AHRQ Guide at Center of Dignity Health Quality Improvement Effort

AHRQ's Preventing Hospital-Related Venous Thromboembolism (VTE) guide was a central component of Dignity Health's systemwide quality collaborative to reduce VTE. The quality improvement effort, which took place in 2012 and 2013, led to a reduction of an estimated 330 VTEs per year compared with the baseline for the 39-hospital system.

San Francisco-based Dignity Health, which operates hospitals and clinics in California, Arizona, and Nevada, collaborated with Gregory A. Maynard, M.D., chief quality officer at University of California Davis Medical Center and Ian H. Jenkins, M.D., a hospitalist at University of California San Diego Medical Center. Dr. Maynard originally developed the AHRQ VTE guide; Dr. Jenkins is a longtime contributor to University of California VTE prevention efforts.

VTEs are blood clots that form in the deep veins of the leg or pelvis (deep vein thrombosis, or DVT). They also cause pulmonary embolisms, which occur when deep vein clots dislodge and travel to the lung. VTEs affect up to 600,000 Americans each year, primarily sick or injured patients who are hospitalized or were recently hospitalized. Up to 15 percent of people who contract a VTE die from it.

"We had been working for years with SCIP [the Surgical Care Improvement Project, an AHRQ-supported national collaboration to improve surgical and postoperative care], and we thought we were doing pretty well on the surgical side—but we were afraid we were ignoring the medical patients," said Tamra O'Bryan, M.H.A., director, quality improvement for Dignity Health. Added Janet Holdych, Pharm.D., vice president of quality, "We went to the hospitals to ask what they were doing for VTE prophylaxis on the medical side, and some were doing it right—but not all were. There was too much variation, so we wanted to standardize the approach."

Complicating matters for Dignity Health: the system was in the midst of a transition from paper to electronic health records. This meant that two sets of tools needed to be developed to integrate with each type of physician ordering system.

The VTE protocols called for assessing all patients in one of three categories: low, medium, or high risk. Low risk meant no prophylaxis, medium meant a medication-based or mechanical (if medication-based contraindicated) prophylaxis, and high meant a combination of mechanical and pharmacological prophylaxis. The protocols were tested in two of the nine pilot sites, one with an electronic health record, one without, then deployed regionally to the other seven pilot hospitals before being rolled out systemwide. A "measure-vention" system, combining real-time monitoring and interventions where necessary, was employed.

Implementation started in early 2012, with measure-vention beginning in May of that year and webinars beginning in November. Of nearly 1.2 million inpatient admissions in the nine pilot hospitals, there were approximately 34,000 measure-vention checks.

The results: at the start of 2012, compliance with Joint Commission VTE protocols were in the low 70-percent range; by May 2013, they were consistently in the mid 90-percent range, where they have remained. VTE rates and actual numbers have fallen systemwide, both in terms of inpatient VTEs and readmissions.

AHRQ published its initial guide, Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement, in 2008. Dr. Maynard was a primary author of that guide, and led the effort to update the AHRQ guide in 2015. Before he worked with Dignity Health on its QI initiative, Dr. Maynard used the AHRQ materials to lead the five University of California hospitals in a quality improvement initiative that reduced VTEs by 24 percent between 2011 and 2014.