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Program helped reduce VTE in trauma patients


 

Team performing surgery

Photo by Piotr Bodzek

Data from a statewide quality collaborative helped the University of Michigan Trauma Service reduce its annual rate of venous thromboembolism (VTE), according to an article published in the Journal of the American College of Surgeons.

The data suggested that changing first-line VTE prophylaxis from unfractionated heparin to enoxaparin would decrease the incidence of VTE, and it did. The annual VTE incidence fell from about 36 cases to about 14.

Researchers said this study should not be interpreted as a head-to-head comparison of unfractionated heparin and enoxaparin as VTE prophylaxis in trauma patients. Instead, it should be seen as a model of how hospitals and physicians can use quality improvement data in a real-world setting.

Existing medical evidence has shown that both heparin and enoxaparin can be effective in preventing VTE, depending on factors such as how the agents are dosed and administered.

“Based on our data, the enoxaparin regimen was more effective than heparin,” said study author David A. Machado-Aranda, MD, of the University of Michigan in Ann Arbor.

“Now, this result could be different in another institution, another collaborative, another geographical area, or another patient population based on the circumstances encountered.”

Dr Machado-Aranda and his colleagues participate in the Michigan Trauma Quality Improvement Program (MTQIP), a statewide program of 27 ACS Level 1 and 2 trauma centers.

The program showed the researchers that the rate of VTE was higher for the University of Michigan Trauma Service than the collaborative average.

A closer look at the data revealed that VTE rates among trauma patients who received unfractionated heparin were twice as high as rates for patients who received enoxaparin.

After the University of Michigan Trauma Service switched from using unfractionated heparin to enoxaparin as first-line VTE prophylaxis, the rate of VTE dropped from 6.2% to 2.6%.

“What we’ve done is to use the collaborative as our ‘mission control’ to see where we’re heading and what our trajectory is,” Dr Machado-Aranda said. “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.”

Dr Machado-Aranda noted that the trauma team encountered some challenges in changing the protocol for VTE prophylaxis. Hospital administration and other departments were concerned about the higher cost of enoxaparin.

In the end, “the increased costs of using enoxaparin were more than offset by savings generated by reducing the rate of venous thromboembolism complications,” he said.

The trauma surgeons also found they had to review the data with the neurosurgeons and orthopedic surgeons on staff to understand and alleviate their concerns about enoxaparin and potential higher rates of bleeding complications.

The neurosurgical group had previously published a study that showed higher rates of intracranial bleeding in patients undergoing brain tumor surgery who received enoxaparin rather than sequential compression devices alone.

“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,” Dr Machado-Aranda said.

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