National Surgical Quality Improvement Program (NSQIP) data showed Boston Medical Center to be a high outlier for VTE. “Looking at our semi-annual report, which contains risk-adjusted data, we realized that our patients were three times as likely as comparable medical centers across the nation to get a VTE," Director of Clinical Quality and Patient Safety Pamela Rosenkranz said, looking back at how they realized the problem in 2010. “Nobody wants to be a high outlier for something like this, and we didn't want that happening to our patients."
Determined to address the VTE issue, Rosenkranz and Vice Chair of Surgery David McAneny assembled a multidisciplinary team to develop a VTE prevention protocol. The team included pharmacy, nursing, physical therapy, and IT specialists, as well as surgeons and residents. The committee collectively decided to use the well-validated Caprini DVT (deep venous thrombosis) risk assessment tool because they felt it offered a high degree of adaptability for measuring individual patient risk. They then could use that risk score to trigger mandatory interventions.
Boston Medical Center built the VTE scoring system into its electronic medical record system in a way that required surgeons to complete the risk assessment before they could sign surgical orders. “Our goal was to build electronic order sets that contained a 'hard stop,' meaning the surgical orders could not be signed unless the Caprini risk assessment was completed," Rosenkranz said. “Then an order set would come up with the correct interventions based on the patient's specific risk class, and the physician would order what the patient would need, including ambulation, sequential compression devices and chemoprophylaxis."
Putting the protocol into the medical record helped enhance compliance by surgeons, though doctors could still opt out for valid medical reasons. “If there was some reason a surgeon felt a patient shouldn't have chemoprophylaxis or sequential compression devices, they could pt out. However, they had to put in a reason why," Rosenkranz said.