By Lola Butcher
As of July 15, every hospitalized patient admitted to Borgess Medical Center, Kalamazoo, Mich., automatically receives an order set that spells out how to prevent venous thromboembolism (VTE), commonly referred to as blood clots.
"Our goal is 100 percent success," says Nic Oprescu, MD, a hospitalist at Borgess Medical Center.
Oprescu's goal is aggressive because VTEs are so common. More than 10 percent of hospitalized medical patients develop blood clots, which are most prevalent in patients with heart failure, stroke, or heart attacks.
The initiative is still young, but Borgess staff are hopeful that they will soon be able to report a major decrease in the number of patients with blood clots. A high percentage of medical patients admitted since July have received treatments aimed at preventing VTEs.
Borgess Medical Center-the flagship hospital of Borgess Health, which serves southwestern and south-central Michigan-is one of 17 hospitals across the state that are working together to identify, measure, and promote the use of best practices to reduce the risk of blood clots in patients through the Hospital Medicine Safety Consortium, sponsored by Blue Cross Blue Shield of Michigan (BCBSM).
More than half of the approximately 1 million Americans who suffer from blood clots each year develop VTE in the hospital or within 30 days after discharge-and nearly 300,000 people die from VTEs. That is why patient safety advocates have a laser-like focus on the problem.
Treating blood clots also adds to the overall costs of care in the United States. For example, treating deep vein thrombosis, or a blood clot in the deep leg or pelvic veins, costs $10,000, according to estimates from the Agency for Healthcare Research and Quality, while treating another, more serious type of clot that lodges in the lung-pulmonary embolism-costs $20,000.
To prevent blood clots, the Borgess Medical Center's VTE Prophylaxis Committee, chaired by Oprescu, adopted an order set for use in all hospitalized patients.
The specific order set is comprised of two parts:
The order set is a refinement of a set previously developed by a multidisciplinary team at Borgess for use in specific patient populations. The VTE Prophylaxis Committee revitalized the order set with minor modifications and expanded its use to include all admitted patients.
The order set begins with a paper order form that is placed in every inpatient record for providers to complete at the time of admission. The provider uses the form to document the patient's risk, then checks a box that corresponds to the specific orders related to the level of risk. If prophylaxis is contraindicated, providers can document the reason by selecting from a list of possible exclusions and contraindications.
Nurses carry out the physician orders. For example, they ensure that mechanical devices to prevent blood clots are applied and documented as ordered. Nurses also independently perform an initial assessment for blood clot risk factors, as well as daily prevention checks.
Borgess and the other hospitals in the Hospital Medicine Safety Consortium are collaborating to identify and standardize best practices for the prevention of blood clots. "The whole idea is that we are collecting and sharing data so we can develop best practices throughout Michigan-not just for our hospital-to reach the best outcome," says Kathleen Hall, RN, BS, quality data analyst in the Quality Clinical Excellence department at Borgess.
Since January, Hall has been abstracting 200 charts each quarter to identify what VTE prevention strategy was used at Borgess or the reason why no VTE prevention was used. She sends the data to the University of Michigan Medical Center, Ann Arbor, which serves as the coordinating center for the initiative. The university is collecting and analyzing these data with the following goals in mind.
The data collection effort-800 cases from each of the 17 hospitals each year-provides enough data points for the coordinating center to assist participants in establishing and implementing quality improvement goals and best practices, says Tom Leyden, director of Value Partnerships, BCBSM.
"If a hospital wanted to do this for itself, it may not have the volume to be able to notice any discernible pattern of care," he says.
BCBSM provides $70,000 a year to each participating hospital to subsidize the expense of data abstraction. Hospitals are also eligible for pay-for-performance bonuses if they hit three benchmarks for VTE prevention.
Oprescu and his team meet quarterly with hospitalists and teams from other hospitals in the Hospital Medicine Safety Consortium to review data and discuss improvement strategies. While Borgess standardized its VTE prevention strategies by developing the order set, its protocols will be adjusted-if necessary-based on the consortium's consensus of what works best.
"It's fascinating to attend one of these meetings and see someone from the west side of the state saying to someone from the southeast side, 'This is what we did, and I can send you the documentation,'" says Leyden. "It's like watching neutrons and protons bounce off one another. It's very encouraging."
Lola Butcher is a freelance writer/editor based in Missouri and a contributing writer to Leadership.
Interviewed for this article:
Nic Oprescu, MD, is a hospitalist, Borgess Medical Center, Kalamazoo, Mich.
Kathleen Hall RN, BS, is a quality data analyst, Quality Clinical Excellence, Borgess Medical Center.
Tom Leyden is director of Value Partnerships, Blue Cross Blue Shield of Michigan, Detroit (firstname.lastname@example.org).
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