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Effective prevention of thromboembolic complications in emergency surgery patients using a quality improvement approach
  1. Simon Kreckler1,
  2. Robert D Morgan1,
  3. Ken Catchpole2,
  4. Steve New3,
  5. Ashok Handa1,
  6. Gary Collins4,
  7. Peter McCulloch1
  1. 1Nuffield Department of Surgical Science, University of Oxford, Oxford, Oxfordshire, UK
  2. 2Cedar Sinai Health System, Los Angeles California, Los Angeles, California, USA
  3. 3Said Business School, University of Oxford, Oxford, UK
  4. 4Centre for Statistics in Medicine, University of Oxford, Oxford, UK
  1. Correspondence to P McCulloch, Nuffield Department of Surgery, University of Oxford, Level 6 JRII, The John Radcliffe Hospital, Oxford OX3 9DU, UK; peter.mcculloch{at}nds.ox.ac.uk

Abstract

Objective To assess the effectiveness of a multifaceted intervention based on industrial process improvement to identify and sustainably correct deficiencies in thromboprophylaxis delivery.

Summary background data Deep vein thrombosis and pulmonary embolism are major causes of morbidity and mortality in surgical patients, but effective prophylactic treatments are available. Ensuring reliable delivery of the intended thromboprophylaxis is, however, a long-standing problem.

Methods Delivery of thromboprophylactic treatment on an emergency general surgery admissions ward was targeted during a multidisciplinary intervention to improve process reliability using industrial quality improvement approaches. Delivery was audited against guidelines before and after 3- month intervention. Clinical outcome was evaluated by reviewing all radiological investigations for suspected Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE) from patients admitted to the unit in the 1 year immediately before and that immediately after intervention.

Results Delivery of thromboprophylaxis according to guidelines was improved from 35% before to 87% 3 months after intervention (χ2=87.412, p<0.0001) and sustained at 86% 10 months after intervention. Radiologically identified thromboembolic events occurring up to 60 days after admission in patients admitted for over 48 h fell from 23/3075 (0.75%) before to 9/3080 (0.29%) after intervention (HR 0.39, CI 0.29 to 0.53, χ2=6.18, p=0.01292). The risk of thromboembolism in the two groups diverged during follow-up to 60 days, before converging again.

Conclusions A quality improvement process resulted in major sustainable improvements in the delivery of thromboprophylaxis associated with a 61% reduction in radiologically detected clinical episodes of thromboembolism 2 months after admission. Further study of this approach to improving care quality is warranted.

  • Quality improvement
  • Surgery
  • Lean management

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