Early Prevention Guidelines and Protocols Produce Dramatic Results
Protocols undertaken by NYC Health + Hospitals/Jacobi in October 2016 to identify and reduce the threat of deep vein blood clots, or venous thromboembolism, have resulted in dramatic improvements.
In the first year following the protocols’ implementation, the number of cases of deep vein blood clots following surgery declined 53 percent, from 13 cases (baseline, November 2015 to October 2016) to 6 cases (November 2016 to November 2017), according to hospital-wide data. In the second year (December 2017 to December 2018), the number of cases declined to 4—an additional 15 percent decline from the baseline—demonstrating sustainability. Patient safety satisfaction scores also improved by 83 percent in the first year, according to Press Ganey data.
Venous thromboembolism refers to a blood clot that starts in a vein. A clot that develops in a deep vein, most often in the legs, is referred to as deep vein thrombosis. When such a clot breaks free from a vein wall and travels to the lungs—especially dangerous because it can block some or all of the blood supply—that is known as a pulmonary embolism.
The federal Centers for Disease Control and Prevention estimates that between 60,000 to 100,000 Americans die from venous thromboembolism every year. Patients recovering from surgery are at an increased risk for the condition. Other risk factors include age (starting at about age 40 and increasing over time), obesity, and cancer.
Clinicians at NYC Health + Hospitals/Jacobi sought to improve post-surgical safety by instituting a risk assessment scale to identify the patients at highest risk and introduce special monitoring and new preventive measures into their care. Among the interventions are:
· Introduction of an intermittent pneumatic compression device or stockings to allow for compression of blood veins to stabilize blood flow, used both before anesthesia (pre-surgery) and after surgery.
· Proper pharmaceutical prophylaxis, including the use of drugs like heparin only after applying the risk assessment scale.
· One-on-one consultations with all at-risk patients, addressing education about risk factors and warning signs. Follow-up with patients occurs at three days, two weeks, and one month post-operatively to screen for warning signs and reconfirm medication regimens.
"Between 60,000 and 100,000 Americans die every year from deep vein blood clots, according to the CDC,” said New York State Senator Luis Sepulveda. “I applaud NYC Health + Hospitals/Jacobi for dramatically improving the identification and reduction of the threat from deep vein blood clots. Lives will be saved through this medical innovation."
“The joint effort undertaken by the medical team at NYC Health + Hospitals/Jacobi is nothing short of astounding,” said Assemblywoman Nathalia Fernandez. “To see the number of cases of venous thromboembolism, which has been fatal to so many, taken down from 13 three years ago to 4 cases last year is an amazing accomplishment. I would like to extend my most sincere thank you to the team for limiting the number of fatal incidents post-surgery and for continuing to help the people in our communities.”
The article “NSQIP Impacts Patient Experience,” published in the December issue of the peer-reviewed Journal of Patient Experience, provides additional data and detail, focusing on implementation and related metrics in the hospital’s General Surgery service. (Unlike the article, today’s reported numbers reflect hospital-wide data. The sets of data, while different, reflect similar improvement.)
The article was written by Maria Castaldi, MD, former Director of Breast Health Service at NYC Health + Hospitals/Jacobi; Geena George, MPH, of Westchester Medical Center; Pamela O. Turner, MSN, Director of Nursing for Perioperative Services at NYC Health + Hospitals/Jacobi; and John McNelis, MD, Chairman of Surgery at NYC Health + Hospitals/Jacobi. The authors from NYC Health + Hospitals/Jacobi are also those who led the implementation of the protocols.
The article notes the dramatic change underscoring the improvement in patient satisfaction. Before the new interventions, only four patients of 109 who were surveyed recalled having a conversation with their doctor before surgery about the risk of blood
clots during surgery, the need for screening and prophylaxis to reduce the risk, and patient safety being a top priority. After the intervention, 145 of 147 patients surveyed reported that the indications, risks, and benefits of screening and prophylaxis were explained well or very well.
“This was truly a multi-disciplinary approach among members of our medical team,” said Dr. McNelis. “Surgeons, nurses, physician assistants, and anesthesiologists worked together to identify the risks to our patients and reduced them dramatically, and more important, the results have been sustainable.”
These protocols are just one component of the hospital’s ongoing efforts to make surgical care as safe as possible.