Improving uptake of prophylaxis for venous thromboembolism in general surgical patients using prospective audit

A multifaceted quality improvement intervention on venous thromboembolism prophylaxis compliance in hospitalized medical patients at a comprehensive cancer center

INTRODUCTION

Previous studies suggest that quality improvement initiatives focused on hospital-acquired venous thromboembolism have a positive impact on prescribing rates of venous thromboembolism prophylaxis, especially those that incorporate computerized changes.

METHODS

We conducted a quality improvement project to determine whether education and computerized prescriber order entry system changes affect venous thromboembolism prophylaxis compliance rates in hospitalized medical patients at a Comprehensive Cancer Center. Between 1 January 2021 and 31 January 2023, 37,739 non-surgical, adult patient encounters with a length of stay > 48 h were analyzed in our study. From 18 December 2021 to 8 March 2022, provider education was delivered to the three largest admitting services, and computerized prescriber order entry changes were implemented incorporating a mandatory requirement to either order venous thromboembolism prophylaxis or document a contraindication for all patients at moderate venous thromboembolism risk.

RESULTS

Monthly venous thromboembolism prophylaxis compliance rates, as defined by the Centers for Medicare and Medicaid Services VTE-1 metric, increased from a mean of 74% to 93% after the interventions. This change was driven primarily by an increased utilization of mechanical venous thromboembolism prophylaxis from 37% to 53%.

CONCLUSION

Our study demonstrated that a multi-faceted intervention incorporating provider education and computerized prescriber order entry system changes can significantly increase venous thromboembolism prophylaxis compliance rates in cancer patients.

Improving Venous Thromboembolism Prophylaxis Administration in an Acute Surgical Unit

OBJECTIVES

Venous thromboembolism (VTE) prophylaxis regimes frequently have a wide variation in application. Nepean acute surgical unit was established in 2006 as a novel model for emergency surgical care. As part of the model's rollout, there were several areas of clinical management targeted for improvement, one being VTE prophylaxis compliance. It was decided all patients older than 18 years treated for a variety of acute surgical conditions within the acute surgical unit should be administered routine VTE prophylaxis with heparin and compression stockings. A novel multifaceted intervention was implemented at the time to achieve this goal. The primary aim of this study was to determine VTE prophylaxis administration rates before and after this intervention.

METHODS

A before-after study conducted as a retrospective review of medical records of all patients 18 years or older, having an appendicectomy in 3 periods: Before acute surgical unit (ASU) (November 2004 to October 2006), Early ASU (November 2006 to October 2008), and Established ASU (January 2012 to December 2013). Outcomes were mechanical and pharmacological VTE prophylaxis administration rates for each group.

RESULTS

There were 1149 patients included in the study: Before ASU, 167; Early ASU, 375; and Established ASU, 607. There was a significant stepwise increase in parmacological VTE prophylaxis administration: Before ASU, 54.5%; Early ASU, 74.7%; and Established ASU, 96.9% (Before versus Early: odds ratio [OR], 2.46; 95% confidence interval [CI], 1.68-3.61; P < 0.001; Early versus Established: OR, 10.500; 95% CI, 6.29-17.53; P < 0.001). Mechanical VTE prophylaxis was significantly increased in the established group (Before versus Established: OR, 47.18; 95% CI, 25.61-86.91; P < 0.001).

CONCLUSIONS

There was a significant increase in VTE prophylaxis administration after the implementation of our multifaceted intervention. Allocating a responsible provider dedicated to VTE prophylaxis prescription and compliance checking was a key component to this intervention.

Exploring sub-optimal use of an electronic risk assessment tool for venous thromboembolism

International guidelines and consensus groups recommend using a risk assessment tool (RAT) to assess Venous Thromboembolism (VTE) risk prior to the prescription of prophylaxis. We set out to examine how an electronic RAT was being used (i.e. if by the right clinician, at the right time, for the right purpose) and to identify factors influencing utilization of the RAT. A sample of 112 risk assessments was audited and 12 prescribers were interviewed. The RAT was used as intended in only 40 (35.7%) cases (i.e. completed by a doctor within 24 h of admission, prior to the prescription of prophylaxis). We identified several reasons for sub-optimal use of the RAT, including beliefs about the need for a RAT, poor awareness of the tool, and poor RAT design. If a user-centred approach had been adopted, it is likely that a RAT would not have been implemented or that problematic design issues would have been identified.

A Simple Way to Improve DVT Protocol Compliance

Objective:

To assess the impact on deep vein thrombosis (DVT) protocol violations of the introduction of a label attached to the patient's drug chart, which specifically allows low-dose subcutaneous heparin or thromboembolic deterrent stockings (TEDS) to be prescribed as appropriate.

Design:

An audit study.

Setting:

Department of General Surgery of a District General Hospital in the United Kingdom.

Method:

All adult general surgical inpatients on a Weekday were studied. Staff were not forewarned of the studies. Patient details and risk factors for DVT were noted. Details of administered DVT prophylaxis were recorded. In total four separate studies were undertaken, namely: with original protocols (I), with refined protocol 1 and 3 years later (II, III) and finally after introduction of the label (IV).

Results:

Protocol violations were defined as being ‘acceptable’ or ‘unacceptable’. Raising awareness between studies I and II reduced acceptable violations to zero. There was no statistically significant reduction in unacceptable violations (24 in 80 patients, 1; 17 in 75, II; 13 in 60, III). In study IV, following introduction of the label, there were only 6 violations in 51 patients ( p<0.02).

Conclusion:

Combining increased awareness with the attachment of a label to the drug chart reduced unacceptable violations by 63%.

Venous thromboembolism prophylaxis guideline compliance: a pilot study of augmented medication charts

INTRODUCTION

Venous thromboembolism (VTE) is a common complication of hospital admission. The incidence of hospital-acquired deep vein thrombosis is approximately 10-40% amongst medical and general surgical patients without prophylaxis. Pulmonary embolism accounts for 5-10% of deaths in hospitalised patients, making hospital-acquired VTE the most common preventable cause of in-hospital death. Studies suggest that prophylactic measures are widely under- and inappropriately used.

AIMS

We hypothesised that the introduction of a medication chart with a dedicated VTE prophylaxis section would improve compliance with local guidelines.

METHODS

Trial medication charts were piloted over a 4-week period in one surgical and two medical wards. Data on compliance with hospital guidelines were collected before and after introduction using a detailed chart review. The difference in prescribing compliance was assessed with the Chi-squared test.

RESULTS

70 patients were assessed before and 38 after the introduction of the new charts. Initially, only 58.6% (n = 41) of patients' prescriptions were in compliance with local guidelines. In 28.6% (n = 20) of patients, VTE prophylaxis was needed and not prescribed. 7.1% (n = 5) of patients were prescribed an inappropriately low dose of low molecular weight heparin (LMWH) prophylaxis. 2.9% (n = 2) of patients were prescribed inappropriately high dose of LMWH prophylaxis. After introduction of the new medication chart, compliance with guidelines rose to 71% (n = 27, p = 0.09).

CONCLUSION

Compliance with VTE guidelines is inadequate. Medication charts with specific sections on VTE assessment and prophylaxis may increase compliance with guidelines.

Interventions for implementation of thromboprophylaxis in hospitalized medical and surgical patients at risk for venous thromboembolism

BACKGROUND

Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in hospitalized patients. Numerous randomized controlled trials (RCTs) show that using thromboprophylaxis in hospitalized patients at risk for VTE is safe, effective and cost-effective. Despite this, prophylactic therapies for VTE are underutilized. System-wide interventions may be more effective to improve the use of VTE prophylaxis than relying on individual providers' prescribing behaviors.

OBJECTIVES

To assess the effects of interventions designed to increase the implementation of thromboprophylaxis in hospitalized adult medical and surgical patients at risk for venous thromboembolism (VTE), assessed in terms of: 1. Increase in the proportion of patients who receive prophylaxis and appropriate prophylaxis 2. Reduction in risk of symptomatic VTE3. Reduction in risk of asymptomatic VTE4. Safety of the intervention.

SEARCH METHODS

The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator (TSC) searched the Group's Specialised Register (last searched July 2010) and the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library) 2010, Issue 3. We searched the PubMed, EMBASE, and SCOPUS databases (19 April 2010) as well as the reference lists of relevant review articles.

SELECTION CRITERIA

We included all studies whose interventions aimed to increase the use of prophylaxis and/or appropriate prophylaxis, decrease the proportion of symptomatic VTE, or decrease the proportion of asymptomatic VTE in hospitalized adult patients. We excluded studies that simply distributed published guidelines and studies whose interventions were not clearly described.

DATA COLLECTION AND ANALYSIS

We collected the following outcomes: the proportion of patients who received prophylaxis (RP), the proportion of patients who received appropriate prophylaxis (RAP) (primary outcomes), and the occurrence of symptomatic VTE, asymptomatic VTE, and safety outcomes such as bleeding. We categorized interventions into education, alerts, and multifaceted interventions. We meta-analyzed RCTs and non-randomized studies (NRS) separately by random effects meta-analysis, and assessed heterogeneity using the I(2)statistic and subgroup analyses. Before analysis, we decided that results would be pooled if three or more studies were available for a particular intervention. We assessed publication bias using funnel plots and cumulative meta-analysis.

MAIN RESULTS

We included a total of 55 studies. One of these reported data in patient-days and could not be quantitatively analyzed with the others. The 54 remaining studies (8 RCTs and 46 NRS) eligible for inclusion in our quantitative synthesis enrolled a total of 78,343 participants. Among RCTs, there were sufficient data to pool results for one primary outcome (received prophylaxis) for the 'alert' intervention. Alerts, such as computerized reminders or stickers on patients' charts, were associated with a risk difference (RD) of 13%, signifying an increase in the proportion of patients who received prophylaxis (95% confidence interval (CI) 1% to 25%). Among NRS, there were sufficient data to pool both primary outcomes for each intervention type. Pooled risk differences for received prophylaxis ranged from 8% to 17%, and for received appropriate prophylaxis ranged from 11% to 19%. Education and alerts were associated with statistically significant increases in prescription of appropriate prophylaxis, and multifaceted interventions were associated with statistically significant increases in prescription of any prophylaxis and appropriate prophylaxis. Multifaceted interventions had the largest pooled effects. I(2) results showed substantial statistical heterogeneity which was in part explained by patient types and type of hospital. A subgroup analysis showed that multifaceted interventions which included an alert may be more effective at improving rates of prophylaxis and appropriate prophylaxis than those without an alert. Results for VTE and safety outcomes did not show substantial benefits or harms, although most studies were underpowered to assess these outcomes.

AUTHORS' CONCLUSIONS

We reviewed a large number of studies which implemented a variety of system-wide strategies aimed to improve thromboprophylaxis rates in many settings and patient populations. We found statistically significant improvements in prescription of prophylaxis associated with alerts (RCTs) and multifaceted interventions (RCTs and NRS), and improvements in prescription of appropriate prophylaxis in NRS with the use of education, alerts and multifaceted interventions. Multifaceted interventions with an alert component may be the most effective. Demonstrated sources of heterogeneity included patient types and type of hospital. The results of our review will help physicians, nurses, pharmacists, hospital administrators and policy makers make practical decisions about local adoption of specific system-wide measures to improve prevention of VTE, an important public health issue. We did not find a significant benefit for VTE outcomes; however, earlier RCTs assessing the efficacy of thromboprophylaxis which were powered to address these outcomes have demonstrated the benefit of prophylactic therapies and a favourable balance of benefits versus the increased risk of bleeding events.

Simple multidisciplinary education of junior doctors and nurses improves prescription of venous thromboembolism prophylaxis

Venous thromboembolism is the most common preventable cause of hospital death. Rates of thromboprophylaxis were studied prospectively in 158 surgical patients before and after multidisciplinary intervention. Prescription of mechanical prophylaxis improved from 58.8% to 76.6% (p = 0.015) following multidisciplinary education. Non-significant increases were seen in pharmacological prescription. Simple multidisciplinary education improves prescription of thromboprophylaxis. As postgraduate curricula for junior doctors and nurses evolve, we advocate routine inclusion of such sessions.

Venous thromboembolism prevention: a systematic review of methods to improve prophylaxis and decrease events in the hospitalized patient

Prevention of venous thromboembolism (VTE) is currently a key initiative internationally and in US hospitals, where there has been a recent focus on national quality initiatives to prevent hospital-acquired VTE. Multiple strategies exist to prevent VTE by increasing prophylaxis rates in the hospitalized setting. Active, multifaceted interventions, including provider education, an active reminder to the provider, and regular audit and feedback to medical and hospital staff, appear to be the most effective current interventions. Active intervention programs have been validated both as electronic alerts, with or without computerized clinical decision support software and, more recently, human alerts, many of which utilize in-hospital pharmacists. A passive strategy, such as guideline dissemination, should not be used as a lone method. Although inappropriate duration remains a key reason as to why at-risk patients do not receive appropriate thromboprophylaxis within the hospital (defined by type, dose, and duration of prophylaxis), few studies address duration compared with hospital length of stay. Preventable VTE is a new quality outcome measure for hospitals but is measured in few studies. Future studies should focus on comparing various multifaceted interventions to assess their effect over time, including endpoints of bleeding for safety, appropriate type, dose, and duration of prophylaxis, overall and preventable VTE, and the impact on unnecessary prophylaxis for patients not at risk.

Bridging the gap between evidence and practice in venous thromboembolism prophylaxis: the quality improvement process

Venous thromboembolism (VTE) is considered to be the most common preventable cause of hospital-related death. Hospitalized patients undergoing major Surgery and hospitalized patients with acute medical illness have an increased risk of VTE. Although there is overwhelming evidence for the need and efficacy of VTE prophylaxis in patients at risk, only about a third of those who are at risk of VTE receive appropriate prophylaxis. To address the shortfall in VTE prophylaxis, the US Joint Commission and the National Quality Forum (NQF) endorse standardized VTE prophylaxis practices, and are identifying and testing measures to monitor these standards. Hospitals in the USA accredited by Centers for Medicare and Medicaid Services to receive medicare patients will need VTE prophylaxis programs in place to conform to these national consensus standards. This review aims to give background information on initiatives to improve the prevention of VTE and to identify key features of a successful quality improvement strategy for prevention of VTE in the hospital. A literature review shows that the key features of effective quality improvement strategies includes an active strategy, a multifaceted approach, and a continuous iterative process of audit and feedback. Risk assessment models may be helpful for deciding which patients should receive prophylaxis and for matching VTE risk with the appropriate intensity of prophylaxis. This approach should assist in implementing the NQF/Joint Commission-endorsed standards, as well as increase the use of appropriate VTE prophylaxis.

Improved use of thromboprophylaxis for deep vein thrombosis following an educational intervention

BACKGROUND

We evaluated venous thromboembolism (VTE) prophylaxis rates in hospitalized medical patients in a teaching hospital, the State University of New York-Downstate Medical Center-University Hospital of Brooklyn, before and after implementation of a multifaceted VTE prophylaxis quality improvement intervention that combined regular education, dissemination of a decision support tool, and regular audit-and-feedback to resident physicians.

METHODS

The charts of 312 hospitalized medical patients were retrospectively reviewed to assess baseline rates of appropriate VTE prophylaxis. Rates of appropriate VTE prophylaxis were then determined 12 and 18 months after implementation of the quality improvement intervention. Data collected included risk factors for VTE, contraindications to anticoagulant prophylaxis, type of VTE prophylaxis prescribed, and whether the prophylaxis was appropriate.

RESULTS

Most of the hospitalized medically ill patients had 3 or more risk factors for VTE. At baseline, the proportion of patients receiving any form of VTE prophylaxis, primarily unfractionated heparin, was 47%. The proportion of patients for whom a physician provided appropriate prophylaxis was 43%. After the intervention, the proportion of patients receiving prophylaxis significantly increased, to 86% at 12 months, and this level was maintained at 18 months. The rate of appropriate prophylaxis increased to 68% and 85% after 12 and 18 months, respectively.

CONCLUSIONS

The proportion of hospitalized medical patients receiving appropriate VTE prophylaxis as recommended by evidence-based guidelines can be increased significantly by combining regular education, a decision support tool, and regular audit-and-feedback.

A systematic review of strategies to improve prophylaxis for venous thromboembolism in hospitals

OBJECTIVE

To assess the effectiveness of different strategies for increasing the uptake of prophylaxis for venous thromboembolism (VTE) in hospitalized patients through a systematic review of the literature.

METHODS

Literature databases and the Internet were searched from 1996 to May 2003. Studies of strategies to improve VTE prophylaxis practice were included. Studies where no policy or guideline was implemented or where the focus of the study was not VTE prevention were excluded.

RESULTS

Thirty studies were included. The quality of the available evidence was average with the majority of studies being uncontrolled before and after design and thus limited by the historical nature of much of the available data. Adherence to guidelines and the provision of adequate prophylaxis were poor in studies which relied on passive dissemination of guidelines. In general, the use of multiple strategies was more effective than a single strategy used in isolation. The most effective strategies incorporated a system for reminding clinicians to assess patients for VTE risk, either electronic decision-support systems or paper-based reminders, and used audit and feedback to facilitate the iterative refinement of the intervention. There were no studies adequately powered to demonstrate a reduction in rates of VTE. Insufficient evidence was available to make useful comparisons of strategies in terms of costs and resource utilization.

CONCLUSIONS

Passive dissemination of guidelines is unlikely to improve VTE prophylaxis practice. A number of active strategies used together, which incorporate some method for reminding clinicians to assess patients for DVT risk and assisting the selection of appropriate prophylaxis, are likely to result in the achievement of optimal outcomes.

Use of venous thromboprophylaxis and adherence to guideline recommendations: a cross-sectional study

Background

Consensus Conferences and Guidelines for deep vein thrombosis prophylaxis have been published, which recommend the use of prophylactic heparins in patients with risk of venous thromboembolism (VTE). The aim of this study was the assessment of the prophylaxis of VTE and the adherence to accepted guideline recommendations throughout the hospital.

Methods

A cross-sectional study was carried out in a teaching hospital after guidelines were implemented. Patients' risk factors of deep vein thrombosis, risk categories of patients, and prophylaxis used in different wards were recorded. Appropriate adherence to the guidelines was analysed.

Results

Of 397 patients, prophylaxis was used in 231 patients (58%), and low-molecular-weight heparins (LMWH) were used in 224 of them (97%). Patients with prophylaxis had a higher mean number of risk factors (SD) than those without prophylaxis [3.1 (1.4) vs 1.9 (1.4); p < 0.05)]. Prophylaxis was used in 72% and 90% of moderate and high-risk patients respectively. Appropriate adherence to all guideline recommendations was observed in 42% of patients. Adherence to guidelines was high as regards the use of prophylaxis according to patients' risk factors (78%) and the use of appropriate types of prophylaxis (99%), but was low regarding appropriate heparin dosage (47%) and preoperative dosage (37%). Appropriate prophylaxis use was higher in critical care and surgical wards than in medical wards.

Conclusion

Prophylaxis of VTE is generally used in risk patients, but appropriate adherence to guidelines is less frequent and variable among different wards. Continuing medical education, discussion and dissemination of guidelines, and regular clinical audit are necessary to improve prophylaxis of VTE in clinical practice.

Complications after discharge for surgical patients

AIM

To measure the type and frequency of complications for surgical patients 1 month after discharge.

METHODS

A post-discharge patient survey was conducted in 2000 for patients who had undergone one of five elective operations: transurethral resection of the prostate, hysterectomy, major joint replacement, cholecystectomy, herniorrhaphy. Two hundred and fourteen patients (74%) returned the survey forms, which were sent 1 month after surgery. Patients were recruited from two teaching hospitals in the Hunter Area Health Service, New South Wales, Australia.

RESULTS

One hundred and thirty-five (63%) patients reported one or more complications and 78 (37%) received treatment for 109 complications. Eighty-six per cent reported pain after discharge and 41% reported moderate to severe pain. Seventeen per cent reported infections after discharge and 94% of these patients were given treatment. Twenty-eight per cent reported bleeding after discharge and 20% of these were given treatment. Eleven (5%) patients were readmitted for treatment of problems related to their surgery including four who required further surgery. One hundred and seventy-two patients accessed a range of health services during the first month after discharge, resulting in 266 occasions of service. Twenty-eight per cent of post-discharge services were unplanned.

CONCLUSIONS

The lack of post-discharge monitoring conceals information about surgical outcomes. Patient reporting is an effective method of monitoring post-discharge outcomes. There is scope to develop post-discharge services to improve the quality of care in the areas of post-discharge pain management, the use of prophylactic measures and to provide treatment for complications that occur during this period.

Deep vein thrombosis prophylaxis protocol--needs active enforcement

Each hospital department tends to have its own DVT prophylaxis protocol generally based on the recommendations of the THRIFT consensus group. This is developed to help the junior medical staff to prescribe the appropriate prophylaxis according to risk assessment. However, adherence to the protocol tends to be haphazard unless actively enforced. This study is aimed at determining whether active enforcement of the protocol improves the uptake of prophylaxis.

Educational campaign to improve the prevention of postoperative venous thromboembolism

BACKGROUND

Recent studies have revealed considerable scope for improvement in preventing postoperative venous thromboembolism. This project comprised a baseline assessment of the use of preventive measures within the Royal Hobart Hospital, followed by the implementation and evaluation of an educational program directed at hospital staff.

AIM

To determine whether the Royal Hobart Hospital's guidelines for the prophylaxis of postoperative venous thromboembolism were being utilized effectively and, if necessary, attempt to improve use of the guidelines through an educational programme.

METHODS

Data were collected retrospectively from the medical records of 250 surgical patients undergoing a procedure during February 1997. Patients were classified as being at a low, medium or high risk of venous thromboembolism using two sets of criteria. The percentage of patients receiving the appropriate prophylaxis was determined. An educational programme to promote the hospital's guidelines for the prophylaxis of postoperative venous thromboembolism was then implemented. Included were presentations to staff, posters placed throughout the hospital and the wide distribution of the results and a glossy card showing the hospital's guidelines. Follow-up data were subsequently collected from another 250 surgical patients.

RESULTS

Only 59% of patients received appropriate prophylaxis according to the hospital's approved guidelines, with little change when those patients with possible contraindications to thromboprophylaxis were excluded. When those patients at a high risk of venous thromboembolism were examined, only 25% were prescribed the recommended preventive measures. There was no difference between elective versus emergency surgery and the use of appropriate prophylaxis. Following the implementation of the educational programme, data collection from another 250 surgical patients revealed a significant increase (P < 0.05 by chi-square test) in the level of appropriate thromboprophylaxis to 70% of patients, with 77% of the high-risk patients being prescribed the recommended preventive measures.

CONCLUSIONS

A pharmacy-based educational intervention significantly improved adherence to the hospital's guidelines for the prophylaxis of postoperative venous thromboembolism.

Protocol violation in deep vein thrombosis prophylaxis

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Protocol violation in deep vein thrombosis prophylaxis

This study aimed to determine how closely deep vein thrombosis (DVT) prophylactic policies are adhered to in routine general surgical practice, to identify reasons for policy violations and to assess the effects of policy modification. Eight adult patients, sixty of whom had undergone an operation, under the care of six general surgeons, each with their own written DVT protocol, were studied on one weekday. Thirty patients (50%) did not receive DVT prophylaxis according to the policy of the relevant consultant. Most violations occurred for unacceptable reasons, mainly starting low-dose subcutaneous heparin or using thromboembolic stockings postoperatively. However, 43% of protocol violations occurred for acceptable clinical reasons. Following the initial study, a uniform departmental DVT prophylaxis policy was introduced. Nursing and medical staff were thoroughly appraised of the new policy. In a repeat study of 75 patients 1 year later, there were 15 protocol violations among 58 patients who had undergone an operation (27%). However, there were no violations for acceptable reasons. The number of unacceptable protocol violations in the two studies was similar (24/60 and 17/56). The number of patients at moderate or high DVT risk who received no preoperative prophylaxis was the same in both studies (8/48 in both audits). DVT protocol violations are common in routine general surgical practice. Policy modification and unification results in fewer violations, but made little impact on the level of thromboprophylactic care.