Effectiveness of a novel and scalable clinical decision support intervention to improve venous thromboembolism prophylaxis: a quasi-experimental study (original) (raw)
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Clinical and Applied Thrombosis/Hemostasis, 2013
Hospitalized acutely ill patients face high risk for venous thromboembolism (VTE) unless appropriate thromboprophylaxis is applied. This study aimed to determine VTE prophylaxis practices for inpatients in Turkey and to evaluate the impact of physicians' training via a modified ''Standard Medical Patients' VTE Risk Assessment Model (MERAM).'' A total of 607 inpatients included in this national multicenter noninterventional observational registry were evaluated in terms of demographics, VTE risk, and preventive measures at 2 consecutive cross-sectional visits. Physicians were asked to complete a questionnaire on current VTE method risk assessment and other models including MERAM. The VTE prophylaxis rates significantly increased from 49.4% to 62.4% between visits (P < .05). The lack of risk evaluation decreased from 74.6% to 19.5% (P < .001). Percentage of physicians using prophylaxis and use of MERAM increased between visits. Physician training proved effective for providing general ''awareness'' of VTE prophylaxis and led to higher rates of risk assessment model-based appropriate VTE prophylaxis.
Archives of Surgery, 2012
Objective: Venous thromboembolism is associated with substantial morbidity and mortality and is largely preventable. Despite this fact, appropriate prophylaxis is vastly underutilized. To improve compliance with best practice prophylaxis for VTE in hospitalized trauma patients, we implemented a mandatory computerized provider order entry-based clinical decision support tool. The system required completion of checklists of VTE risk factors and contraindications to pharmacologic prophylaxis. With this tool, we were able to determine a patient's risk stratification level and recommend appropriate prophylaxis. To evaluate the effect of our mandatory computerized provider order entry-based clinical decision support tool on compliance with prophylaxis guidelines for venous thromboembolism (VTE) and VTE outcomes among admitted adult trauma patients.
2012
Michael B Streiff associate professor of medicine 1 2 , Howard T Carolan quality and innovations project administrator 3 , Deborah B Hobson patient safety clinical specialist, surgical intensive care nurse and coordinator 3 4 , Peggy S Kraus clinical specialist for anticoagulation 5 , Christine G Holzmueller senior research coordinator II, medical writer and editor 3 6 , Renee Demski senior director, quality and safety 3 , Brandyn D Lau medical informatician 7 , Paula Biscup-Horn clinical pharmacy specialist, anticoagulation management Abstract Problem Venous thromboembolism (VTE) is a common cause of potentially preventable mortality, morbidity, and increased medical costs. Risk-appropriate prophylaxis can prevent most VTE events, but only a small fraction of patients at risk receive this treatment. Design Prospective quality improvement programme. Setting Johns Hopkins Hospital, Baltimore, Maryland, USA. Strategies for change A multidisciplinary team established a VTE Prevention Collaborative in 2005. The collaborative applied the four step TRIP (translating research into practice) model to develop and implement a mandatory clinical decision support tool for VTE risk stratification and risk-appropriate VTE prophylaxis for all hospitalised adult patients. Initially, paper based VTE order sets were implemented, which were then converted into 16 specialty-specific, mandatory, computerised, clinical decision support modules.
JAMA internal medicine, 2014
IMPORTANCE Hospitalization for acute medical illness is associated with increased risk of venous thromboembolism (VTE). Although efforts designed to increase use of pharmacologic VTE prophylaxis are intended to reduce hospital-associated VTE, whether higher rates of prophylaxis reduce VTE in medical patients is unknown. OBJECTIVE To examine the association between pharmacologic VTE prophylaxis rates and hospital-associated VTE. DESIGN, SETTING, AND PARTICIPANTS Retrospective, multicenter cohort study conducted at 35 Michigan hospitals participating in a statewide quality collaborative from January 1, 2011, through September 13, 2012. Trained medical record abstractors at each hospital collected data from 31 260 general medical patients. Use of VTE prophylaxis on admission, VTE risk factors, and VTE events 90 days after hospital admission were recorded using a combination of medical record review and telephone follow-up. Hospitals were grouped into tertiles of performance based on rate of pharmacologic prophylaxis use on admission for at-risk patients.
JAMA Internal Medicine, 2014
IMPORTANCE Hospitalization for acute medical illness is associated with increased risk of venous thromboembolism (VTE). Although efforts designed to increase use of pharmacologic VTE prophylaxis are intended to reduce hospital-associated VTE, whether higher rates of prophylaxis reduce VTE in medical patients is unknown. OBJECTIVE To examine the association between pharmacologic VTE prophylaxis rates and hospital-associated VTE. DESIGN, SETTING, AND PARTICIPANTS Retrospective, multicenter cohort study conducted at 35 Michigan hospitals participating in a statewide quality collaborative from January 1, 2011, through September 13, 2012. Trained medical record abstractors at each hospital collected data from 31 260 general medical patients. Use of VTE prophylaxis on admission, VTE risk factors, and VTE events 90 days after hospital admission were recorded using a combination of medical record review and telephone follow-up. Hospitals were grouped into tertiles of performance based on rate of pharmacologic prophylaxis use on admission for at-risk patients.
Clinical and Applied Thrombosis/Hemostasis, 2015
Venous thromboembolism (VTE) is the most common preventable cause of hospital death; the burden of VTE includes the management of the acute event (deep vein thrombosis [DVT]/pulmonary embolism) and the chronic subsequents such as postthrombotic syndrome and recurrent DVT. All experts agree that despite the abundance of knowledge available on VTE and how to prevent it, it is still underused, and since the first step in prophylaxis is to identify those who are at high risk of VTE, several risk assessment models have been developed to identify these patients and provide appropriate prophylaxis. In our study, the institutional guideline in a tertiary educational hospital is the Caprini score (2006), a comparison was conducted between the institutional guideline and the American College of Chest Physicians guideline (ACCP ninth edition [ACCP-9]) in terms of the degree of agreement of the actual prophylaxis with the institutional guideline and the ACCP-9 and the differences in risk levels. The concordance with the ACCP-9 guideline was higher than with the institutional guideline, specifically in those patients receiving prophylaxis, and there was an overestimation of the risk levels in the institutional guideline, especially in medical patients. The replacement of the existing Caprini-2006 with the ACCP-9 is prudent, since it agrees with the physicians' clinical judgment and may result in reduced use of pharmacologic prophylaxis which could lead to lower costs and fewer adverse effects.
The Joint Commission Journal on Quality and Patient Safety, 2009
V enous thromboembolism (VTE) is considered the most common preventable cause of hospital-related death in the US. 1 More than 12 million patients, or nearly a third of hospital discharges, are classified as being at-risk of VTE. 2 Thromboprophylaxis substantially reduces the incidence of VTE in these patients. 3,4 However, many patients at risk of VTE do not receive any thromboprophylaxis or are given inappropriate thromboprophylaxis, defined as the incorrect type at the wrong dose or for an insufficient duration. Indeed, one study showed that appropriate VTE prophylaxis is provided to only one-third of hospitalized medical patients at risk of VTE. 5 In recognition of the need to improve the prevention and care of VTE, a number of organizations have established performance measures to reduce the healthcare and economic burden of VTE in the US (see Appendix 1 in online version). This article reviews these ongoing national quality initiatives and discusses strategies to help hospitals and health care professionals (HCPs) optimize current VTE prophylaxis practices. Methods In June 2008 and in June 2009, prior to the final acceptance of this article, a computerized literature search was performed using PubMed and MEDLINE, and this was complemented by manual searches of relevant journals and Web sites to identify additional literature related to VTE prevention and QI. Findings There are many performance measure initiatives derived from public agencies and private organizations, including the National Quality Forum (NQF), The Joint Commission, and the Agency for Healthcare Research and Quality (AHRQ). These measures aim to improve quality of care and reduce unnecessary health care costs. NQF. The NQF recognized that VTE is an important patient safety issue and has formulated the "NQF-Endorsed ™ Set of Safe Practices. This consists of 30 safe practices, two of which focus on VTE. If adopted, these would have a major pos-Article-at-a-Glance Background: Venous thromboembolism (VTE) is associated with a substantial healthcare and economic burden, yet many VTE events are preventable. Despite the availability of evidence-based guidelines detailing effective thromboprophylaxis strategies, the underuse and inappropriate prescribing of VTE prophylaxis are common. Current national quality initiatives were reviewed to identify strategies that may help hospitals and health care professionals optimize current VTE prophylaxis practices. Methods: A computerized literature search was performed using PubMed and MEDLINE, and this was complemented by hand searches of relevant journals and Web sites to identify additional literature related to VTE prevention and quality improvement. Findings: Many organizations, including the Centers for Medicare and Medicaid Services, the National Quality Forum, the Joint Commission, and the Agency for Healthcare Research and Quality have developed performance measures, quality indicators, public reporting initiatives, incentive programs and "negative reimbursement" that are designed to help improve VTE prevention. Conclusions: It remains the responsibility of individual hospitals to identify specific areas in which they can improve their VTE prophylaxis rates to obtain positive results from the reporting initiatives and incentive programs if performance measures are to be met, all hospital departments will need to implement effective VTE prevention policies, including early risk assessment, appropriate prophylaxis prescribing, monitoring, and follow-up. Multifaceted, integrated initiatives involving risk assessment tools, decision support, electronic alert systems, and hospitalwide education, with a mechanism for audit and feedback, may help ensure that all health care professionals comply with VTE prevention policies and initiatives.
2019
TO THE EDITOR: We read with interest the new clinical practice guidelines for venous thromboembolism (VTE) made available on 27 November 2018.1 The evidence-based guidelines from the American Society of Hematology (ASH) highlight the risk of VTE in a variety of settings and provide recommendations for prophylaxis, diagnosis, and optimal management of anticoagulation therapy. Thank you for taking on this important work. However, we feel that the widespread problem of nonadministered doses of prescribed VTE prophylaxis to hospitalized patients is unappreciated in the current guidelines. Despite recognition of the risk of VTE, it remains a significant health care problem. Although continuous efforts are being made to improve VTE prophylaxis presciption,2 these efforts are based on the implied assumption that appropriate VTE prophylaxis prescription guarantees its administration. Nonadministration of VTE prophylaxis can lead to preventable harm,3,4 and regrettably, it is endemic within hospitals. At our institution, we found that ∼12% of prescribed doses of pharmacologic VTE prophylaxis were not administered to hospitalized patients. The most noteworthy finding of our investigation was that nearly 60% of nonadministered doses were due to patient or family member refusal.5 Similarly, researchers at another major academic medical center reported that adherence to unfractionated heparin (UFH) and low-molecular-weight heparin for VTE prophylaxis in hospitalized patients was 87% and 95%, respectively; for both, patient refusal (44%) was the most common reason for missed doses.6 Several factors may have contributed to the observed differences in the nonadministration of UFH and low-molecular-weight heparin. Providers’ perception of patients’ risk might be driven by the patient population or the medication dose frequency, potentially influencing administration. For instance, it has been described that twice daily heparin was missed more frequently than thrice daily heparin. However, twice daily heparin is more frequently prescribed for more medically ill patients.5 Recently, we found that nonadministration is common and perhaps more prevalent at community hospitals compared with academic medical centers.7 These findings suggest that nonadministration of VTE prophylaxis is a ubiquitous deficit in patient care.8 Although some may suggest that these missed doses are inevitable, we would strongly disagree, as evidence suggests that missed doses may be the next salient target to improve care and VTE prevention.9⇓-11 In an attempt to reduce missed doses of VTE, the Johns Hopkins Medicine VTE Collaborative, with funding from the Patient Centered Outcomes Research Institute (PCORI), developed and implemented 2 complementary approaches. The first was a Web-based education module for bedside nurses that decreased missed doses significantly.12 The second was a patient education bundle. The bundle was tested in a controlled pre-post clinical trial to assess the effectiveness of this patient education bundle on VTE prophylaxis and medication administration practices for hospitalized patients. Implementation of the bundle was associated with a 43% reduction in missed doses of VTE prophylaxis and a 47% reduction in patient refusal of prescribed VTE prophylaxis medication.13 Successful strategies to reduce VTE prophylaxis nonadministration have been tested at several other institutions.9⇓-11 In addition, patient surveys and cohort studies suggest that the availability of an oral agent for VTE prophylaxis would significantly reduce nonadministration.14⇓-16 Although patient preferences are important, published literature to help guideline committees is often lacking. However, in this case, data do exist. The majority of patients if presented with an option would choose an oral agent. However, there are a substantial amount of patients who would choose an injectable agent.14 We are in full agreement with ASH that it is important to assess risk and prescribe risk-appropriate VTE prophylaxis. However, we believe that it is critically important to focus on all phases of care for VTE prevention. Although we understand the limitations of time and energy available for a complete systematic review and meta-analysis review of this topic, perhaps a mention of the concept in the discussion would have been appropriate. Even the best evidence-based regimen prescribed would be ineffective if it is not actually administered. Future work to study oral agents for prevention may be warranted as subcutaneous injections for VTE prophylaxis seem to be missed more than other medications,16,17 and many patients would prefer an oral option.15 There are still instances though when UFH and LWMH would be more suitable for prophylaxis (eg, patients with a status of nothing by mouth or some critically ill patients). We have advocated for outcome measures that link a process measure failure and a negative outcome, in particular, in VTE.18 This approach has led to a publicly reported measure of potentially preventable VTE (VTE-6). Perhaps it is time to change this measure to include missed doses alongside prescription failures to define poor quality care.8 We strongly feel that the evidence suggests monitoring missed doses of prescribed VTE prophylaxis within hospitals to further reduce potentially preventable harm from VTE.