Biffl Walter L, Beno Matthew, Goodman Philip, Bahia Amit, Sabel Allison, Snow Karen, Steele Andrew W, Swartwood Claire, Thienelt Christiane, MacKenzie Thomas D, Mehler Philip S
Denver Health Medical Center, Denver, USA.
Jt Comm J Qual Patient Saf. 2011 Mar;37(3):99-109. doi: 10.1016/s1553-7250(11)37012-2.
Lean principles have been used at Denver Health Medical Center since 2005 to streamline nonclinical processes. Despite allocation of significant resources, particularly the expense of low molecular weight heparin (LMWH), to prophylaxis of venous thromboembolism (VTE), the incidence of postoperative VTE was significantly worse than national benchmarks. VTE risk factors were not consistently assessed, and the prescribing of prophylaxis varied widely. Lean was employed to standardize and implement risk assessment and evidence-based VTE prophylaxis for the institution.
In a rapid improvement event, a multidisciplinary group formulated an evidence-based risk assessment tool and clinical practice guideline for VTE prophylaxis, with plans for hospitalwide implementation and monitoring.
The effects were immediate and improved steadily with feedback to clinicians. Within six months, compliance with the standard approached 100%. One year after implementation, the use of LMWH decreased more than 60% below baseline, and the use of sequential compression devices decreased by nearly 30%. With increased use of unfractionated heparin, the cost savings on VTE prophylaxis exceeded $15,000 per month, for a total of $425,000 since implementation. Moreover, the incidence of VTE decreased markedly during the same period. By reducing VTE rates, a total cost savings of $6.2 million was estimated for the past 28 months.
Applying Lean to the clinical management of VTE prophylaxis improved compliance with standards and saved the hospital a significant amount of money. This was achieved without compromising clinical outcomes. This experience could be replicated at other institutions.
自2005年以来，丹佛健康医疗中心一直运用精益原则来简化非临床流程。尽管在预防静脉血栓栓塞症（VTE）方面投入了大量资源，尤其是低分子量肝素（LMWH）的费用，但术后VTE的发生率仍显著高于全国基准。VTE风险因素未得到持续评估，预防措施的处方差异很大。于是采用精益方法为该机构规范并实施VTE风险评估和循证预防措施。
在一次快速改进活动中，一个多学科团队制定了基于证据的VTE风险评估工具和临床实践指南，并计划在全院实施和监测。
效果立竿见影，并随着向临床医生反馈而稳步改善。六个月内，标准的依从率接近100%。实施一年后，LMWH的使用量比基线水平下降了60%以上，序贯加压装置的使用量下降了近30%。随着普通肝素使用量的增加，VTE预防的成本节约超过每月15,000美元，自实施以来总计节约425,000美元。此外，同期VTE的发生率显著下降。通过降低VTE发生率，估计在过去28个月内总共节约成本620万美元。
将精益方法应用于VTE预防的临床管理提高了标准依从率，并为医院节省了大量资金。这一成果在不影响临床结果的情况下实现。其他机构也可借鉴这一经验。
