1. Confidential: Quality Improvement Material Reducing Clotting Events for Post-Surgical Orthopedic Patients Loyola Anticoagulation Clinic Spring 2009

2. 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

3. 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.

4. Confidential: Quality Improvement Material Project Aim Statement The aim of the project was to reduce the incidents of VTE in post-surgical orthopedic patients through an increased International Normalized Ratio (INR) range, derived from The American College of Chest Physicians’ (CHEST) guidelines on antithrombotic therapy 1. The aim of the project was to reduce the incidents of VTE in post-surgical orthopedic patients through an increased International Normalized Ratio (INR) range, derived from The American College of Chest Physicians’ (CHEST) guidelines on antithrombotic therapy 1. The measurement goal for this project was to reduce the number of clotting events for the patient population actively taking oral anticoagulants while enrolled in the LUHS Anticoagulation clinic, with the primary diagnosis code of 719.96 (post-surgical orthopedic prophylaxis). The measurement goal for this project was to reduce the number of clotting events for the patient population actively taking oral anticoagulants while enrolled in the LUHS Anticoagulation clinic, with the primary diagnosis code of 719.96 (post-surgical orthopedic prophylaxis). 1 Geerts, WH, Bergqvist,, D Pineo, GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Practice Guidelines (8th Edition). Chest 2008; 133:381s.

5. Confidential: Quality Improvement Material Forces of Magnetism Involved Organizational Structure Management Style Quality Of Care Autonomy Professional Staff as Teachers Interdisciplinary Relationships

6. Confidential: Quality Improvement Material 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.

7. Confidential: Quality Improvement Material Results

8. Confidential: Quality Improvement Material Results Pre-Intervention Adjusted Hemorrhage Risk 11/06 – 09/07 = 10 in 1000 Post-Intervention Adjusted Hemorrhage Risk 10/07 – 11/08 = 14 in 1000

9. Confidential: Quality Improvement Material Results

10. Confidential: Quality Improvement Material 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.

11. Confidential: Quality Improvement Material 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.