Deep vein thrombosis or pulmonary embolism after vascular or general surgery

A deep vein thrombosis (DVT) is a blood clot that forms in a deep vein, usually in the legs. A pulmonary embolism (PE) is a condition that occurs when an artery in your lung becomes blocked. In most cases, it is caused by a blood clot that becomes dislodged then travels to the lungs and blocks blood flow. A DVT may lead to a PE. This measure evaluates general and vascular surgical procedures.

PE and DVT are both serious potential complications of any surgery. Though not all PEs and DVTs are preventable, some of them are. It is our goal to minimize the number of preventable post-operative PEs and DVTs.

At Northwestern Memorial Hospital, we have procedures in place to avoid these complications. The two most important things we do are to prescribe anticoagulant medication (blood thinners) and, when medication is not an option, to have patients wear compression boots. The medication thins the blood, and compression boots squeeze the bottom of the legs to keep the blood flowing. Both of these treatments help prevent clots from forming.

What we are doing to improve

To go one step further toward patient safety and fewer PEs and DVTs, we have set up a team of doctors, nurses and pharmacists to review everything we do to prevent DVT/PE. That team is working to ensure consistent DVT/PE prevention is provided for all medicine and surgery patients. Pharmacists now play an expanded role in checking that patients have the right medications prescribed while they are in the hospital.  We have also conducted an educational program for nurses that focused on prevention.  We believe our education and team approach will better prevent DVT and PE.

About this measure

This measure tracks surgical patients who experienced DVT or PE after their surgery, based on a sampling methodology developed by the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP).

The rate of general and vascular surgery patients who have a blood clot after surgery is expressed as an odds ratio. This reports the estimated odds of an event happening at Northwestern Memorial compared to the estimated odds of that event happening in all hospitals in the ACS NSQIP database. A number of 1.0 means the hospital is performing as expected. A number less than 1.0 means the hospital is performing better than expected. A number greater than 1.0 means the hospital is performing worse than expected.

Note: While Northwestern Memorial results may be higher or lower than ACS NSQIP comparisons each period, our most recent performance is considered by ACS NSQIP to be "as expected" within the range expected for this surgical outcome. Given the number of patients in the measure, the results are statistically worse than expected.

In this case, a lower number is better.