Prevention of Venous Thromboembolism in an Urban Academic Medical Center

Purpose:
To address inconsistent nursing practice around venous thromboembolism prevention in our hospital, Lean methodologies were used to achieve the goals of increasing appropriate utilization of prophylaxis, decreasing variability of practices, and in effect reducing venous thromboembolism events.

Relevance/Significance:
Hospitalized patients are at increased risk for developing venous thromboembolism which may lead to death. Prevention practices by nurses are critical to patient safety. Prophylaxis rates well below national average and an increase in venous thromboembolism events in our hospital indicated a need for improvement in prevention practices. A rapid-cycle improvement process called Kaizen enabled immediate and sustainable improvement in nursing practice which has been reflected in patient outcomes.

Strategy and Implementation:
An interdisciplinary Kaizen event was held in January 2014. Barriers to nurses providing venous thromboembolism prophylaxis identified were a shortage of mechanical prophylaxis, multiple charting options in the electronic health record leading to double documentation, missing prophylaxis orders, and lack of empowerment to address prophylaxis. Standard work was implemented for nurses including mechanical prophylaxis on at all times except ambulation, documentation every 4 hours with vitals, and empowering nurses to apply mechanical prophylaxis and promote ambulation. Additional mechanical prophylaxis devices were procured, documentation options were streamlined, and prophylaxis was added to admission order sets. Nurses were educated over 3 months on the standard work. To reinforce, nurse managers perform audits and follow up with staff on missed ambulation and prophylaxis. Prevention measures are placed on the nursing units key performance indicator board that is reported every shift.

Evaluation:
Perioperative venous thromboembolism rate for the first 6 months of FY14 was 15.55 per 1,000. Final rate for FY14 was 13.94 per 1,000. Rate for first 7 months of FY15 was 11.2 per 1,000. 73% of inpatients received prophylaxis in 2013 compared with 94% in 2014 and 100% since October 2014. Of venous thromboembolism events in 2013, 15% were potentially preventable which improved to 0% in 2014.

Implications for Practice:
Implementation of standard work has empowered nurses to proactively address venous thromboembolism prevention in medical and surgical patients. As a next step, an initiative called Project Walk which identifies patients with high risk mobility problems and promotes early ambulation has been started.