagnosed than distal DVT. Proximal DVT incidence decreased from 0.32% to 0.25% (RR: 0.77, 95% CI: 0.64‐0.93), whereas distal DVT incidence decreased from 0.09% to 0.05% (RR: 0.58, 95% CI: 0.39‐0.86). The lower overall VTE rate in the postimplementation period compared with the baseline period corresponds to an estimated 170 fewer cases of VTE per year (89 DVT, 81 PE).

Table 1.Pulmonary and Deep Vein Thrombosis Rates Calendar Years 2011 to 2014

	2011 (Baseline), No./%	2012, No./%	2013, No./%	2014 (Mature), No./%	2014 Versus 2011 Relative Risk (95% CI)	2014 Versus 2011 Estimated Averted Events (95% CI)
NOTE: All adult Inpatients (with and without cancer diagnosis), discharged from all University of California Hospitals are included. The impact of improvement efforts was highest in the surgical population. See text for additional detail on proximal versus distal DVT. Abbreviations: CI, confidence interval; DVT, deep vein thrombosis; PE, pulmonary embolism.
Total discharges (medical and surgical)	73,941	76,100	77,300	79,565
Total PE + leg DVT	667/0.90%	650/0.85%	568/0.73%	546/0.69%	0.761 (0.680‐0.852)	170 (103‐247)
Total PE	363/0.49%	359/0.47%	340/0.44%	309/0.39%	0.791 (0.680‐0.920)	81 (32‐135)
Total leg DVT	304/0.41%	291/0.38%	228/0.29%	237/0.3%	0.725 (0.612‐0.858)	89(40‐135)
Medical discharges	31,219	32,597	33,805	34,875
Total PE + leg DVT	178/0.57%	168/0.52%	164/0.49%	179/0.51%	0.900 (0.732‐1.1071)
PE	110/0.35%	94/0.29%	106/0.31%	104/0.30%	0.846 (0.648‐1.106)
Leg DVT	68/0.22%	74/0.23%	58/0.17%	75/0.22%	0.987 (0.711‐1.371)
Surgical discharges	42,722	43,503	43,495	44,690
Total PE + leg DVT	489/1.14%	482/1.11%	404/0.93%	367/0.82%	0.718 (0.627‐0.821)
PE	253/0.59%	265/0.61%	234/0.54%	205/0.46%	0.775 (0.645‐0.931)
Leg DVT	236/0.55%	217/0.50%	180/0.41%	162/0.36%	0.656 (0.538‐0.801)

The baseline rate of HA‐VTE and degree of improvement varied between institutions (Figure 1). UCI and UCD began the study with significantly higher VTE rates, and enjoyed the largest improvements. UCLA's VTE rate decreased to a lesser extent, whereas UCSD and UCSF rates remained relatively flat or were marginally higher. In contrast to the highly variable 2011 baseline rate of HA‐VTE (0.60%1.36%), all 5 sites had HA‐VTE rates within a very narrow range (0.65%0.73%) at maturity in 2014.

Figure 1

Cancer Versus Noncancer Patients

The incidence of HA‐VTE was higher in cancer patients than in noncancer patients. In 2011, 227 of 18,487 (1.23%) cancer patients developed VTE, versus 440 of 55,454 (0.79%) noncancer patients (Figure 2). After implementation of the VTE prevention initiative, the incidence of VTE in cancer patients fell by 0.21% (210 events in 20,544 patients in 2014, 1.02%), and the incidence of VTE in noncancer patients fell by 0.22% (336 events in 59,021 patients, 0.57%). The relative risk of HA‐VTE after the VTE interventions was reduced by 17% (RR: 0.83, 95% CI: 0.69‐1.00) in cancer patients and 28% (RR: 0.72, 95% CI: 0.62‐0.83) in noncancer patients.

Figure 2

DISCUSSION

Our initiative, comprised of a collaborative infrastructure, a proven quality‐improvement framework, and a bundle of interventions, was associated with a 24% reduction in the risk of HA‐VTE across our 5 academic medical centers. This represents avoidance of significant clinical morbidity (an estimated 81 PEs and 89 DVTs per year) and significant cost. Assuming costs of $9250 per DVT and $13,050 per PE,[17] the estimated short‐term cost savings are almost $1.9 million per year (minus expenditures on VTEP). Further savings might be expected over a longer time horizon because of the avoidance of recurrent VTE, post‐thrombotic syndrome, and the costs and complications of long‐term anticoagulation.

We believe the highly variable degree of improvement seen across our 5 sites was due to the relatively mature VTEP efforts at the onset of this collaborative improvement effort at UCSD and UCSF. As we noted earlier, the interventional bundle and methods were derived from earlier work at UCSD that had already demonstrated published marked improvement in prophylaxis and a 40% decrease in HA‐VTE.[14] The narrow range of low HA‐VTE rates in 2014 (the mature intervention time period) suggests there may be some HA‐VTE rate beyond which further prevention efforts are less productive.

Our study has several limitations. As a longitudinal collaborative improvement effort introducing a bundle of interventions, we cannot ascribe improved outcomes to individual components in the bundle; for example, we did not record the number of measure‐vention calls or resulting prophylaxis changes. We also did not measure adverse events due to VTEP, believing benefits to be greater than risks, but some adverse events likely did occur and attenuated benefits and cost savings. Although we had rigorous measures to assess the prevalence of appropriate prophylaxis, we failed to capture the baseline rate of VTEP, which means we cannot show that improved HA‐VTE rates corresponded to improvements in VTEP rates. The bundle of interventions was not implemented uniformly. Some metrics, like adherence to mechanical prophylaxis, were monitored in a decentralized fashion, without collation or collective analysis.

Were improved VTE rates due to decreases in HA‐VTE detection? We could not detect postdischarge HA‐VTE that presented to other hospitals, but we have no reason to think the proportion of missed HA‐VTE changed over the study. We discouraged the practice of routinely extending duplex ultrasound testing below the knee, and also discouraged surveillance of asymptomatic patients with Doppler ultrasound. This raises the question of ascertainment bias. Did we have fewer HA‐VTE in 2014 because our interventions worked, or did we reduce how aggressively we looked for HA‐VTE? Higher frequencies of ultrasound testing are correlated with higher rates of DVT because of surveillance bias.[18] Although some reduction in DVT was due to changes in ultrasound practices, several factors suggest the majority of improvement resulted from our interventions. First, only 1 of our 5 sites (UCD) routinely extended ultrasound testing below the knee in the baseline period. Second, we distinguished distal DVT from proximal/unspecified DVT, and the rates of both showed significant improvement. Screening asymptomatic patients with ultrasounds for DVT was limited to a few services in special circumstances (for example, the trauma service at UCSD screened patients at highest risk who could not be prophylaxed with anticoagulation). We did not have the capability to formally track which patients were being diagnosed with screening exams versus for symptoms, but screen‐detected patients were a small minority. We did not successfully dissuade these few services from stopping this approach, but we did head off some services that were considering this strategy, and think it likely that at best, we kept screening from spreading. Third, PE was reduced by over 20%, in addition to reductions in DVT, even though several of our sites acquired computed tomography scanners more sensitive for small thrombi/emncidental PE. Finally, the aggressiveness of ultrasound testing often goes up with aggressive prevention efforts, which would have led to surveillance bias with increasedrather than decreasedrates of HA‐VTE.

Our study has a number of strengths. Our effort encompassed a large and inclusive adult inpatient population over a long period of observation, with a relatively large reduction in HA‐VTE. These reductions occurred even though the proportion of patients with cancer (our most powerful predictor of VTE risk) was 34.8% in 2014 versus 33.3% in 2011. Our metrics captured patients readmitted to the hospital within 30 days of a prior VTE‐free admission as well as patients suffering VTE during the hospital stay, with the limitation that we captured only patients readmitted back to our own institutions. Our metrics for VTEP scrutinized prophylaxis rates at different points during hospitalizations, and risk‐appropriate prophylaxis was assessed, in contrast to some common regulatory measures that monitor only whether any prophylaxis is in place on the first day of admission or transfer.[11]

Our study should be instructive in terms of focusing improvement efforts. The rate of HA‐VTE was much higher in cancer and surgical patients than in medical patients, and we only achieved a nonsignificant 10% reduction in risk among medical patients (RR: 0.90, 95% CI: 0.73‐1.11). This is consistent with literature demonstrating a more limited benefit of prophylaxis in medical inpatients.[19] Although we continue to recommend prophylaxis in high‐risk medical inpatients, efforts targeting cancer and surgical populations are likely to yield greater results.

Our collaborative used methods that are portable, sustainable, and provide an excellent platform for spread of improvement across a system. The portability of these strategies is underlined by the variable baseline performance and the different stages of electronic health record development at our unique sites. Toolkits that describe the interventions (such as order sets, educational tools, measures, measure‐vention) are freely available, and reflect established guidelines.[1] Our collaborative model is consistent with successful models published in the literature.[1, 14, 20] In these models, clinical experts distill the evidence down into key best practices, and design processes that need to occur with the lowest barriers to use. Metrics, expert advice, and toolkits are assembled centrally, while each hospital identifies local barriers to implementation, educates and engages staff, executes implementation, and continually evaluates performance, modifying interventions accordingly. Embedding clinical decision and risk‐assessment into VTE prevention modules within commonly used order sets and documentation tools helps to hard‐wire the interventions, tightly linking risk assessment to appropriate prophylaxis options. The approach to standardization allows for flexibility for special populations and special needs of unique patients, while minimizing needless variation based on the ordering providers. Program management tools and regular webinars keeps sites on track, coordinate interventions, sustain enthusiasm, and provide a venue for sharing tools and lessons learned. Multiple active interventions are utilized rather than relying on passive educational techniques or order sets alone. Active surveillance (i.e., measure‐vention) deserves special attention. Measure‐vention has demonstrated utility in inpatient glycemic control and a variety of hospital‐associated infections in addition to VTE prevention, and some systems now uses measure‐ventionists as the lynchpin for a whole host of successful improvement programs.[12, 14, 21, 22] We believe high‐quality metrics, standardized protocol‐driven order sets, and measure‐vention are the crucial elements for success.

CONCLUSIONS

Hospital systems can reduce HA‐VTE by implementing a bundle of active interventions including standardized VTEP orders with embedded risk assessment and measure‐vention. Good measurement of HA‐VTE, appropriate VTEP that exceeds minimum regulatory standards, and a robust collaborative infrastructure inform and accelerate improvement. Surgical and cancer populations are at higher risk for HA‐VTE and should be a prime focus of improvement efforts.

Venous thromboembolism (VTE), comprised of pulmonary embolism (PE) and deep vein thrombosis (DVT), impacts hundreds of thousands of Americans annually.[1] The complications of VTE can be severe, including the post‐thrombotic syndrome, pulmonary hypertension, and complications of anticoagulation. VTE is often a complication of hospitalization, and PE is a common preventable cause of hospital mortality.[2, 3] Pharmacologic VTE prophylaxis (VTEP) in at‐risk patients is effective and endorsed by prominent guidelines.[4, 5, 6] However, VTEP is underutilized, with only 30% to 50% of eligible patients receiving the right drug, dose, and duration.[7, 8]

Public reporting and reimbursement policies reflect the magnitude of VTE as a public health concern. The Centers for Medicare and Medicaid Services (CMS) withholds incremental payment for VTE complications.[9] The rate of hospital‐associated VTE (HA‐VTE) is used by benchmarking organizations as a quality indicator.[10, 11]

The University of California (UC) has 5 major academic medical centers, located in Irvine (UCI), Los Angeles (UCLA), Sacramento (UC Davis [UCD]), San Diego (UCSD), and San Francisco (UCSF). In both 2010 and 2011, almost 700 UC patients suffered from HA‐VTE annually. Barriers to optimal VTEP included the absence of standardized VTE risk assessment, lack of consensus on appropriate VTEP options for various inpatient populations, and a lack of collaborative infrastructure. Other barriers included poor adherence to mechanical prophylaxis and suboptimal measurement of prophylaxis and HA‐VTE outcomes.

In late 2011, leaders from the 5 medical centers, supported by an internal competitive grant from the UC Office of the President and the Center for Health Quality and Innovation, formed a collaborative to address barriers, optimize VTEP in inpatients, and reduce HA‐VTE across the system. Prior efforts at UCSD illustrated single‐center improvement, with an increase in adequate VTEP from 50% to over 95%, and a nearly 40% reduction in the incidence of HA‐VTE.[12] We set out to scale this success across all 5 sites as a coordinated collaborative.

METHODS

This was a prospective, unblinded, open‐intervention study with historical controls that assessed prespecified outcomes before, during, and after institution of multiple VTEP strategies in 5 independent, but cooperating, academic hospitals. All adult medical and surgical inpatients were included; psychiatric, obstetricsgynecology, rehabilitation, observation status, and pediatric populations were excluded. The study period was July 1, 2012 through June 30, 2015. Calendar year (CY) 2011 was the baseline year for comparison; interventions were initiated in CY 2012 to CY 2014, and CY 2014 was considered the mature postintervention period.

RESULTS

Robust sampling (421 to 728 patients at each site) revealed attainment of high rates of adequate VTE prophylaxis (82% to 96% at all sites, collectively 89%) by early 2014. Common measures for adequate VTEP were not finalized and collected by all sites until early 2013, so we did not capture baseline VTEP rates, and could not compare baseline to mature prophylaxis rates. Reliable administration of mechanical and anticoagulant prophylaxis was monitored and targeted by each institution, albeit not in an identical fashion at each site. Adherence to mechanical prophylaxis was reported as improved at the sites, but these data were not collated and analyzed centrally.

Hospital‐Associated VTE

There were 2431 HA‐VTE events observed in 306,906 adult inpatients across CY 2011 to 2014 (Table 1). The baseline incidence of HA‐VTE was 0.90% (667 events in 73,941 hospitalizations in 2011). The incidence of HA‐VTE in the postintervention period was 0.69% (546 HA‐VTE events in 79,565 hospitalizations in 2014, P < 0.001), an overall reduction of 24%. The absolute risk for PE decreased from 0.49% to 0.39% (RR: 0.79, 95% CI: 0.68‐0.92), a reduction of 21%, and the absolute risk of leg DVT fell from 0.41% to 0.30% (RR: 0.73, 95% CI: 0.61‐0.86), a reduction of 27%. Both proximal and distal DVT were reduced significantly. Proximal DVT was much more commonly diagnosed than distal DVT. Proximal DVT incidence decreased from 0.32% to 0.25% (RR: 0.77, 95% CI: 0.64‐0.93), whereas distal DVT incidence decreased from 0.09% to 0.05% (RR: 0.58, 95% CI: 0.39‐0.86). The lower overall VTE rate in the postimplementation period compared with the baseline period corresponds to an estimated 170 fewer cases of VTE per year (89 DVT, 81 PE).

Table 1.Pulmonary and Deep Vein Thrombosis Rates Calendar Years 2011 to 2014

	2011 (Baseline), No./%	2012, No./%	2013, No./%	2014 (Mature), No./%	2014 Versus 2011 Relative Risk (95% CI)	2014 Versus 2011 Estimated Averted Events (95% CI)
NOTE: All adult Inpatients (with and without cancer diagnosis), discharged from all University of California Hospitals are included. The impact of improvement efforts was highest in the surgical population. See text for additional detail on proximal versus distal DVT. Abbreviations: CI, confidence interval; DVT, deep vein thrombosis; PE, pulmonary embolism.
Total discharges (medical and surgical)	73,941	76,100	77,300	79,565
Total PE + leg DVT	667/0.90%	650/0.85%	568/0.73%	546/0.69%	0.761 (0.680‐0.852)	170 (103‐247)
Total PE	363/0.49%	359/0.47%	340/0.44%	309/0.39%	0.791 (0.680‐0.920)	81 (32‐135)
Total leg DVT	304/0.41%	291/0.38%	228/0.29%	237/0.3%	0.725 (0.612‐0.858)	89(40‐135)
Medical discharges	31,219	32,597	33,805	34,875
Total PE + leg DVT	178/0.57%	168/0.52%	164/0.49%	179/0.51%	0.900 (0.732‐1.1071)
PE	110/0.35%	94/0.29%	106/0.31%	104/0.30%	0.846 (0.648‐1.106)
Leg DVT	68/0.22%	74/0.23%	58/0.17%	75/0.22%	0.987 (0.711‐1.371)
Surgical discharges	42,722	43,503	43,495	44,690
Total PE + leg DVT	489/1.14%	482/1.11%	404/0.93%	367/0.82%	0.718 (0.627‐0.821)
PE	253/0.59%	265/0.61%	234/0.54%	205/0.46%	0.775 (0.645‐0.931)
Leg DVT	236/0.55%	217/0.50%	180/0.41%	162/0.36%	0.656 (0.538‐0.801)

The baseline rate of HA‐VTE and degree of improvement varied between institutions (Figure 1). UCI and UCD began the study with significantly higher VTE rates, and enjoyed the largest improvements. UCLA's VTE rate decreased to a lesser extent, whereas UCSD and UCSF rates remained relatively flat or were marginally higher. In contrast to the highly variable 2011 baseline rate of HA‐VTE (0.60%1.36%), all 5 sites had HA‐VTE rates within a very narrow range (0.65%0.73%) at maturity in 2014.

Figure 1

Cancer Versus Noncancer Patients

The incidence of HA‐VTE was higher in cancer patients than in noncancer patients. In 2011, 227 of 18,487 (1.23%) cancer patients developed VTE, versus 440 of 55,454 (0.79%) noncancer patients (Figure 2). After implementation of the VTE prevention initiative, the incidence of VTE in cancer patients fell by 0.21% (210 events in 20,544 patients in 2014, 1.02%), and the incidence of VTE in noncancer patients fell by 0.22% (336 events in 59,021 patients, 0.57%). The relative risk of HA‐VTE after the VTE interventions was reduced by 17% (RR: 0.83, 95% CI: 0.69‐1.00) in cancer patients and 28% (RR: 0.72, 95% CI: 0.62‐0.83) in noncancer patients.

Figure 2

DISCUSSION

Our initiative, comprised of a collaborative infrastructure, a proven quality‐improvement framework, and a bundle of interventions, was associated with a 24% reduction in the risk of HA‐VTE across our 5 academic medical centers. This represents avoidance of significant clinical morbidity (an estimated 81 PEs and 89 DVTs per year) and significant cost. Assuming costs of $9250 per DVT and $13,050 per PE,[17] the estimated short‐term cost savings are almost $1.9 million per year (minus expenditures on VTEP). Further savings might be expected over a longer time horizon because of the avoidance of recurrent VTE, post‐thrombotic syndrome, and the costs and complications of long‐term anticoagulation.

We believe the highly variable degree of improvement seen across our 5 sites was due to the relatively mature VTEP efforts at the onset of this collaborative improvement effort at UCSD and UCSF. As we noted earlier, the interventional bundle and methods were derived from earlier work at UCSD that had already demonstrated published marked improvement in prophylaxis and a 40% decrease in HA‐VTE.[14] The narrow range of low HA‐VTE rates in 2014 (the mature intervention time period) suggests there may be some HA‐VTE rate beyond which further prevention efforts are less productive.

Our study has several limitations. As a longitudinal collaborative improvement effort introducing a bundle of interventions, we cannot ascribe improved outcomes to individual components in the bundle; for example, we did not record the number of measure‐vention calls or resulting prophylaxis changes. We also did not measure adverse events due to VTEP, believing benefits to be greater than risks, but some adverse events likely did occur and attenuated benefits and cost savings. Although we had rigorous measures to assess the prevalence of appropriate prophylaxis, we failed to capture the baseline rate of VTEP, which means we cannot show that improved HA‐VTE rates corresponded to improvements in VTEP rates. The bundle of interventions was not implemented uniformly. Some metrics, like adherence to mechanical prophylaxis, were monitored in a decentralized fashion, without collation or collective analysis.

Were improved VTE rates due to decreases in HA‐VTE detection? We could not detect postdischarge HA‐VTE that presented to other hospitals, but we have no reason to think the proportion of missed HA‐VTE changed over the study. We discouraged the practice of routinely extending duplex ultrasound testing below the knee, and also discouraged surveillance of asymptomatic patients with Doppler ultrasound. This raises the question of ascertainment bias. Did we have fewer HA‐VTE in 2014 because our interventions worked, or did we reduce how aggressively we looked for HA‐VTE? Higher frequencies of ultrasound testing are correlated with higher rates of DVT because of surveillance bias.[18] Although some reduction in DVT was due to changes in ultrasound practices, several factors suggest the majority of improvement resulted from our interventions. First, only 1 of our 5 sites (UCD) routinely extended ultrasound testing below the knee in the baseline period. Second, we distinguished distal DVT from proximal/unspecified DVT, and the rates of both showed significant improvement. Screening asymptomatic patients with ultrasounds for DVT was limited to a few services in special circumstances (for example, the trauma service at UCSD screened patients at highest risk who could not be prophylaxed with anticoagulation). We did not have the capability to formally track which patients were being diagnosed with screening exams versus for symptoms, but screen‐detected patients were a small minority. We did not successfully dissuade these few services from stopping this approach, but we did head off some services that were considering this strategy, and think it likely that at best, we kept screening from spreading. Third, PE was reduced by over 20%, in addition to reductions in DVT, even though several of our sites acquired computed tomography scanners more sensitive for small thrombi/emncidental PE. Finally, the aggressiveness of ultrasound testing often goes up with aggressive prevention efforts, which would have led to surveillance bias with increasedrather than decreasedrates of HA‐VTE.

Our study has a number of strengths. Our effort encompassed a large and inclusive adult inpatient population over a long period of observation, with a relatively large reduction in HA‐VTE. These reductions occurred even though the proportion of patients with cancer (our most powerful predictor of VTE risk) was 34.8% in 2014 versus 33.3% in 2011. Our metrics captured patients readmitted to the hospital within 30 days of a prior VTE‐free admission as well as patients suffering VTE during the hospital stay, with the limitation that we captured only patients readmitted back to our own institutions. Our metrics for VTEP scrutinized prophylaxis rates at different points during hospitalizations, and risk‐appropriate prophylaxis was assessed, in contrast to some common regulatory measures that monitor only whether any prophylaxis is in place on the first day of admission or transfer.[11]

Our study should be instructive in terms of focusing improvement efforts. The rate of HA‐VTE was much higher in cancer and surgical patients than in medical patients, and we only achieved a nonsignificant 10% reduction in risk among medical patients (RR: 0.90, 95% CI: 0.73‐1.11). This is consistent with literature demonstrating a more limited benefit of prophylaxis in medical inpatients.[19] Although we continue to recommend prophylaxis in high‐risk medical inpatients, efforts targeting cancer and surgical populations are likely to yield greater results.

Our collaborative used methods that are portable, sustainable, and provide an excellent platform for spread of improvement across a system. The portability of these strategies is underlined by the variable baseline performance and the different stages of electronic health record development at our unique sites. Toolkits that describe the interventions (such as order sets, educational tools, measures, measure‐vention) are freely available, and reflect established guidelines.[1] Our collaborative model is consistent with successful models published in the literature.[1, 14, 20] In these models, clinical experts distill the evidence down into key best practices, and design processes that need to occur with the lowest barriers to use. Metrics, expert advice, and toolkits are assembled centrally, while each hospital identifies local barriers to implementation, educates and engages staff, executes implementation, and continually evaluates performance, modifying interventions accordingly. Embedding clinical decision and risk‐assessment into VTE prevention modules within commonly used order sets and documentation tools helps to hard‐wire the interventions, tightly linking risk assessment to appropriate prophylaxis options. The approach to standardization allows for flexibility for special populations and special needs of unique patients, while minimizing needless variation based on the ordering providers. Program management tools and regular webinars keeps sites on track, coordinate interventions, sustain enthusiasm, and provide a venue for sharing tools and lessons learned. Multiple active interventions are utilized rather than relying on passive educational techniques or order sets alone. Active surveillance (i.e., measure‐vention) deserves special attention. Measure‐vention has demonstrated utility in inpatient glycemic control and a variety of hospital‐associated infections in addition to VTE prevention, and some systems now uses measure‐ventionists as the lynchpin for a whole host of successful improvement programs.[12, 14, 21, 22] We believe high‐quality metrics, standardized protocol‐driven order sets, and measure‐vention are the crucial elements for success.

CONCLUSIONS

Hospital systems can reduce HA‐VTE by implementing a bundle of active interventions including standardized VTEP orders with embedded risk assessment and measure‐vention. Good measurement of HA‐VTE, appropriate VTEP that exceeds minimum regulatory standards, and a robust collaborative infrastructure inform and accelerate improvement. Surgical and cancer populations are at higher risk for HA‐VTE and should be a prime focus of improvement efforts.