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Quality Improvement Project Lowers VTE Rate for Trauma Patients

October 6th, 2016

ANN ARBOR, MI – How does your trauma center’s patient care measure up to others in your state?

That’s what a team of trauma surgeons from the University of Michigan in Ann Arbor, MI, found out when they participated in the Michigan Trauma Quality Improvement Program (MTQIP), a statewide program of 27 ACS Level 1 and 2 trauma centers.

What they discovered was alarming: The rate of venous thromboembolism (VTE) events at their facility was higher than the collaborative average. Drilling down in the data, it became clear that VTE rates were doubled among their trauma patients who received the anti-clotting agent unfractionated heparin as opposed to a different agent, enoxaparin, according to a report published online by the Journal of the American College of Surgeons.

MTQIP, sponsored by Blue Cross Blue Shield of Michigan and Blue Care Network, provides feedback reporting on a statewide basis. National level comparisons were available through the Trauma Quality Improvement Program sponsored by the American College of Surgeons.

After the UM Trauma Center switched from using unfractionated heparin as its first-line anti-clotting agent to enoxaparin, the rate of VTE dropped from 6.2% percent (about 36 cases a year) to 2.6% percent (14 cases a year), according to the study.

"What we've done is to use the collaborative as our mission control to see where we're heading and what our trajectory is," explained study coauthor David A. Machado-Aranda, MD, FACS. "Once we saw ourselves deviating from a favorable trajectory, we used the data derived from the collaborative to investigate our problem. We also accessed many different resources to review best practices, receive suggestions from other collaborative participants, and perform root cause analysis. An action plan was formulated, approved, and implemented to get our trauma service off of an unfavorable trajectory for VTE complications."

Here’s how study authors described their new plan: “consolidation to single VTE prophylaxis agent and dose, focused education of providers, initiation of VTE prophylaxis for all patients –with clear exception rules –and dose withholding minimization.”

Machado-Aranda cautioned that the study shouldn’t be interpreted as a head-to-head comparison of unfractionated heparin to enoxaparin in preventing VTE events; both products have been found to be effective in preventing blood clots based on factors such as how the agents are dosed and administered.

The changes weren’t made without a hitch, however. Enoxaparin is more expensive, creating concerns from hospital administration. Ultimately, the study team was able to prove how the additional costs were offset by reducing VTE.

Another issue was that neurosurgical colleagues had previously published a study finding higher rates of intracranial bleeding with enoxaparin in some surgical patients. "These results became extrapolated into the trauma setting, and it took us some time convincing our neurosurgeons to consider changing their practice for trauma patients," Machado-Aranda said.