What Was Done?
Global Problem Addressed
Venous thromboembolism (VTE) occurrences are defined by a deep vein thrombosis (DVT), pulmonary embolism (PE), or both. The incidence of VTE affects nearly one in 1,000 people and contributes to 60,000 to 100,000 deaths annually.1 Risk factors for VTE can be both hereditary and acquired. We have come to understand patients that require surgery are at a higher risk of developing a VTE.
Identification of Local Problem
Our ACS NSQIP January 2018 Semi-Annual Report (SAR) identified that Mercy Hospital Springfield was a high outlier for venous thromboembolism (VTE) occurrences in neurosurgery. Mercy Hospital Springfield, in comparison with our Mercy Collaborative, was found to have greater than 50 percent of the VTE occurrences within the same time frame. A 4.32 percent occurrence rate was reported for VTE within our neurosurgical patient population.
How Was the Quality Improvement (QI) Activity Put in Place?
Context of the QI Activity
Mercy Hospital Springfield is a community hospital located in Springfield, Missouri. It is known as the region’s longest-serving health care provider. With 914 beds, we serve patients serves people throughout southwest Missouri and northwest Arkansas. We are home to a Missouri and Arkansas designated Level I trauma center and burn center, Life Line air ambulance service, a dedicated children’s hospital, cancer center, Level III neonatal ICU, heart institute, and a nationally certified stroke center.
Mercy Hospital Springfield is part of the Mercy Health system. Mercy, named one of the top five large U.S. health systems for four consecutive years (2016 to 2019) by IBM Watson Health, serves millions annually. Mercy includes more than 40 acute care, managed, and specialty (heart, children’s, orthopaedic and rehab) hospitals; 900 physician practices and outpatient facilities; 45,000 co-workers; 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 IT division, Mercy Technology Services, and Mercy Virtual commercially serve providers and patients from coast to coast.
Planning and Development Process
The neurosurgery section group, comprised of physicians and mid-level providers, met officially in early March 2018 and comprehensively discussed factors that were felt to be contributory to the high VTE occurrence rates. Among the factors identified were a lack of uniformity in applying VTE chemoprophylaxis across the practice. This was felt to be due to differing treatment biases of the various practitioners, the heterogeneity of the patient population secondary to varying co-morbidities and risk factors, and ultimately the lack of a defined protocol for standardizing this aspect of patient care. To this end, a body of literature was reviewed and recent data from a recent completed protocol implementation at a major academic medical center was also discussed. No Level 1 guidelines exist in the scientific literature. However, based on review of various meta-analyses and recent unpublished data from a major academic medical center pertaining to implementation of a VTE prevention protocol, it was felt that there was a definite advantage to implementing a standard protocol for chemical VTE prevention. 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 a general consensus from the neurosurgeons to move forward with the protocol.
Description of the Quality Improvement Activity
Three separate protocols were created for the Neurosurgery patient populations: Neurosurgical Postoperative Spine, Neurosurgical Postoperative Adult Cranial, and Neurosurgical Adult Trauma. Neurosurgical Postoperative Spine and Neurosurgical Postoperative Adult Cranial are similar. Chemical and mechanical prophylaxis would be utilized for the patient population as set forth by the defined criteria and assessment of any contraindications. The Neurosurgery section agreed to initiate preventative treatment 24 hours after surgery completion barring any exceptions (i.e., patients in shock; existing or emerging hemorrhagic complications without shock; clinically or radiologically identified postoperative hematoma formation; physicians with reasonable concern for postoperative hematoma formation based on intraoperative findings/course; significant postoperative anemia that has not stabilized; coagulopathy). To maintain standardization of dosing and to account for body weight variation, pharmacy would be consulted for weight-based adjustments of the prophylactic dosage. The Neurosurgical Adult Trauma protocol is defined for patients with traumatic brain and spinal cord/spine injuries. VTE prophylaxis is initiated 72 hours after the injury/procedure for most intracranial hemorrhages, after craniotomy, and most spinal cord injuries. Criteria has been established to consider chemical prophylaxis 24 hours after a stable repeat head CT scan for patients with mild Traumatic Brain Injury (TBI) and the following: GCS of 15 within 30 minutes of injury; subdural or epidural hematoma < 8mm; contusion or intraventricular hemorrhage < 2cm (single lobe only).
Implementation of the VTE protocol took place in June 2018. The Neurosurgery section agreed that given the concern for possible increased incidence of postoperative hemorrhagic complications, they would re-evaluate the protocol at six months. At that time, the section would review the incidence of postoperative hemorrhages following implementation of the protocol and then make a final decision on whether to modify the protocol or implement the existing paradigm permanently. The protocol was reviewed in late 2018. Based on the successful results, the protocol was left in place without modifications.
Resources Used and Skills Needed
The ACS NSQIP Surgical Clinical Reviewers, ACS NSQIP Surgeon Champion, neurosurgery section, quality department and neurosurgical nursing staff were involved in the implementation, adherence, and outcomes of this developed protocol. No additional costs or funding beyond normal hospital operations were necessary to implement and maintain this protocol.
What Were the Results?
Overall Results
Following the deployment of the VTE Neurosurgery Chemoprophylaxis protocol, downward trending occurrence rates were observed utilizing SAR and ISAR data. VTE occurrence rates in Neurosurgery have decreased from 3.97 percent at the time of protocol initiation to 0.72 percent as based on our January 2020 SAR.
Setbacks
There were no encountered barriers related to the implementation of this protocol.
Cost Savings
Cost savings for this initiative was not calculated; however, a decrease in VTE rates does yield shorter hospital length of stays, decreased need for pharmaceutical treatment, and less likely need for additional readmissions and/or follow-up visits. As a result of this, decreased VTE instances is a large cost savings investment.
