PERFORMANCE IMPROVEMENT (PI) MONITORING

POPULATION OF INTEREST

All trauma patients admitted to Role 2 or higher.

INTENT (EXPECTED OUTCOMES)

1. All patients in population of interest receive VTE prophylaxis with sequential compression device within 24 hours of injury.
2. All patients in population of interest start chemical VTE prophylaxis within 24 hours of injury or contraindication documented.
3. All ordered doses of chemical VTE prophylaxis are administered (no missed doses) or contraindication documented.
4. When IVCF is inserted, there is documentation in the medical record regarding the indication for procedure, whether the IVCF is retrievable, manufacturer, brand, serial number, lot number, and exact location of placement.
5. Retrievable IVC filters are removed within 6 months.

PERFORMANCE / ADHERENCE METRICS

1. Number and percentage of patients in the population of interest who start VTE prophylaxis with sequential compression device within 24 hours of injury.
2. Number and percentage of patients in the population of interest who receive chemical VTE prophylaxis within 24 hours of injury or have contraindication documented.
3. Number and percentage of patients in the population of interest who receive all ordered doses of chemical VTE prophylaxis or have contraindication documented.
4. Number and percentage of patients who receive IVC filter placement who have complete documentation of indication for procedure, whether the IVCF is retrievable, manufacturer, brand, serial number, lot number, and exact location of placement.
5. Number and percentage of retrievable IVC filters placed that are removed within 6 months.

DATA SOURCE

- Patient Record
- Department of Defense Trauma Registry (DoDTR)

SYSTEM REPORTING & FREQUENCY

The above constitutes the minimum criteria for PI monitoring of this CPG. System reporting will be performed annually; additional PI monitoring and system reporting may be performed as needed.

The system review and data analysis will be performed by the JTS Chief and the JTS PI Branch.

RESPONSIBILITIES

It is the trauma team leader’s responsibility to ensure familiarity, appropriate compliance, and PI monitoring at the local level with this CPG.

All health care providers will:

1. Become familiar with the guidelines for the prevention of DVT (see Appendix A).
2. Appropriately manage patients who may be at risk of developing DVT.
3. Provide feedback on these guidelines and suggestions for changes to the CPG to the JTS Chief.

The senior surgeon and/or Intensivist at each Role 3 facility will:

1. Review all thromboembolic events in the Level III facility to assess ways to reduce the risk to the patient.
2. Coordinate with the JTS Performance Improvement Chief on the appropriateness of the guidelines being used and provide input for updates on an as needed basis.