What are the barriers to clinical practice improvement?

Impact of Introducing Anticoagulation-Related Prescribing Guidelines in a Hospital Setting using Academic Detailing

AIM

Assess the impact of using academic detailing-assisted guideline roll-out on warfarin initiation, reversal of warfarin overanticoagulation, and uptake of deep vein thrombosis (DVT) prophylaxis across 4 metropolitan teaching hospitals.

METHODS

Baseline data were collected for 3 months prior to intervention. Prescribers were then informed about the guidelines, including feedback of current hospital performance and the basis for the guidelines. Post-intervention data were collected for 3 months after guideline implementation.

RESULTS

Uptake of DVT prophylaxis in medical patients increased from 52.8% to 67.0% (p=0.004). No impact on operative surgical patients was seen, possibly due to the high pre-existing rate of uptake (86.1% vs 84.1%, p=0.7). DVT prophylaxis rates in non-operative surgical patients were similar to medical patients, with similar, but non-significant improvements. The time to reach a stable therapeutic international normalized ratio (INR) after warfarin initiation was reduced (p=0.03) as were the number of INR's >4 in the first week of therapy (p=0.03). There were significant improvements in appropriate vitamin K use for warfarin overanticoagulation in patients with an INR above 6 (48% vs 74%, p=0.007), timely follow-up tests (49% vs 62%, p=0.009), and the proportion of next INR's being less than 4 (49% vs 61%, p=0.04).

CONCLUSIONS

The use of academic detailing to facilitate guideline roll-out had a positive impact on nearly all areas studied. The academic detailing process within the hospital setting was received enthusiastically by prescribers.

Barriers to the implementation of patient safety initiatives

Since release of the Institute of Medicine Report "To Err is Human:Building a Safer Health System" in 1999, a huge effort has been expended on error-related clinically applied research and on the implementation of new standards and practices related to quality improvement and patient safety. Nonetheless, measurable improvements in the quality of delivered care and reductions in medical errors have been variable and modest in most cases. Multiple barriers to the implementation of patient safety and error reduction initiatives have been identified in the literature. The greater part of this article is devoted to three fundamental barriers: physicians' intolerance for uncertainty, health professionals' fears, and an organizational structure and culture that are incongruent with increasing patient safety.