Transcript Reducing Clotting Events for Post

Reducing Clotting Events
for Post-Surgical
Orthopedic Patients
Loyola Anticoagulation Clinic
Spring 2009
Confidential: Quality Improvement Material
Team Members
 Michael Grant, MA
 Anita Calistro, RN, MSN
 Peggy Thueson RN, BSN
 Brian Ing, MD
Special Thanks To:
 Penny Bleffer-Riding and Mike Wall from CCE
 Joan White, RN, MS
 Robert Schiff, MD
Confidential: Quality Improvement Material
Background
Orthopedic surgery can place an otherwise
healthy person at risk of having a Venous
Thromboembolic Event (VTE). VTEs, such as
Deep Vein Thrombosis (DVT) and Pulmonary
Embolism (PE), can occur post-surgically in
this population even when the patient has no
previous history of cardiovascular disease.
Anticoagulants are administered postsurgically to mitigate the risk of clot formation.
Confidential: Quality Improvement Material
Project Aim Statement
 The aim of the project was to reduce the incidents of
VTE in post-surgical orthopedic patients through an
increased International Normalized Ratio (INR)
range, derived from The American College of Chest
Physicians’ (CHEST) guidelines on antithrombotic
therapy1.
 The measurement goal for this project was to reduce
the number of clotting events for the patient
population actively taking oral anticoagulants while
enrolled in the LUHS Anticoagulation clinic, with the
primary diagnosis code of 719.96 (post-surgical
orthopedic prophylaxis).
1 Geerts, WH, Bergqvist, , D Pineo, GF, et al. Prevention of venous thromboembolism:
American College of Chest Physicians Evidence-Based Practice Guidelines (8th Edition).
Chest 2008; 133:381s.
Confidential: Quality Improvement Material
Forces of Magnetism Involved
 Organizational Structure
 Management Style
 Quality Of Care
 Autonomy
 Professional Staff as Teachers
 Interdisciplinary Relationships
Confidential: Quality Improvement Material
Solutions Implemented
Based on CHEST guidelines, the clinic worked
in conjunction with the Orthopedic
Surgery department to raise the INR level for
post-surgical orthopedic patients from
1.5 – 2.0 to 2.0 – 2.5. Nursing and pharmacy
staff then monitored the patients,
adjusting their anticoagulant doses to attain
therapeutic levels.
Confidential: Quality Improvement Material
Results
Clotting Events for Post-Surgical Orthopedic Patients Over a 24 Month Period
2.5
1.5
1
0.5
Risk of
Clotting
78 in 1000 from
11/06 - 09/07
INR
Intervention
10/07
Risk of
Clotting
6 in 1000 from
10/07 - 11/08
ov
-0
6
D
ec
-0
6
Ja
n0
Fe 7
b07
M
ar
-0
7
Ap
r07
M
ay
-0
7
Ju
n07
Ju
l-0
Au 7
g07
Se
p07
O
ct
-0
7
N
ov
-0
7
D
ec
-0
7
Ja
n0
Fe 8
b08
M
ar
-0
8
Ap
r08
M
ay
-0
8
Ju
n08
Ju
l-0
Au 8
g08
Se
p08
O
ct
-0
8
N
ov
-0
8
0
N
Number of Events Per Month
2
Month/Year
Confidential: Quality Improvement Material
Results
Adjusted Bleeding Risk Over a 24 Month Period
50
45
Hemorrhaging Risk Per 1000 Patients
40
35
30
25
20
15
10
5
0
Pre-Intervention
Adjusted Hemorrhage
Risk 11/06 – 09/07 =
10 in 1000
Post-Intervention
Adjusted Hemorrhage
Risk 10/07 – 11/08 =
14 in 1000
Confidential: Quality Improvement Material
Results
Total Active Post-Surgical Orthopedic Patient Population Over a 24 Month period
70
10/07-11/08
Monthly Patient
Average = 57
50
40
30
INR
Intervention
10/07
20
10
11/06-9/07
Monthly Patient
Average = 27
ov
-0
6
D
ec
-0
6
Ja
n0
Fe 7
b07
M
ar
-0
7
Ap
r07
M
ay
-0
7
Ju
n07
Ju
l-0
Au 7
g07
Se
p07
O
ct
-0
7
N
ov
-0
7
D
ec
-0
7
Ja
n0
Fe 8
b08
M
ar
-0
8
Ap
r08
M
ay
-0
8
Ju
n08
Ju
l-0
Au 8
g08
Se
p08
O
ct
-0
8
N
ov
-0
8
0
N
Number of Active Patients Per Month
60
Month/Year
Confidential: Quality Improvement Material
Analysis
 The average patient INR was raised from 1.9 to 2.2 during this 24





month period.
Clotting events were reduced from 8 before the intervention to 2
afterwards, decreasing by a factor of 13 after accounting for patient
population growth (See chart 1).
As clotting dropped, hemorrhaging remained stable, rising only slightly
from 10 in 1000 to 14 in 1000(See chart 3).
This intervention was implemented at a time of rapid growth in the
clinic’s post-surgical orthopedic patient population, with average
monthly numbers rising from 27 to 57 patients per month (See chart 2).
These results were statistically significant, achieving significance at the
.001 level using a chi-square test for independence.
It is estimated that this intervention has prevented $144,000 in health
care costs during the 13 months after its inception (assuming a cost of
$6,000 per VTE).1
1 Hawkins, David. “Economic considerations in the prevention and treatment of venous
thromboembolism.”American Journal of Health-System Pharmacists 61(2004): S18.
Confidential: Quality Improvement Material
Next Steps
 Data are available for further studies should these be warranted.
 A growing body of literature supports a minimum INR range of
2.0 – 3.0 for post-surgical orthopedic prophylaxis.
 Future consideration may be given to further adjustments of the
INR, at which time we may conduct another study.
Confidential: Quality Improvement Material