Pregnant women have a five fold increased risk of venous thromboembolism (VTE) compared with non-pregnant women due to hypercoagulability, stasis, and endothelial injury.  Pulmonary embolism is the leading cause of maternal mortality, causing 20% of all pregnancy related deaths.
     In 2004, Baptist Hospital for Women participated in an IHI Impact Collaborative for Perioperative Safety.  Research was completed regarding best practice for VTE prophylaxis.  The IHI Perioperative Safety Committee created a standard VTE screening tool that was to be utilized for the surgical and obstetric populations.  They discovered the unique nature of obstetrics necessitated a specific screening tool and treatment recommendations.  A screening form was presented to the OB/GYN Medical Staff Committee.  They felt that there was not enough evidence based practice to support standardized VTE prophylaxis in obstetrics, but did support the use of intermittent compression devices on all C-sections.  This became standard practice.
     In 2006, BMHW became involved in a system collaborative to reduce occurrences of VTE with surgical patients, expanding to medical patients, and branching to the obstetric population.  Additional work was completed to construct an obstetric risk assessment form.  The committee was unable to obtain enough data to support standardized pharmacological prophylaxis, however, recommended the use of intermittent compression devices on all acutely ill obstetric patients.  
     In early 2007, a catastrophic outcome with VTE precipitated formation of a multidisciplinary team to review the literature and develop a more aggressive approach for identification of those at high risk and prevention of morbidity/mortality.  The goal was to develop obstetric VTE prophylaxis and intervention practice guidelines.  Approval was sought through the Medical Staff Leadership Committee. The team was facilitated by Performance Improvement and included medical staff from obstetrics, perinatology, hematology, and anesthesiology.  Additional team members were unit managers from L&D, Surgery, Mother-Baby, and PACU; nursing technical experts from L&D/AP, MBU, and GYN; and representatives from pharmacy, staff development, physical therapy, and administration. 
     After intensive literature review and deliberation, an OB VTE Risk Assessment form was created.  Initiated on the antepartum unit, it was later expanded to Labor and Delivery.  An attribute of this form was identification of the obstetric patient at high risk for VTE.  Specific recommendations included treatment based upon risk (low to moderate or high), with mechanical and pharmacologic treatment for high risk.  Bleeding risk assessment was included with contraindications to pharmacological/mechanical prophylaxis.  Regional anesthesia guidelines outlined treatment with Heparin/Enoxaparin based upon timing of neuraxial block.  Additional guidelines recommended use of intermittent compression devices until discharge, continuation of pharmacologic prophylaxis for the high risk patient following discharge, and recommendations for consultation when appropriate for perinatology, hematology, pharmacy, and physical therapy.  Physical therapy became involved with the utilization of a bedrest antepartum exercise program.
     Despite the fact that VTE is relatively rare, we are seeing a decline in morbidity/mortality associated with VTE.  Currently, we are in the process of re-measurement of data to evaluate effectiveness and compliance of the VTE interventional program and have had no identified occurrences thus far in 2008.