654 Improving Inflammatory Bowel Disease Care: A Quality Improvement Project for Venous Thromboembolism Prophylaxis

Abstract

INTRODUCTION: Inflammatory Bowel Disease (IBD) patients admitted with a flare are 5-6x more likely to have a complication with venous thromboembolism (VTE). As a result, more emphasis is being placed on administering chemical prophylaxis to these patients. A 6-month retrospective chart review of patients hospitalized at our institution with an IBD flare without severe GI bleeding revealed that only 39% received chemical VTE prophylaxis. Herein, we designed a quality improvement project with an aim to improve this rate to over 75%. METHODS: Our initial Ishikawa diagram was used to map out the entire process from which a patient enters the emergency room until they are admitted to their hospital bed to analyze reasons DVT chemoprophylaxis was withheld. “Bleeding” was the most commonly documented reason. We then decided to target the patient population to hospitalized IBD flares without severe GI bleeding. The parameters we set for this included Hemoglobin <7 g/dL, tachycardia, and/or hypotension. Our main intervention was placing reminder sheets in each Internal Medicine team room with the aforementioned parameters for appropriate use of chemical prophylaxis. Further, a department-wide e-mail was sent to all of Internal Medicine with the reminder sheet attached and educational text. RESULTS: Over the 4 months post-intervention, VTE prophylaxis rates for hospitalized IBD flares without severe bleeding (n = 14) improved to 100%. Hospitalization related costs for a diagnosis of “DVT” or “PE” are reportedly ∼$10,000 & $20,000, respectively. The cost of Lovenox for a 5 day length of stay for an 80 kg man is $420. There is an estimated 7.6 to 41% risk of VTE amongst patients hospitalized for flares. At University Hospital, we averaged about 4 flares without severe bleeding/month. Using 25% risk for 48 patients per year, this could potentially lead to 12 VTE prevented/year. Taking all of this into account there is a potential 900% return on investment with savings of about $160,000/year. CONCLUSION: It does appear that our interventions helped us reach our goal to improve VTE prophylaxis rates in IBD flares. A weakness, however, is the low sample size of patients, but we do plan to continue collecting data over the next year. Further, education has been proven to be a weak intervention with poor sustainability in the world of QI. The main plan for sustainability remains to work with IT to implement “IBD flare without severe bleeding” as a check-mark for high-risk of VTE on the admission order set.