Introduction Inferior vena cava (IVC) filters are used to prevent pulmonary embolism (PE) in patients with venous thromboembolism (VTE) who cannot receive anticoagulation. However, their use has often extended beyond evidence-based indications. The American Society of Hematology (ASH) guidelines recommend against routine insertion of IVC filters in patients who are eligible for anticoagulation, advise against their use as primary prophylaxis in surgical patients, and emphasize prompt retrieval once anticoagulation can be safely resumed.

The need of the project: At our institution, baseline analysis revealed that 27% of IVC filters were inserted without an appropriate indication based on our institutional guidelines, which are aligned with ASH recommendations. Additionally, 24% of filters were not retrieved. These patterns posed significant clinical risks for the patient as well as organizational concerns in the form of increased cost, inefficiency, and reputational harm.

The aim : was to improve the use of IVC filters in accordance with evidence-based guidelines and to increase the rate of retrieval.

Methods We applied the Harvard 7-step quality improvement methodology and iterative Plan–Do–Study–Act (PDSA) cycles to address both overuse and under retrieval of IVC filters. It was carried out across the three tertiary hospitals of the National Guard Health Affairs in Riyadh: King Abdulaziz Medical City, King Abdullah Specialized Children's Hospital, and the Women's Health Hospital.

Outcomes were measured over two periods: a pre-intervention phase (March–September 2024) and a post-intervention phase (October 2024–May 2025). We used Fisher's exact test to assess statistical significance of pre-post differences. Statistical process control (SPC) charts were constructed to identify special cause variation using standard Western Electric rules.

Based on these insights, we implemented four interventions:

  • Establishment of guidelines with a policy restricting insertion decisions: Baseline data showed that hematology consultation was associated with significantly higher appropriateness of IVC filter insertion (92.3% vs. 70.6%).Based on this, a policy requiring hematology approval prior to filter insertion was implemented.

  • Automatic Consultation to IVC filter team Upon Filter Request To prevent avoidable IVC filter insertions, an automatic email alert system triggered by any filter order in the EHR was established. The thrombosis quality specialist receives the alert and informs the IVC filter team, who assess appropriateness, document a recommendation in the EHR before insertion, and communicate directly with the primary team to guide evidence-based decisions.

  • Weekly Review by a Dedicated Team A dedicated IVC filter team—comprising a hematology consultant, fellow, and quality specialist —conducts weekly rounds to review all inpatients with filters. Each case is reassessed, a retrieval plan is documented, and the primary team is contacted to ensure implementation.

  • Education of Healthcare Providers A structured education to physicians across departments involved in filter management.

Result Following the intervention implemented in October 2024, the appropriateness of IVC filter insertion improved from 72.7% (48/66) to 91.4% (64/70), p = 0.0028. SPC analysis using a p-chart demonstrated special cause variation, triggered by Rule #3 (four out of five consecutive points above the +1 sigma line),

Similarly, the retrieval rate among eligible patients increased from 76% (38/50) to 92.3% (48/52), p = 0.0062. SPC analysis showed special cause variation triggered by Rule #4 (eight consecutive points above the centerline),

The median time to IVC filter retrieval decreased from 35 days (IQR 18–60) pre-intervention to 22 days (IQR 14–51) post-intervention; the difference did not reach statistical significance (p = 0.180, Mann–Whitney U test).

Conclusion This quality improvement initiative successfully translated clinical guidelines into practice through a multifaceted strategy that included policy enforcement, automated consultation, structured case review, and targeted education. The intervention led to significant improvements in IVC filter appropriateness and timely retrieval, demonstrating the impact of coordinated, system-level efforts on patient safety and care quality. Next steps include sustaining the improvements locally and scaling the model to other centers to support broader guideline adherence in thrombosis care.

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2025
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