title: Effective prevention of thromboembolic complications in emergency surgery patients using a quality improvement approach.
abstract: OBJECTIVE
  To assess the effectiveness of a multifaceted intervention based on industrial process improvement to identify and sustainably correct deficiencies in thromboprophylaxis delivery.
  
  
  BACKGROUND
  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 (χ(2)=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, χ(2)=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.
authors.affiliation: Nuffield Department of Surgical Science, University of Oxford, , Oxford, Oxfordshire, UK.
authors.forename: Simon
authors.initials: S
authors.lastname: Kreckler
authors.forename: Robert D
authors.initials: RD
authors.lastname: Morgan
authors.forename: Ken
authors.initials: K
authors.lastname: Catchpole
authors.forename: Steve
authors.initials: S
authors.lastname: New
authors.forename: Ashok
authors.initials: A
authors.lastname: Handa
authors.forename: Gary
authors.initials: G
authors.lastname: Collins
authors.forename: Peter
authors.initials: P
authors.lastname: McCulloch
mesh_terms: D004638:Emergency Treatment; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D011183:Postoperative Complications / Q000517:prevention & control*; D058996:Quality Improvement; D013923:Thromboembolism / Q000517:prevention & control*; D006113:United Kingdom
keywords: Lean management; Quality improvement; Surgery