Impact of a Venous Thromboembolism Prophylaxis “Smart Orderset”: Improved Compliance, Fewer Events

Abstract

Abstract 172▪FN2▪This icon denotes a clinically relevant abstract Introduction:Venous Thromboembolism affects 900,000 Americans annually. Prophylaxis reduces the risk of VTE by 60% but many patients do not receive risk-appropriate VTE prophylaxis. We developed mandatory computer decision support “smart ordersets” (i.e. electronic menus with DVT prophylaxis recommendations) to improve our institution's VTE prophylaxis performance. The ordersets require providers to respond to 2 questions that assess VTE risk factors and contraindications to pharmacologic prophylaxis. Using these answers along with known patient demographics, the orderset gives providers an evidence-based risk-appropriate VTE prophylaxis recommendation. Methods:To study the impact of Medicine service-specific orderset on compliance with the 2008 American College of Chest Physicians (ACCP) VTE prophylaxis guideline and clinical outcomes, we conducted a retrospective cohort chart review of consecutive patients admitted to the Medicine service during one month immediately prior to (November 2007) and a single month subsequent to (April 2010) orderset launch. Data collection included patient demographics, VTE risk factors, and use and type of VTE prophylaxis. Patient characteristics before and after implementation of the protocol were compared. The primary outcome measures were compliance with thromboprophylaxis guidelines in patients at risk for VTE and the 90-day VTE rate. Secondary outcomes were bleeding events and 30-day mortality. Outcomes were compared by Student's t-test and Fisher's exact test. Results:The before and after cohorts contained 1,025 and 1,057 patients, respectively. Demographic characteristics and contraindications to pharmacologic prophylaxis were similar between groups. (Table 1) Some VTE risk factors were more prevalent in the before group. (Table 1) ACCP compliant prophylaxis increased significantly from 68.3% to 85.9% (p <.0001). Provider choices for prophylaxis changed with an increase in mechanical prophylaxis and twice daily heparin in the post-orderset implementation cohort. (Table 2) Radiographically-documented symptomatic VTE by day 90 post-hospital discharge declined from 2.8% to 0.7% after orderset implementation (p=0.001). There was also a trend toward fewer in-hospital VTE (0.8% versus 0.2%, p=0.06). (Figure 1) Major bleeding remained unchanged (0.3% to 0.1%, p=0.47).Table 1Patient CharacteristicsPatient CharacteristicsPre-Orderset (n = 1,025)Post-Orderset (n = 1,057)p-valueMean Duration of Hospital Stay ± S.D., days5.10 ± 6.354.65 ± 5.190.09Mean Age ± S.D. yr55.9 ± 17.055.0 ± 16.50.19Male Sex — no. (%)516 (50.3)549 (51.9)0.47Race/Ethnicity — no. (%)0.88White391 (38.5)399 (37.8)African American582 (57.3)608 (57.5)Hispanic13 (1.3)15 (1.4)Asian/Pacific Islander12 (1.2)11 (1.0)Other17 (1.7)24 (2.3)VTE Risk Factors — no. (%)Previous VTE91 (8.9)108 (10.2)0.30Cancer92 (9.0)64 (6.0)0.01Stroke7 (0.7)4 (0.4)0.34Congestive Heart Failure103 (10.1)96 (9.1)0.45Hypercoagulable State9 (0.9)13 (1.23)0.43Sepsis/Infection218 (21.3)120 (11.4)<0.0001Mechanical Ventilation30 (2.9)23 (2.2)0.33Contraindications — no. (%)Bleeding on Admission46 (4.5)49 (4.6)0.88Platelet < 50,00024 (2.3)27 (2.6)0.75APTT > 1.390 (8.8)70 (6.6)0.06INR > 1.5120 (11.7)111 (10.5)0.38In-Hospital Mortality13 (1.3)22 (2.1)0.29Table 2Comparison of ACCP Compliance, Pharmacologic Prophylaxis and Clinical Outcomes Pre- and Post-Implementation of VTE “Smart Orderset”VariablePre-Orderset (n = 1,025)Post-Orderset (n = 1,057)p-valueACCP Compliance — no. (%)700 (68.3)908 (85.9)<0.0001Prophylaxis— no. (%)Heparin 5000 BID142 (13.9)316 (29.9)<0.0001Heparin 5000 TID451 (44.0)373 (35.3)<0.0001Enoxaparin 40 mg daily8 (0.80)13 (1.23)0.31TED/SCDS60 (5.90)205 (19.4)<0.0001None363 (35.4)150 (14.2)<0.0001Clinical Outcomes— no. (%)In-hospital VTE8 (0.8)2 (0.2)0.06VTE by 90 days post-DC25 (2.4)6 (0.6)0.001Major Bleeding3 (0.3)1 (0.1)0.47 Conclusion:A VTE prophylaxis computerized decision support “smart orderset” improves ACCP-compliant VTE prophylaxis and results in lower risk of symptomatic VTE without an increase in major bleeding. Disclosures:Streiff:BristolMyers Squibb: Research Funding; sanofi-aventis: Consultancy; Daiichi-Sankyo: Consultancy; Eisai: Member of study outcome adjudication committee; sanofi-aventis: Honoraria.