Venous thromboembolism (VTE) occurrences are defined by a deep vein thrombosis (DVT), pulmonary embolism (PE), or both. VTE affects nearly one in 1,000 people and contributes to 60,000–100,000 deaths annually.* Risk factors for VTE can be both hereditary and acquired. We have come to understand that patients who require surgery are at a higher risk of developing a VTE.
The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) January 2018 Semi-Annual Report (SAR) identified Mercy Hospital Springfield, MO, as a high outlier for VTE occurrences in neurosurgery. Mercy Hospital Springfield, in comparison with our Mercy Collaborative, was found to have more than 50 percent of the VTE occurrences in the same time frame. A 4.32 percent occurrence rate was reported for VTE within our neurosurgery patient population.
Context of the quality improvement activity
Mercy Hospital Springfield is a community hospital and is known as the region’s longest-serving health care provider. With 914 beds, the hospital serves patients throughout southwest Missouri and northwest Arkansas. It is home to a Missouri and Arkansas designated Level I Trauma Center & Burn Center, Life Line air ambulance service, a dedicated children’s hospital, cancer center, Level III neonatal intensive care unit, heart institute, and a nationally certified stroke center.
Mercy Hospital Springfield is part of Mercy Health, which IBM Watson Health has named one of the top five large U.S. health systems for four consecutive years (2016 to 2019), and serves millions annually. Mercy includes more than 40 acute care, managed and specialty (heart, children’s, orthopaedic, and rehabilitation) hospitals, 900 physician practices and outpatient facilities, 45,000 staff, and 2,400 Mercy Clinic physicians in Arkansas, Kansas, Missouri, and Oklahoma. Mercy also has clinics, outpatient services, and outreach ministries in Arkansas, Louisiana, Mississippi, and Texas. In addition, Mercy’s information technology division, Mercy Technology Services and Mercy Virtual, commercially serve providers and patients from coast to coast.
The neurosurgery section group, which comprises physicians and mid-level providers, met officially in early March 2018 and comprehensively discussed factors that were considered to be contributory to the high VTE occurrence rates. Among the factors identified was a lack of uniformity in applying VTE chemoprophylaxis across the practice. This variance was believed to be the result of differing treatment biases among the neurosurgeons at the hospitals, the heterogeneity of the patient population secondary to varying comorbidities and risk factors, and, ultimately, the lack of a defined protocol for standardizing this aspect of patient care.
To resolve these inconsistencies, a body of literature was reviewed and data from a recently completed protocol implementation at a major academic medical center were discussed. No level 1 guidelines exist in the scientific literature; however, based on a review of various meta-analyses and recent unpublished data from a major academic medical center pertaining to implementation of a VTE prevention protocol, the quality improvement (QI) team determined that a standard protocol for chemical VTE prevention would be advantageous. The data indicated a lower risk of VTE with no statistically significant increased risk for hemorrhagic complications. The VTE protocol was developed and discussed at a subsequent neurosurgery section meeting, with the neurosurgeons agreeing to move forward with the protocol.
FIGURE 1. MERCY HOSPITAL SPRINGFIELD NEUROSURGERY VTE
