Does Institution of an Electronic Medical Alert Tool for Venous Thromboembolism Prophylaxis Improve Venous Thromboembolism Prophylaxis after Endoscopic Procedure?

Abstract

Introduction: Venous thromboembolism (VTE) is a common cause of hospital death. VTE prophylaxis (ppx) is often held prior to an endoscopic procedure (procedure) and with it the risk of failure to resume VTE ppx. We sought to evaluate an electronic medical alert (EMA) for VTE ppx resumption after procedure compared by procedure risk. ASGE defines high-risk as a ≥ 1% chance of needing transfusion or intervention to stop bleeding. The EMA reminds physicians to order VTE ppx during order entry if an order is not present. Methods: Retrospective cohort study chart review was done 3 months prior and after EMA for all inpatient procedures in patients with length of stay ≥ 3 days. Information analyzed include timing, procedural risk and decision of VTE ppx after procedure. Logistic regression models were used to estimate the relationship between procedure risk and physicians' decision patterns. Chi square tests were used to test the differences between physicians' decision patterns and procedure risk. Bleeding and patients on anticoagulants were excluded. Results: 723 procedures were reviewed. 664 fit inclusion and exclusion criteria for behavior of VTE ppx after procedure. 266 occurred prior to EMA. 108 of these were high-risk procedures. Of these 61 had their VTE ppx resumed, while 47 never had it started. 158 were low risk. Of these 75 had their VTE ppx resumed, while 83 never had them started. 398 occurred after EMA. 150 of these were high-risk procedures. Of these 85 had their VTE ppx resumed, while 65 never had it restarted. 248 were low risk. Of these 94 had VTE ppx resumed after procedure while 154 never had it started. Excluding those who continued VTE ppx throughout, the odds of resuming ppx after procedure were (OR 2.142 95% Cl 1.421-3.245; P=0.0003) among those with high versus low procedure after EMA and (OR 1.436 95% Cl 0.879-2.356; P=0.1493) prior to EMA. When high and low-risk procedures were combined analysis showed that the odds of VTE ppx after procedure were (OR 0.781; 95% Cl 0.572-1.066; P=0.1198). Conclusion: The rate of VTE ppx post procedure decreased after EMA, but analysis of results showed that most of the decrease in VTE ppx after procedure came from low-risk procedures as 56.48% of VTE ppx was resumed for high-risk prior to EMA and 58.66% of VTE ppx was resumed for high-risk after EMA. The EMA tool may have helped physicians better risk stratify patients for VTE ppx post procedure and is a potential tool that can improve VTE ppx in patients of higher risk.Table 1: Odds of Resuming Venous Thromboembolism Prophylaxis after the Endoscopic Procedure Associated with High-Risk Compared to Low-Risk Procedure - Prior to and After the Implementation of Electronic Medical Alert ToolTable 2: Odds of Resuming Venous Thromboembolism Prophylaxis after the Endoscopic Procedure Associated with the Implementation of Electronic Medical Alert Tool