1. Surgical Care Improvement Project Prevention of Post-operative Venous Thromboembolism Team Membership Department of Surgery, Nursing, Pharmacy, CCE Confidential: For Quality Improvement Purposes Only

2. Opportunity Statement Venous thromboembolism (VTE- deep vein thrombosis and pulmonary embolism) is the most common preventable cause of death following surgery. The rate of post-operative VTE at LUMC appears to be trended at 2-3% Confidential: For Quality Improvement Purposes Only

3. Project Goals Achieve a 50% reduction in the occurrence rate of post-operative venous thromboembolism Confidential: For Quality Improvement Purposes Only

4. Most Likely Causes for Current Opportunity Wide variability in use of prophylactic methods Variable awareness of national, evidence- based guidelines* Under utilization of pharmacologic prophylaxis (heparin) * Geerts, WH et al. Prevention of venous thromboembolism: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126:338s-400s. Confidential: For Quality Improvement Purposes Only

5. Solutions Implemented Developed and piloted Risk Assessment Tool in the Department of Surgery Developed guideline for selection of appropriate VTE prophylaxis for surgical patients Revised current standing post-operative orders in the Department of Surgery, Orthopaedics, Neurosurgery and Urology to include heparin or enoxaparin. Confidential: For Quality Improvement Purposes Only

6. Definition: General Surgery patients in the ICU, craniotomy patients, hip and pelvic fracture patients, total hip and total knee replacement patients and Trauma patients in the ICU with pharmacologic VTE prophylaxis administered within 24 hours of surgery end-time divided by patients without contraindications (active bleeding, allergy to heparin / enoxaparin) Data Source: Chart reviews Analysis: Performance has significantly improved since March 2007. VTE Summit (June 2007) LUHS-wide QI project initiated (Sept 2005) VTE Summit (October, 2007)

7. Definition: General Surgery patients in the ICU with pharmacologic VTE prophylaxis administered within 24 hours of surgery end-time divided by general surgery patients without contraindications (active bleeding, allergy to heparin / enoxaparin) Data Source: Chart reviews Analysis: Utilization of pharmacologic prophylaxis has improved significantly in the past year. LUHS-wide QI project initiated (Sept 2005) VTE Risk Tool and Guideline piloted with Dept of Surgery (March 2006) Ordersets modified (August 2006) VTE Summit (June, 2007) VTE Summit (October, 2007)

8. Definition: Number of Trauma ICU patients with pharmacologic VTE prophylaxis administered within 24 hours of surgery end-time or within 24 hours of admission for non-surgical patients divided by trauma ICU patients with no contraindications (allergy to heparin / enoxaparin, active bleeding, intra-cranial bleed, liver laceration, splenic laceration) Data Source: Chart reviews Analysis: The use of pharmacologic VTE prophylaxis has improved since February 2007. LUHS-wide QI project initiated (Sept 2005) VTE Summit (June 2007) VTE Summit (October, 2007)

9. Definition: Patients with pelvic or hip fracture who receive pharmacologic VTE prophylaxis administered within 24 hours of surgery end-time divided by pelvic or hip fracture patients without contraindications (active bleeding, allergy to heparin / enoxaparin) Data Source: Chart reviews Analysis: Performance significantly improved since June 2007. Modified ordersets VTE Summit (June 2007) VTE Summit (October, 2007)

10. Definition: Craniotomy patients with pharmacologic VTE prophylaxis administered within 24 hours of surgery end-time divided by craniotomy patients without contraindications (active bleeding, allergy to heparin / enoxaparin, intra-cranial bleed) Data Source: Chart reviews Analysis: There appears to be significant improvement since June 2007. VTE orders added to ordersets (March 2007) Leadership implemented standard use of pharmacologic prophylaxis (Feb 2007) VTE Summit (June 2007) VTE Summit (October, 2007)

11. Definition: Urology patients with pharmacologic VTE prophylaxis administered within 24 hours of surgery end-time divided by urology patients without contraindications (active bleeding, allergy to heparin / enoxaparin, intra-cranial bleed) Data Source: Chart reviews Analysis: There is not enough data points to determine progress. Leadership implemented standard use of pharmacologic prophylaxis (March 2008)

12. Definition: Craniotomy patients with pharmacologic VTE prophylaxis administered within 48 hours of surgery end-time divided by craniotomy patients without contraindications (active bleeding, allergy to heparin / enoxaparin, intra-cranial bleed) Data Source: Chart reviews Analysis: There appears to be significant improvement since June 2007.

13. Definition: Number of surgery cases in which orders were placed for appropriate measure to prevent venous thromboembolism (VTE; blood clots in legs or lungs) / Patient undergoing intracranial neurosurgery, elective spinal surgery, general surgery, gynecologic surgery, urologic surgery, elective total hip or knee replacement, or hip fracture surgery. Data source: LUMC medical records abstracted by RNs. Analysis: The rate of ordering recommended measures to prevent VTE averages 98%. Percent of Surgery Patients with VTE Prophylaxis Ordered Core Measures Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered Month (number of patients) UCL = 108.02 Mean = 97.58 LCL = 87.14 Oct 2006 (n=23) Nov 2006 (n=19)Dec 2006 (n=16) Jan 2007 (n=16) Feb 2007 (n=17)Mar 2007 (n=14) Apr 2007 (n=20) May 2007 (n=15) Jun 2007 (n=16) Jul 2007 (n=22) Aug 2007 (n=17)Sep 2007 (n=18) Oct 2007 (n=25) Nov 2007 (n=20)Dec 2007 (n=24) Jan 2008 (n=26) Feb 2008 (n=23) 85 90 95 100 105 110 Confidential: For Quality Improvement Purposes Only

14. Definition: Number of surgery cases receiving recommended measures to prevent venous thromboembolism (VTE) / Patient undergoing intracranial neurosurgery, elective spinal surgery, general surgery, gynecologic surgery, urologic surgery, elective total hip or knee replacement, or hip fracture surgery. Data source: LUMC medical records abstracted by RNs. Analysis: The rate of administering recommended VTE preventive measures (prophylaxis) is 89% since October 2006. Confidential: For Quality Improvement Purposes Only

15. Next Steps Ongoing monitoring prophylaxis use Continued education of physicians and nursing staff Continue comparison with UHC data Confidential: For Quality Improvement Purposes Only