The VTE Protocol

The VTE Protocol

We recommend that a systematic effort to improve VTE prophylaxis prevalence starts with a single, specific intervention – a VTE protocol. Once the VTE protocol is in place, the team can layer additional interventions to leverage it (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 to 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.

It may be useful to returning to the VTE protocol and its components: 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.

1. standardized VTE risk assessment – delivers decision support to the point of care so that, 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 – assists providers with making the best choice for VTE prophylaxis
3. contraindications to pharmacologic or heparin prophylaxis – delivers decision support to the point of care so that, at the moment of medical decision-making, providers know when to choose alternative prophylaxis

One of the great determinants of success will be whether the team can make use of the VTE protocol so easy and automatic that all patients coming into the hospital at any time from any place will be ‘funneled’ through it. 

Transitions of Care: Extending the Range of the 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 the hospitalization. The evidence-base may eventually identify other populations that may benefit from extended prophylaxis. We recommend that the team address this issue, and incorporate guidance on extended duration of VTE prophylaxis into the discharge process.