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MetroHealth Medical Center Outpatient Treatment of Venous
Thromboembolism with Low-Molecular-Weight Heparin
Quality Resource Unit
CATALYST INITIATIVE
Catalyst Initiative Improvement Project
Aim of Project
• To provide safe outpatient management of patients
with Venous Thromboembolism (VTE), including
Deep Vein Thrombosis (DVT) and/or stable
Pulmonary Embolism (PE), through the use of
enoxaparin, a low-molecular-weight heparin
(LMWH) which can be given by subcutaneous
injection at home.
Improvement Cycles Required
• Development of a Patient Education Program
• Development of a standardized follow-up system in the
outpatient setting
• Involvement of multiple health care disciplines
• Resolution of cost issues
Conclusions / Results
• Patients admitted to MHMC with VTE can be
safely and effectively treated as outpatients
with LMWH after a short hospital stay
Pre-Protocol Protocol
Total patients
60
59
Related re-admits
4
3
Avg. Length of Stay 5.8 days
2.8 days
• Average days on protocol = 8 days
Background
• Conventional treatment consisted of:
• IV Heparin to prevent further clots
• Frequent blood draws during hospital stay
• LOS 5-7 days
• Proposed treatment consisted of:
• Injections given once or twice per day instead of
IV Heparin
• Blood draws once a day at home or clinic
• Less time in hospital (LOS 1-2 days)
Barriers
• Increased drug cost (~ $300 for a 7 day supply)
• Lack of insurance for drug coverage
• Uninsured and underinsured patients
• Lack of reimbursement for Home Care
• Lack of routine retail pharmacy stocking
How did we overcome the Barriers?
• Team developed pre-printed orders which included:
• Inclusion, exclusion criteria
• Weight-based LMWH dosing
• Initial oral blood thinner dosing
• Patient education materials
• Discharge Planning Orders
• Monitoring log
• Information on Indigent Medication Assistance Program
• Nursing and Physician Staffs were educated about the new
protocol
Team Members
• Marigel Constantiner (Team Leader)
• Matt Eisen (Facilitator)
• Sandie Amin (Facilitator)
• Robert Bahler
• Manoharan Balakrishnan
• Teresa Drocton
• Gaby El-Khoury
• Linda Horvath
• Cheryl Horvitz
• Marcia Kucler
• Kathy Lehman
• Thomas Lukens
• Margie Mazur
• Greg Palmer
• Lynette Seebohm