Improving Compliance with Guidelines for Venous Thromboembolism (VTE) Prophylaxis Significantly Reduces VTE Events.

Abstract

Background: Venous thromboembolism (VTE) is reported in about five percent of patients with malignancy and is often associated with serious clinical outcomes such as major infarction, hemorrhage and death. The prevalence rates of malignancy-related VTE is most likely underestimated, in part because of the frequent presence of confounding risk factors, such as advanced age, prolonged immobilization, surgical procedures, and chemotherapeutic regimens. Occurrence of VTE can increase the likelihood of death for cancer patients by 2- to 8-fold. Prophylactic anticoagulation therapy and mechanical prophylaxis is recommended for all inpatients with a diagnosis of active malignancy. Mechanical prophylaxis alone is recommended for patients if contraindication to anticoagulation therapy exists. Roswell Park Cancer Institute (RPCI), a Comprehensive Cancer Center with 24,000 active patients under its care, initiated an Institute-Wide Quality Improvement Initiative in 2006 to improve the rates of VTE prophylaxis for all adult inpatient admissions. The objectives were to improve compliance with national guidelines on VTE prophylaxis and to reduce future VTE events in our patient population.Methods: VTE prophylaxis based on National Comprehensive Cancer Network (NCCN) guidelines was instituted on all Medical services. Surgical services followed guidelines in accordance with NCCN and Surgical Best Practice and published standards. Mandatory physician order entry forms including computerized physician order entry were implemented. VTE awareness and staff education was promoted via informational materials, field in-services and seminars. In order to track compliance, manual audits of patient charts were performed every 3 months.Results: Results: Initial surveys revealed 61% compliance with guidelines on the medicine service and 86% on the surgical services. Overall institute-wide VTE Prophylaxis compliance improved from 80% to 95% following implementation of the initiative (shown in table 1). This has resulted in a decrease in VTE incidence from 0.39% in the last quarter of 2006 when the initiative was launched to 0.13% and 0.08% seen in the first and second quarters of 2008 respectively (P<0.0001). The actual events dropped from 40 in the last quarter of 2006 to 14 events and 10 events in the first and the second quarter of 2008 respectively. The greatest benefit was seen in reduction in outpatient VTE and on the medical services.Conclusions: Implementation of our VTE Prophylaxis Initiative resulted in improved compliance with national guidelines at RPCI and has resulted in a highly significant and clinically relevant reduction of VTE in our vulnerable patient population.Table 1: Institute Compliance rate on VTE prophylaxis200620072008ComplianceQ4Q1Q2Q3Q4Q1Q2Medical Services61%78%86%95%96%90%90%Surgical Service86%92%98%98%97%97%100%Institute-Wide80.40%86.80%93.60%96.60%96.50%94.60%95.4%Table 2: VTE events200620072008Q1Q2Q3Q4Q1Q2Q3Q4Q1Q2# VTE/Quarter31304040382934171410# Admission/Outpatients10439115181036710298102301107210815118521088713234%0.30%0.26%0.39%0.39%0.37%0.26%0.31%0.14%0.13%0.08%