The VTE Protocol

The VTE Protocol

We recommend that systematic efforts to improve VTE prophylaxis prevalence start with a single, specific intervention – a VTE protocol. Once the VTE protocol is in place, your team can layer additional interventions to leverage it and to boost its effectiveness (e.g. educational efforts, audit-and-feedback of performance, etc).

This first layer is so fundamental that your team should consider the VTE protocol the pre-requisite, enabling layer for any subsequent interventions.

The VTE Protocol

Your team may come up with a dozen interventions to optimize prevalence of appropriate VTE prophylaxis. One intervention every team should implement first is a very well integrated VTE protocol.

Why a protocol?

The key concept is routine. Doing a complex activity the same way each time is the best way to make sure that nothing is left out. In the hospital, protocols serve that purpose. They standardize and structure care delivered by a group of providers.

Why is routine important?

Across a population of patients, one of the most common sources of sub-optimal care arises from provider inconsistency. For variety of reasons providers inevitably vary care inappropriately, whether compared to each other or compared to themselves. In fact, a graph that depicts improved system performance over time almost always shows a progressive narrowing of the range of performance. In a powerful way, protocols have the capacity improve care by specifically reducing this unnecessary variation in performance, from medical decision-making to ordering.

The best protocols preserve our ability to customize care for special patient situations or circumstances. In contrast to variation arising from provider behavior, variation from the protocol that arises due to special patient situations is always acceptable. The protocol should make that clear.

What exactly is the VTE protocol?

The VTE protocol consists of a standardized VTE risk assessment with a linked menu of appropriate prophylaxis options (plus a method to determine contraindications to pharmacologic VTE prophylaxis).

Let’s look at the components of the VTE protocol:

1. VTE risk assessment
   – this simply adds decision support to the point of care; in other words, at the moment of medical decision-making, providers have what they need to stratify the patient to a specific VTE risk level
2. Linked menu of appropriate prophylaxis options
   – this simply allows providers to select appropriate VTE prophylaxis once the VTE risk level is determined
3. Contraindications to pharmacologic or heparin prophylaxis
   – like the VTE risk assessment, this simply adds decision support so providers know when to choose alternative prophylaxis, i.e. if specific contraindications to anticoagulation or heparin products exist

The great challenge for your team is to make use of the VTE protocol so easy and automatic that all patients coming into your hospital at any time from any place will be ‘funneled’ through it. 

Transitions in Care: Extending the Range of Your VTE Protocol

For selected inpatients, such as those with major orthopedic procedures, there are high level ACCP recommendations to extend the VTE prophylaxis beyond the duration of their hospitalization. Selected other populations may also benefit. We recommend that your team address this issue, and incorporate guidance on extended duration of VTE prophylaxis into your discharge process.