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
Putting the QI activity in place
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 protocols are similar. Chemical and mechanical prophylaxis would be used in accordance with the defined criteria and assessment of any contraindications. The neurosurgery section agreed to initiate preventative treatment 24 hours after completion of an operation, barring any exceptions, including the following:
- Patients in shock
- Existing or emerging hemorrhagic complications without shock
- Clinically or radiologically identified postoperative hematoma formation
- Reasonable concerns for postoperative hematoma formation based on intraoperative findings
- Significant postoperative anemia that has not stabilized
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 protocol.
To maintain standardized dosing and to account for body weight variation, pharmacy staff would be consulted for weight-based adjustments of the prophylactic dosage. The neurosurgery 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 have been established to consider chemical prophylaxis 24 hours after a stable repeat head computed tomography scan for patients with mild traumatic brain injury (TBI) and the following:
- Glasgow coma score of 15 within 30 minutes of injury
- Subdural or epidural hematoma < 8 mm
- Contusion or intraventricular hemorrhage < 2 cm (single lobe only)
The VTE protocol was implemented in June 2018. The neurosurgery section agreed to reevaluate the protocol at six months, given the concern for possible increased incidence of postoperative hemorrhagic complications. The section then would review the incidence of postoperative hemorrhages following implementation of the protocol and make a final decision regarding whether to modify the protocol or implement the existing paradigm permanently.
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 protocol. No additional costs or funding beyond normal hospital operations was necessary to implement and maintain this protocol.
TABLE 1. MERCY HOSPITAL NEUROSURGERY VTE OCCURRENCES
Results of the QI protocol
The protocol was reviewed in late 2018. Based on the successful results, the protocol was left in place without modifications.
Following the deployment of the VTE neurosurgery chemoprophylaxis protocol, downward trending occurrence rates were observed using ACS NSQIP SAR (Semi-Annual Report) and ISAR (Interim Semi-Annual Report) data. VTE occurrence rates in neurosurgery have decreased from 3.97 percent at the time of protocol initiation to 0.72 percent in January 2020, albeit with a slight increase to 1.02 percent in April 2020 (see Table 1 and Figure 1).
There were no encountered barriers related to the implementation of this protocol.
Cost savings for this initiative were not calculated; however, a decrease in VTE rates does yield shorter hospital length of stay, less need for pharmaceutical treatment, and reduced need for additional readmissions and/or follow-up visits. So, a decrease in VTE incidents is a large cost savings investment.
Tips for other facilities
Other facilities that provide neurosurgery services should implement the following practices:
- Use ACS NSQIP SAR and ISAR data for early trending to identify areas of improvement
- Continuously monitor protocol compliance (medication administration, preoperative and postoperative prophylactic measures, VTE risk assessment, VTE treatment provided)
- Communicate progress monthly with key stakeholders
*Stone J, Hangge P, Albadawi H, et al. Deep vein thrombosis: Pathogenesis, diagnosis, and medical management. Cardiovasc Diagn Ther. 2017;7(Suppl 3):S276-S284.