In 2023, the Department of Anesthesiology focused on PSI 11 – improving respiratory failure and sepsis – which decreased by about 80 percent. This progress was conducted by a multidisciplinary team under the leadership of Dr. Michael Kiyatkin, the 2023 MHS Performance Improvement Fellow and Director of Quality Assurance for Critical Care Anesthesiology.

This year, Anesthesiologist and Intensivist Dr. Christopher Tam was selected as the 2024 MHS Performance Improvement Fellow and co-champion in an effort to reduce the incidence of Patient Safety Indicator (PSI) 12 – the rate of perioperative pulmonary embolism or deep vein thrombosis. Dr. Tam is collaborating with Dr. Fran Ganz-Lord, MHS Assistant Vice President for Quality and Performance Improvement, and members of the Anesthesiology Digital Health Lab including Dr. Ling Zhang, Director of IT Innovation, and Dr. Maíra Rudolph, formerly the Digital Health Lab Chief and an incoming Anesthesiology Resident.

As part of these efforts, the Anesthesiology Digital Health Lab created a prediction model to determine which patients are at an increased risk of a thromboembolic event. As part of a bundle intervention, this new tool will be used to improve patient safety and lead to better outcomes for Montefiore Einstein’s most vulnerable patients. Dr. Tam and the performance improvement team are analyzing chemoprophylaxis of deep vein thrombosis to improve patient outcomes in this area. The team will develop guidelines on administering chemoprophylaxis in surgical patients to decrease the adverse event of deep vein thrombosis.

After reviewing patient data from the last two years, Dr. Tam’s team identified three areas that affect the rate of venous thromboembolism: administering chemoprophylaxis, conducting physical therapy, and using bilateral venous duplex ultrasounds to detect blood clots. From reviewing the data, they found that patients undergoing orthopedic surgeries have the highest risk of a pulmonary embolic event – which is analogous to the national trend. Thus, in creating the bundle intervention to reduce the rate of thromboembolic events among Montefiore Einstein patients, the physicians are first addressing chemoprophylaxis for patients undergoing orthopedic trauma surgeries.

Chemoprophylaxis in this case refers to the administration of anticoagulant medications such as enoxaparin, which reduce the risk of blood clots particularly for patients who are immobile due to surgery. Dr. Tam is working together with Montefiore Einstein Clinical Pharmacist Poojah Kumar to develop updated guidelines for chemoprophylaxis administration with the goal of reducing the risk of thromboembolic events. After completing the first set of guidelines for orthopedic trauma surgeries, Dr. Tam and his team will evaluate the risk of thromboembolic events for each surgical specialty so they can create chemoprophylaxis guidelines that are specified to the type of procedure.

“We went through the orthopedic trauma literature to see what the national recommendations are in terms of chemoprophylaxis in that population,” Dr. Tam explained. “We met with Montefiore’s Orthopedic Surgery trauma team as well as the Geriatric team to speak to them about our initiative and how we can collaborate to lower the overall incidence in the hospital starting with the orthopedic group.”

Under the leadership of Department of Anesthesiology Chair Dr. Matthias Eikermann, the Digital Health Lab analyzed risk factors for a thromboembolic event and developed a prediction model to forecast thromboembolic complications after non-cardiac surgery. Aline Grimm, a medical student and Research Fellow in the Digital Health Lab, explained that risk factors that make patients immobile – such as those who underwent hip repair, leg fracture, or spine surgeries – contribute to patients’ increased risk. Other factors that increase a patient’s risk for a thromboembolic event are a history of deep vein thrombosis or pulmonary embolism, specific types of surgery such as spine surgery or neurosurgery, and the patient being female and over 40 years of age.

“Chemoprophylaxis and mobilization would be big contributors to reducing the risk of thromboembolic events,” Ms. Grimm explained. “In the literature you can see that mobilization in critically ill patients for deep vein thrombosis and pulmonary embolism has quite a large impact and is a noninvasive implementation.”

Dr. Rudolph added that the lab’s newly developed tool is more accurate than existing prediction scores. The prediction tool was created using Montefiore Einstein patient data from 2016 to 2021 and has been validated externally at Beth Israel Deaconess Medical Center.

“Our goal was to create a prediction score that could be automated in big healthcare systems using electronic medical record data,” Dr. Rudolph explained. “This is something we’ve done before with machine learning and predicting which patients are at an increased risk of same-day case cancellation.”

Dr. Tam added that for patients who are flagged as high-risk, they will be screened with the bilateral venous duplex ultrasounds to detect blood clots prior to surgery. Because the majority of orthopedic surgeries are performed at Wakefield Hospital, the team there will begin using the prediction tool and bundle interventions to reduce patients’ risk of a thromboembolic event.

“Once we identify the patient’s risk through using the prediction tool, we’ll communicate it to the physical therapy and occupational therapy teams,” Dr. Tam said. “These patients will be on the top of their list to be seen for early physical therapy following an operation or in-bed physical therapy if they’re not able to get out of bed.”

Dr. Eikermann said he looks forward to the continued collaboration between the Department of Anesthesiology and the MHS Network Performance Group to develop interventions that will have an impact on patients’ lives. The team aims to lower Montefiore’s rate of PSI 12 by April 2025.

“In collaboration with Dr. Fran Ganz-Lord and Dr. Peter Shamamian, Vice Chair in the Department of Surgery, we will improve the quality of perioperative thromboembolic prophylaxis and its diagnosis documentation,” Dr. Eikermann said. “We are grateful for the strong support of senior hospital leadership, who appreciate our contributions to further strengthen Montefiore Einstein’s reputation.”