DVT Team Makes Progress

The Quality Council Deep Vein Thrombosis (DVT) Team has made steady progress towards achieving 100 percent compliance with two new JCAHO measures:
  • Surgical patients are recommended to have appropriate VTE prophylaxis ordered during the admission;
  • Surgical patients are to receive appropriate VTE prophylaxis within 24 hours prior to surgery to 24 hours after surgery.

A multidisciplinary team led by Richard (Rick) Riggs, M.D., chair of the Department of Physical Medicine and Rehabilitation, has identified current DVT prophylaxis practices across all inpatient services. The team has been working on a plan to achieve total compliance, including testing and refining the process, gaining approval of the process and implementing the process across all surgical disciplines at Cedars-Sinai.

Last month, working with several orthopedic surgeons, the team implemented a test of change with the Total Knee Replacement (TKR) patient population. A TKR-specific order set was developed to prompt physicians to document the appropriate DVT prophylaxis, including if a patient was at risk for bleeding.

Based on this logic, chemical versus mechanical prophylaxis options were presented, and physicians documented their prophylaxis orders accordingly. Over 80 percent compliance was achieved during the first cycle. Going forward, Daniel Margulies, M.D., director of the Trauma Program, will spearhead the order set implementation process in the general surgery areas.

In addition to TKR, the team has finalized Total Hip Replacement and Hip Fracture order sets.

Next steps for the team include finalizing order sets for:

  • OB/Gyn
  • Spine
  • Neurosurgery
  • Urology
  • General Surgery and Medical DVT
"We are committed to achieving 100 percent compliance with these measures by the end of the current fiscal year," said Riggs.

The first set of data will be submitted to The Joint Commission in April (for fourth quarter 2006).