Confidential: Quality Improvement Material

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 post-surgically to mitigate the risk of clot formation.

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Project Aim Statement

The aim of the project was to reduce the incidents of The aim of the project was to reduce the incidents of VTE in post-surgical orthopedic patients through an VTE in post-surgical orthopedic patients through an increased International Normalized Ratio (INR) increased International Normalized Ratio (INR) range, derived from range, derived from The American College of Chest The American College of Chest PhysiciansPhysicians’ (CHEST) guidelines on antithrombotic ’ (CHEST) guidelines on antithrombotic therapytherapy11..

The measurement goal for this project was to reduce The measurement goal for this project was to reduce the number of clotting events for the patient the number of clotting events for the patient population actively taking oral anticoagulants while population actively taking oral anticoagulants while enrolled in the LUHS Anticoagulation clinic, with the enrolled in the LUHS Anticoagulation clinic, with the primary diagnosis code of 719.96 (post-surgical primary diagnosis code of 719.96 (post-surgical orthopedic prophylaxis).orthopedic prophylaxis).

1 1 Geerts, WH, Bergqvist, , D Pineo, GF, et al. Prevention of venous thromboembolism: Geerts, WH, Bergqvist, , D Pineo, GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Practice Guidelines (8th Edition). American College of Chest Physicians Evidence-Based Practice Guidelines (8th Edition). Chest 2008; 133:381s.Chest 2008; 133:381s.

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Forces of Magnetism Involved

Organizational Structure

Management Style

Quality Of Care

Autonomy

Professional Staff as Teachers

Interdisciplinary Relationships

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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.

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Results

Clotting Events for Post-Surgical Orthopedic Patients Over a 24 Month Period

0

0.5

1

1.5

2

2.5

Nov-0

6

Dec-0

6

Jan-

07

Feb-0

7

Mar

-07

Apr-0

7

May

-07

Jun-

07

Jul-0

7

Aug-0

7

Sep-0

7

Oct-

07

Nov-0

7

Dec-0

7

Jan-

08

Feb-0

8

Mar

-08

Apr-0

8

May

-08

Jun-

08

Jul-0

8

Aug-0

8

Sep-0

8

Oct-

08

Nov-0

8

Month/Year

Nu

mb

er o

f E

ven

ts P

er M

on

th

INRIntervention

10/07

Risk ofClotting

78 in 1000 from11/06 - 09/07

Risk ofClotting

6 in 1000 from10/07 - 11/08

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ResultsAdjusted Bleeding Risk Over a 24 Month Period

0

5

10

15

20

25

30

35

40

45

50H

emo

rrh

agin

g R

isk

Per

100

0 P

atie

nts

Pre-Intervention Adjusted Hemorrhage Risk 11/06 – 09/07 =

10 in 1000

Post-Intervention Adjusted Hemorrhage

Risk 10/07 – 11/08 = 14 in 1000

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Results

Total Active Post-Surgical Orthopedic Patient Population Over a 24 Month period

0

10

20

30

40

50

60

70

Nov-0

6

Dec-0

6

Jan-

07

Feb-0

7

Mar

-07

Apr-0

7

May

-07

Jun-

07

Jul-0

7

Aug-0

7

Sep-0

7

Oct-

07

Nov-0

7

Dec-0

7

Jan-

08

Feb-0

8

Mar

-08

Apr-0

8

May

-08

Jun-

08

Jul-0

8

Aug-0

8

Sep-0

8

Oct-

08

Nov-0

8

Month/Year

Nu

mb

er o

f A

ctiv

e P

atie

nts

Per

Mo

nth

11/06-9/07Monthly Patient Average = 27

10/07-11/08Monthly PatientAverage = 57

INRIntervention

10/07

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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.

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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.