Improving VTE prophylaxis in hospitalized oncologic patients: Institutional impact VTE mentored QI project.
Authors: Halm Josiah 
Published: February 2017

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Background: Venous thromboembolism (VTE), which includes deep vein thrombosis and pulmonary embolism affects hundreds of thousand Americans each year. Pulmonary embolism(PE), is the 3rd leading cause of hospital related death and the most common preventable cause of death in the United States. Cancer is associated with 6-fold increase in the risk of VTE. For those undergoing surgery, the risks of post-operative DVT and fatal PE are 2-3 times greater, respectively, for cancer patients than non-cancer patients. VTE prophylaxis is widely available and effective, but frequently underused. VTE prevention is of particular concern to oncologists. Evidence based oncology-specific guidelines are available from several organizations including American Society of Clinical Oncology (ASCO) to highlight the importance of prophylaxis in oncology patients. An Interdisciplinary team of pharmacists and hospitalists received an educational grant to implement a VTE mentored project in a large Comprehensive Academic Cancer Center in the Southern United States. There was anecdotal evidence and data to suggest adherence to thrombo-prophylaxis was suboptimal, with multiple departments and physicians having their "own" order sets of varying complexities. Performance data on VTE was not routinely being collected and data on hospital-acquired VTE events was not consistently collected and reported. To meet increasing financial, regulatory and the clinical challenge of harmonizing VTE prophylaxis in the institution, a multi-disciplinary team was formed to implement this VTE initiative. Methods: The QI methodology used was the Plan, Do, Study and Act (PDSA). Step 1. Draft a single VTE protocol using best evidence with input from all stakeholders that will be acceptable to most users. Step 2. Analyze the care delivery throughout the hospital Step 3. Set up performance tracking with IT support Step 4. Staggered introduction/education of the VTE protocol across departments/physicians Step 5. Implement and track through cycles of PDSA. Results: The institution went from having about 10 different VTE order sets to a single VTE order set that was a single page and was utilized by medical, surgical and emergency room and ICU physicians. This was embed in all admission, transfer and post op orders. Use of VTE prophylaxis order set went from an aggregate of 40.7 to 76.1%, 3 months after implementation of initiative. 26% percent of patient with no prophylaxis ordered had no contraindications checked. 60.9% and 16% of admitted patients were risk stratified as moderate or high risk respectively. Conclusions: 4 key findings from the implementation project led to improved rates of thrombo-prophylaxis. Prescribers are in the best position to understand all components of the VTE risk as well as contraindications and should be responsible for VTE risk assessment, as hitherto nurses were doing risk assessment and physicians were prescribing prophylaxis. New VTE order set provided a linked menu of appropriate prophylaxis options for each level of risk which the older sets did not do. Embedding VTE order set in admission/transfer and post op orders sets led to increase use. Efforts to raise VTE awareness should be ongoing, routinely monitored and included with other safety indicators such as falls etc and reported back to providers and appropriate medical staff and executive committees.