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Thromboprophylaxis in hospitalized trauma patients: a systematic review and meta-analysis of implementation strategies

Introduction

Venous thromboembolism (VTE) prophylaxis implementation strategies are well-studied in some hospitalized medical and surgical patients. Although VTE is associated with substantial mortality and morbidity in trauma patients, implementation strategies for the prevention of VTE in trauma appear to be based on limited evidence. Therefore, we conducted a systematic review and meta-analysis of published literature on active implementation strategies for VTE prophylaxis administration in hospitalized trauma patients and the impact on VTE events.

Methods

A systematic review and meta-analysis was performed in adult hospitalized trauma patients to assess if active VTE prevention implementation strategies change the proportion of patients who received VTE prophylaxis, VTE events, and adverse effects such as bleeding or heparin-induced thrombocytopenia as well as hospital length of stay and the cost of care. An academic medical librarian searched Medline, Scopus, and Web of Science until December 2022.

Results

Four studies with a total of 1723 patients in the active implementation strategy group (strategies included education, reminders, human and computer alerts, audit and feedback, preprinted orders, and/or root cause analysis) and 1324 in the no active implementation strategy group (guideline creation and dissemination) were included in the analysis. A higher proportion of patients received VTE prophylaxis with an active implementation strategy (OR=2.94, 95% CI (1.68 to 5.15), p<0.01). No significant difference was found in VTE events. Quality was deemed to be low due to bias and inconsistency of studies.

Conclusions

Active implementation strategies appeared to improve the proportion of major trauma patients who received VTE prophylaxis. Further implementation studies are needed in trauma to determine effective, sustainable strategies for VTE prevention and to assess secondary outcomes such as bleeding and costs.

Level of evidence

Systematic review/meta-analysis, level III.

PROSPERO registration number

CRD42023390538.

Interventional bundle for venous thromboembolism prevention: ensuring quality and effectiveness

Hospital-associated thromboses (HATs) are a potentially preventable cause of morbidity and mortality. Oxford University Hospitals NHS Foundation Trust was designated a Venous Thromboembolism (VTE) Exemplar Centre by NHS England in 2014. However, following delayed reporting of a potentially preventable HAT in 2015, a benchmarking exercise suggested HATs were being under-reported, and also that the established hospital-wide audits of VTE prevention had significant limitations. The aim of this interventional bundle was to ensure high-quality data for key VTE prevention measures across the hospital, to identify areas for improvement and demonstrate a reduction in the number of potentially preventable HATs over a 2-year period.

The project team engaged with hospital leadership and collaborated with hospital-wide stakeholders. A multifaceted approach was taken and ‘Plan Do Study Act’ cycles were used to test interventions with continuous evaluation of impact. The percentage of inpatients receiving appropriate thromboprophylaxis progressively increased from 94% to 98%. The project did not achieve its secondary aim of a reduction in the number of potentially preventable HATs. Revision of the HAT reporting process resulted in better detection and an initial increase in reporting of potentially preventable HATs, although data suggest that the level of harm from errors is now reducing.

The improvement in overall appropriate thromboprophylaxis is considered to be due to robust audits of appropriate thromboprophylaxis, upskilling of ward pharmacists, improved detection of potentially preventable HATs resulting in additional safety nets such as linking the ‘outcome recommendation’ of the electronic VTE risk assessment directly to electronic prescribing, and increased awareness and education. Combining low-cost actions in a coordinated interventional bundle has produced measurable improvements in our VTE management programme, enhancing patient safety. We believe the model to be sustainable and replicable in other general hospitals.

A human factors approach to improving electronic performance measurement of venous thromboembolism prophylaxis

OBJECTIVE

In 2011, our institution developed a venous thromboembolism (VTE) prophylaxis order set to monitor prophylaxis management through physician-generated risk assessment orders. Prophylaxis rates obtained using the risk assessment orders were falsely low compared with chart review. Our goal was to redesign the order set to increase the percentage of VTE risk assessments ordered, both to improve care and to better reflect performance.

DESIGN

Quality Improvement Project.

SETTING

Veterans Health Administration.

PARTICIPANTS

Patients admitted to acute care and intensive care medical units.

INTERVENTIONS

Process analysis was used to identify systems failures limiting use of the original order set. The order set was redesigned using a human factors approach.

MAIN OUTCOME MEASURE

VTE risk assessment orders.

RESULTS

The order set was redesigned to reduce complexity and improve integration into provider workflow. The rate of risk assessment orders placed within 24 h increased from 48.6 to 80.4% (P < 0.001). There was no difference in the actual use of prophylaxis. However, for patients on prophylaxis, the rates of having a documented 'moderate' or 'high' risk assessment within 24 h increased from 66.7 to 95.7% (P < 0.001).

CONCLUSIONS

Using human factor principles to redesign an order set led to a significant increase in the percentage of patients with a risk assessment order placed within 24 h of admission. Although the risk assessments using the redesigned order set better reflected physician performance, it remained an imperfect measure for VTE prophylaxis. New technology used to measure human performance must be evaluated following implementation to assess accuracy.