Reducing Clotting Events for Post-Surgical Orthopedic Patients

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Reducing Clotting Events for Post-Surgical
Orthopedic Patients

• Loyola Anticoagulation Clinic
• Spring 2009

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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

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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 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 therapy1.
• 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
  133381s.

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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
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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
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Results
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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 clinics 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.