Team # 926 -- Venous Thromboembolism Prevention
College of Medicine

July 2008


To decrease the rate of venous thromboembolic complications that include deep vein thrombosis and pulmonary embolism not present on admission or within 30 days of discharge.

Penn State Hershey Medical Center (PSHMC) seeks to provide evidence-based, quality care in the treatment of complex hospitalized medical and surgical patients with diagnoses subject to venous thromboembolic (VTE) complications. Hospital acquired VTE events account for a significant percentage of in-hospital mortality. As part of our ongoing quality improvement initiatives, the opportunity to evaluate and address VTE prevention was identified as an organizational quality goal and as one of the four Highmark QualityBLUE program projects for FY 08-09. PSHMC established a VTE project team in July 2008 with the goal of decreasing the rate of VTE that includes deep vein thrombosis (DVT) and pulmonary embolism (PE) not present on admission (POA) or within 30 days of discharge. DVT refers to the formation of one or more blood clots in one of the body's large veins. PE, one of the most serious complications that can arise from DVT, occurs when a portion of the blood clot breaks loose and travels to the lungs partially or completely blocking an artery with the potential for sudden death. Team strategies effectively focused on staff and resident education and use of computerized decision support in the application of venous thromboembolism prevention guidelines and the implementation of therapeutic medical treatment.

Team Membership

  • Kathy Williams, Leader
  • Hamid Al-Mondhiry, Member
  • Lucille Andersen, Member
  • Joy Bair, Member
  • Michael Beck, Member
  • Sandra Blosser, Member
  • Derek Culnan, Member
  • Mary Lou Daxton, Member
  • Carol Houlihan, Member
  • Nicole Kasmar, Member
  • Kevin Laraway, Member
  • Matt Loser, Member
  • Kevin McKenna, Member
  • Patrick McQuillan, Member
  • Gail Ortenzi, Member
  • Kain Robbins, Member
  • John Showalter, Member
  • Patricia Swetland, Member
  • Lisa Wilhelm, Member
  • Sallie Young, Member

Results Achieved to Date

  • ExpectedResults: The outcome measure of performance for the project is the rate of DVT and PE per 100 admissions. The incidence of hospital-acquired DVT and pulmonary embolism has been reported nationally as 1.3% and 0.4% respectively. Our goal is to be at or below 0.6% and 0.4% respectively along with an ongoing decreasing trend. Our current annual rate has decreased from 0.8% to 0.7% for DVT and 0.5% to 0.4% for PE and continues to demonstrate a decreasing trend.
  • PSHMC has continued this performance improvement initiative since start-up in the Fall of 2008. Since that time, the PE rate has remained stable below 0.4%, which is a significant positive outcome given the increased mortality rate for patients with this complication. However, the DVT rate has increased slightly following an initial decrease. This increase may be attributed to increased diagnostic testing of the hospitalized patient and subsequent identification of this condition given heightened healthcare practitioner awareness. Performance improvement efforts continue to identify specific prevention strategies planned for implementation by the project team this year.

    Kathleen Williams
    October 3, 2011




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