Identification of Local Problem
According to the Fall 2022 TQIP benchmark data, instance of pulmonary embolism as a major hospital event was a 10th decile outlier. The Odds Ratio (OR) for pulmonary embolism at our institution since 2017 trends above the national median with the last three reports showing an OR of 1.90, 1.73, and 2.07. Additionally, DVT was an outlier at 2.4% for all patients compared to 1.1% nationally.
The TQIP reports consistently demonstrate that we are an outlier in the major hospital event. Additionally, the benchmark for prophylactic anticoagulation is 76.9% utilization of low molecular weight heparin (LMWH) and 18.9% utilization of unfractionated heparin (UFH). The Elliot utilized 58.7% UFH and 30.1% LMWH, the inverse of the national standard and best practice guidelines in trauma.
This lack of alignment with best practice is affecting patients, resulting in higher incidence of PE and DVT. This leads to longer lengths of stay for the patient, increased overall morbidity, and increased healthcare costs associated with the treatment of these events.
Context of the QI Activity
To address our outlier status, we decided to attempt to hardwire the trauma VTE prophylaxis protocol into an EPIC order set. The majority of the implementation was led by the Trauma Program Manager and a Critical Care Pharmacist who maintained oversight of the process. The trauma PI Coordinators were used in daily rounds to enforce/remind providers of the new order set.
What were the interventions?
We decided to build a pharmacy-driven trauma VTE prophylaxis protocol. The order set was created as a drop-down series of questions and determines appropriate chemoprophylaxis and dosing based on the answers to the preceding questions. The Surgeon or PA decides on appropriateness of timing and initial implementation of VTE prophylaxis, but once decided upon, the order set forces the ordering provider to order the correct medication and dosing based on age, creatinine clearance, and weight. Based on the literature, anti-Xa monitoring is required for patients weighing less than 50 kg or greater than 100 kg. If patients required anti-Xa monitoring based on the drop-down in the order set, a consult to pharmacy would automatically cascade and be ordered. The pharmacist would then utilize the policy/protocol to enter orders for Anti-Xa Monitoring. Additionally, we ensured the pharmacist had the ability within the protocol to adjust the dosing based on the anti-Xa level if it was subtherapeutic or supratherapeutic and order re-check labs.
Once the order set was implemented, we continually monitored PI aspects of the protocol, including incidence of PE/DVT, anti-Xa monitoring compliance, and utilization of SQ heparin compared to LMWH. These metrics were reported out monthly for a 1-year period at trauma operations. Once compliance was determined to be steady for that year, it was removed from monthly trauma operations report out but is still monitored within the PI dashboard for compliance.
