Risk-appropriate Venous Thromboembolism Prophylaxis Research Articles

Defects in Processes of Care for Pharmacologic Prophylaxis Are Common Among Neurosurgery Patients Who Develop In-Hospital Postoperative Venous Thromboembolism

Venous thromboembolism (VTE) is a cause of considerable morbidity and mortality in hospitalized patients. An evidence-based algorithm was developed and implemented at our institution to guide perioperative VTE prophylaxis management. We evaluated compliance with prescription of risk-appropriate VTE prophylaxis and administration of prescribed VTE prophylaxis in neurosurgery patients. This was a retrospective analysis of postoperative neurosurgery patients at a single institution with subsequent diagnosis of acute VTE during their inpatient stay. Descriptive statistics were used to characterize pharmacologic VTE prophylaxis and prescribing patterns. The incidence of VTE in our neurosurgery population was 248/13,913 (1.8%). Of the 123 patients, the median time to VTE diagnosis was 96 hours after surgery (interquartile range [IQR], 58-188 hours). A total of 108 patients (87.8%) were prescribed risk-appropriate VTE prophylaxis, among whom 61 (56.5%) received all doses as prescribed. Fifty-three patients (43.1%) missed ≥1 dose of prescribed prophylaxis and the median missed doses was 3 (IQR, 0-3). The median time to first dose of pharmacologic VTE prophylaxis was 42 hours (IQR, 28-51). More than half (n= 63, 51.2%) of the VTE risk assessments contained ≥1 error, of which 15 (23.8%) would have resulted in a change in recommendation. Our evidence-based VTE prophylaxis algorithm was not accurately completed in more than half of patients. Many patients who developed VTE had a defect in their VTE prophylaxis management during their inpatient stay. Research to improve optimal VTE prevention practice in neurosurgery patients is needed.

Venous Thromboembolism Quality Measures Fail to Accurately Measure Quality.

Venous thromboembolism (VTE) is 1 of the most common causes of preventable harm for patients in hospitals. Consequently, the Joint Commission, the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, the United Kingdom Care Quality Commission, the Australian Commission on Safety and Quality in Health Care, the Maryland Health Services Cost Review Commission, and the American College of Surgeons have prioritized measuring and reporting VTE outcomes with the goal of reducing the incidence of and preventable harm from VTE. We developed a rubric for defect-free VTE prevention, graded each organizational VTE quality measure, and found that none of the current VTE-related quality measures adequately characterizes VTE prevention efforts or outcomes in hospitalized patients. Effective VTE prevention is multifactorial: clinicians must assess patients' risk for VTE and prescribe therapy appropriate for each patient's risk profile, patients must accept the prescribed therapy, and nurses must administer the therapy as prescribed. First, an ideal, defect-free VTE prevention process measure requires: (1) documentation of a standardized VTE risk assessment; (2) prescription of optimal, risk-appropriate VTE prophylaxis; and (3) administration of all risk-appropriate VTE prophylaxis as prescribed. Second, an ideal VTE outcome measure should define potentially preventable VTE as VTE that developed in patients who experienced any VTE prevention process failures.

The Johns Hopkins Venous Thromboembolism Collaborative: Multidisciplinary team approach to achieve perfect prophylaxis.

Venous thromboembolism (VTE) is an important cause of preventable harm in hospitalized patients. The critical steps in delivery of optimal VTE prevention care include (1) assessment of VTE and bleeding risk for each patient, (2) prescription of risk-appropriate VTE prophylaxis, (3) administration of risk-appropriate VTE prophylaxis in a patient-centered manner, and (4) continuously monitoring outcomes to identify new opportunities for learning and performance improvement. To ensure that every hospitalized patient receives VTE prophylaxis consistent with their individual risk level and personal care preferences, we organized a multidisciplinary task force, the Johns Hopkins VTE Collaborative. To achieve the goal of perfect prophylaxis for every patient, we developed evidence-based, specialty-specific computerized clinical decision support VTE prophylaxis order sets that assist providers in ordering risk-appropriate VTE prevention. We developed novel strategies to improve provider VTE prevention ordering practices including face-to-face performance reviews, pay for performance, and provider VTE scorecards. When we discovered that prescription of risk-appropriate VTE prophylaxis does not ensure its administration, our multidisciplinary research team conducted in-depth surveys of patients, nurses, and physicians to design a multidisciplinary patient-centered educational intervention to eliminate missed doses of pharmacologic VTE prophylaxis that has been funded by the Patient Centered Outcomes Research Institute. We expect that the studies currently underway will bring us closer to the goal of perfect VTE prevention care for every patient. Our learning journey to eliminate harm from VTE can be applied to other types of harm. Journal of Hospital Medicine 2016;11:S8-S14. © 2016 Society of Hospital Medicine.

Eliminating Health Care Disparities With Mandatory Clinical Decision Support: The Venous Thromboembolism (VTE) Example.

All hospitalized patients should be assessed for venous thromboembolism (VTE) risk factors and prescribed appropriate prophylaxis. To improve best-practice VTE prophylaxis prescription for all hospitalized patients, we implemented a mandatory computerized clinical decision support (CCDS) tool. The tool requires completion of checklists to evaluate VTE risk factors and contraindications to pharmacological prophylaxis, and then recommends the risk-appropriate VTE prophylaxis regimen. The objective of the study was to examine the effect of a quality improvement intervention on race-based and sex-based health care disparities across 2 distinct clinical services. This was a retrospective cohort study of a quality improvement intervention. The study included 1942 hospitalized medical patients and 1599 hospitalized adult trauma patients. In this study, the proportion of patients prescribed risk-appropriate, best-practice VTE prophylaxis was evaluated. Racial disparities existed in prescription of best-practice VTE prophylaxis in the preimplementation period between black and white patients on both the trauma (70.1% vs. 56.6%, P=0.025) and medicine (69.5% vs. 61.7%, P=0.015) services. After implementation of the CCDS tool, compliance improved for all patients, and disparities in best-practice prophylaxis prescription between black and white patients were eliminated on both services: trauma (84.5% vs. 85.5%, P=0.99) and medicine (91.8% vs. 88.0%, P=0.082). Similar findings were noted for sex disparities in the trauma cohort. Despite the fact that risk-appropriate prophylaxis should be prescribed equally to all hospitalized patients regardless of race and sex, practice varied widely before our quality improvement intervention. Our CCDS tool eliminated racial disparities in VTE prophylaxis prescription across 2 distinct clinical services. Health information technology approaches to care standardization are effective to eliminate health care disparities.

An Analysis of VTE Prophylaxis Practice in Oncology Patients after Implementation of a Standardized Mandatory Computerized Clinical Decision Support Tool

▪Introduction: Venous thromboembolism (VTE) is an important cause of morbidity and mortality in oncology patients. Prophylaxis reduces the risk of VTE by 60% but many patients are not prescribed risk-appropriate VTE prophylaxis. We developed mandatory computerized clinical decision support-enabled, service-specific (CCDS) order sets to improve our institution’s VTE prophylaxis performance. The order sets require providers to complete short check lists to assess VTE risk factors and contraindications to pharmacologic prophylaxis. Based upon the answers to these questions, the order sets display the risk-appropriate VTE prophylaxis regimen for each individual patient. The purpose of this retrospective study is to evaluate VTE prophylaxis and events rates in hospitalized cancer patients admitted using a CCDS medical oncology VTE order set.Methods: Using electronic administrative records, we retrospectively collected prescription and clinical data on patients admitted to the solid tumor and hematologic malignancy services at the Johns Hopkins Sidney Kimmel Comprehensive Cancer Center (JHSKCCC) from October 17, 2010 (date of order set implementation) through June 30, 2014. A two-sided student’s t test or chi-square test were used for statistical analyses, as appropriate.Results: 7920 patients were admitted from 10/17/2010 to 6/30/14. The mean age was 57 years and 46% were female. The median length of stay was 4 days. Solid tumor service providers were more likely to prescribe risk-appropriate VTE prophylaxis (Table 1) and patients on the solid tumor service were more likely to be assessed as being at high risk for VTE (Table 2). Pharmacologic prophylaxis was more common on the solid tumor service while ambulation was the most common form of prophylaxis on the hematologic malignancy service. (Table 3) Risk-appropriate VTE prophylaxis was high on both services (Figure 1). Data on objectively-confirmed hospital-acquired VTE will be presented at the meeting.Conclusion: We report the largest analysis to date of VTE prophylaxis practices in hospitalized cancer patients. Significant differences in perceived VTE risk and prescribed prophylaxis were noted between services. Use of a computerized decision support-enabled VTE prophylaxis order set was associated with high rates of risk-appropriate VTE prophylaxis.Table 1:Patient Population CharacteristicsSolid TumorHeme MalignancyP-ValueTotal – no.49952925Mean Age – no. (SD)58.0 (13.2)56.1 (14.7)<0.001Female – no.2290 (46%)1303 (45%)Median length of stay (IQR)4 (3-6)5 (3-10.5)Risk Appropriate Prophylaxis4410 (88%)2474 (85%)<0.001Table 2:VTE Risk Assessment of Patient PopulationVTE Risk CategorySolid TumorHeme MalignancyP-valueHigh Risk – no. (%)4782 (96%)2338 (80%)<0.001High Risk w/ CI –no. (%)1222 (25%)1789 (61%)<0.001High Risk w/o CI - no. (%)3560 (71%)549 (19%)<0.001Moderate Risk – no. (%)213 (4%)587 (20%)<0.001Mod. Risk w/ CI – no. (%)41 (1%)506 (17%)<0.001Mod. Risk w/o CI – no. (%)172 (3%)81 (3%)<0.001CI= Contraindication to pharmacologic prophylaxisTable 3:VTE Prophylaxis OrdersMedical OncologyHeme MalignancyP-valuePharm Only – no. (%)2992 (69%)412 (15%)<0.001Mech Only – no. (%)700 (16%)563 (20%)Pharm + Mech – no. (%)388 (9%)87 (3%)Ambulation Only – no. (%)230 (5%)1699 (61%)<0.001Pharm= pharmacologic prophylaxis (i.e. unfractionated or low molecular weight heparin, fondaparinux), Mech= graduate compression stockings or sequential compression devices or both [Display omitted] DisclosuresStreiff:Boehringer-Ingelheim: Consultancy; Daiichi-Sankyo: Consultancy; Janssen Healthcare: Consultancy; Pfizer: Consultancy; Portola: Research Funding.

Impact of a venous thromboembolism prophylaxis “smart order set”: Improved compliance, fewer events

Venous thromboembolism (VTE) affects over 700,000 Americans annually. Prophylaxis reduces the risk of VTE by 60% but many patients still do not receive risk-appropriate VTE prophylaxis. To improve our institution's VTE prophylaxis performance, we developed mandatory computerized clinical decision support-enabled "smart order sets" that required providers to assess VTE risk factors and contraindications to pharmacologic prophylaxis. Using provider responses, the order set recommends evidence-based risk-appropriate VTE prophylaxis. To study the impact of our "smart order set" on prescription of risk-appropriate VTE prophylaxis and clinical outcomes, we conducted a retrospective 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) order set launch. Data collection included patient demographics, VTE risk factors, and the use and type of VTE prophylaxis. The pre- and post-implementation cohorts contained 1,000 and 942 patients, respectively. After implementation of the "smart order set", the prescription of risk-appropriate VTE prophylaxis increased from 65.6% to 90.1% (P < 0.0001). Orders for any form of VTE prophylaxis increased from 76.4% to 95.6% (P < 0.0001). Radiographically documented symptomatic VTE within 90 days of hospital discharge declined from 2.5% to 0.7% (P = 0.002). Preventable harm was completely eliminated (1.1% to 0%, P = 0.001) with no difference in major bleeding or all-cause mortality. A VTE prophylaxis computerized clinical decision support-enabled "smart order set" improved prescription of risk-appropriate VTE prophylaxis, reduced symptomatic VTE and eliminated preventable harm from VTE without increasing major bleeding.

Is Venous Thromboembolism in Colorectal Surgery Patients Preventable or Inevitable? One Institution's Experience

The rate of venous thromboembolism (VTE) in colorectal surgery patients is reportedly high. Herein, we describe characteristics of patients developing VTE in the early postoperative period. A retrospective cohort analysis was conducted using institutional comprehensive data on colorectal surgery patients from the National Surgical Quality Improvement Program. All patients from July 2009 to July 2011 were included. Multivariable logistic regression was used to assess which factors were associated with increased risk of developing VTE within 30 days of operation. There were 615 patients who underwent colorectal surgery. Twenty-five (4.1%) developed VTE; 16 (2.6%) deep venous thrombosis (DVT), 4 (0.7%) pulmonary embolus (PE), and 5 (0.8%) developed both DVT and PE. Among VTE patients, 23 (92%) were ordered risk-appropriate VTE prophylaxis. On multivariable analysis, risk factors associated with VTE included postoperative infection (odds ratio [OR] 4.21, 95% CI 1.79, 9.89; p = 0.001), disseminated cancer (OR 4.38, 95% CI 1.24, 15.42; p = 0.022), and emergent status (OR 2.80, 95% CI 1.15, 6.85; p = 0.024). Fourteen (56.0%) of the 25 VTE patients also developed infectious complications compared with 168 (28.5%) of patients without VTE (p = 0.001). Organ space surgical site infections were the most common infection, present in 7 VTE patients. The infectious complications in 9 (64.3%) of the 14 patients occurred before or the same day as the VTE. Most VTE events occurred in colorectal surgery patients ordered current best practice prophylaxis for VTE. Further investigation is warranted to identify patients at increased risk for VTE and to develop new strategies to further reduce the incidence of postoperative VTE.

Hospital-Acquired Venous Thromboembolism (VTE): A Retrospective Consecutive Case Series

AbstractAbstract 4280 Introduction:Venous thromboembolism (VTE) is a common complication in hospitalized patients. To reduce the incidence of this potentially preventable adverse event, we incorporated computerized clinical decision support-enabled “smart order sets” in our electronic order entry system which have significantly increased the prescription of risk-appropriate VTE prophylaxis. Despite our performance improvement, hospital-acquired VTE remains a common complication at our institution. The purpose of the current study was to examine the clinical characteristics of patients developing VTE during their hospital stay and identify potentially modifiable causes for these events. Methods:We conducted a retrospective review of an administrative database of objectively-confirmed VTE among patients hospitalized at the Johns Hopkins Hospital during fiscal year 2011. Demographic and clinical data including VTE risk category, ordered VTE prophylaxis and the number of missed doses of VTE prophylaxis were retrieved from our computerized provider order entry system. VTE were attributed to central venous catheter (CVC) if they occurred in the same vascular distribution. VTE were deemed preventable if risk-appropriate prophylaxis was not ordered or if any doses of pharmacologic prophylaxis were missed. CVC-VTE were not classified as preventable. Results:Between July 1, 2010 and June 30, 2011, 139 hospitalized adult patients were classified as developing potentially preventable VTE. The mean age is 61.3 (SD: 17.7) years, 54.0% were male, the mean BMI was 28.2 (SD: 7.6) kg/m2 and 70.5% had a surgical procedure during hospitalization. Median length of hospitalization was 15 days and median time to VTE was 6 days. Eighty nine patients (64.0%) were classified as being at high or very high risk for VTE; 52 patients admitted to a surgical service and 37 admitted to the medical service. Fifty patients (36.0%) were judged to be at moderate risk, 23 patients admitted to a surgical service and 27 admitted to the medical service.Eighty five patients (61.2%) developed DVT, 45 patients (32.4%) developed PE, and 9 patients (6.5%) had superficial thrombophlebitis (ST). Forty nine events were CVC-VTE; 38 CVC- DVT, 3 CVC- PE and 7 CVC-ST.Among 139 patients who developed in-hospital VTE, 117 patients (84.2%) experienced events that were not preventable by best practice prophylaxis (49 CVC-VTE, 2 ST, 58 received all doses of risk-appropriate prophylaxis). Among 88 patients with potentially preventable VTE events, best-practice prophylaxis was prescribed for 76 (86.5%). The most common reason for potential preventable VTE was missed doses of VTE prophylaxis. For those ordered best-practice prophylaxis, 18 patients (23.7%) missed one or more doses of pharmacologic prophylaxis, 12 patients on the medical and 6 patients on a surgical service. For 7 patients (38.9%), the provider determined that their clinical condition was inappropriate for one or more doses of prophylaxis administration; 4 patients on the medical service and 3 patients on a surgical service. Eight patients (25%) refused one or more doses of prophylaxis; 7 patients on the medical service and 1 patient on a surgical service. Conclusions:This retrospective consecutive case series of hospital-acquired VTE reveals that a substantial percentage of VTE among hospitalized patients are not preventable even with best practice prophylaxis. Therefore, process measures (prescription of risk-appropriate VTE prophylaxis) rather than outcomes (VTE) is the appropriate quality improvement metric for assessing provider and institutional performance. In addition, we noted that missed doses of VTE prophylaxis were the most common finding among patients suffering potentially preventable hospital-acquired VTE. Patient refusal and provider omission were the two leading reasons for missed doses of VTE prophylaxis. These findings underscore the need to track rates of ordered and administered doses of best-practice VTE prophylaxis and identify reasons and solutions for these quality deficits. Disclosures:Streiff:sanofi-aventis: Consultancy, Honoraria; BristolMyersSquibb: Research Funding; Eisai: Consultancy; Janssen Healthcare: Consultancy; Daiichi-Sankyo: Consultancy.

Improved Prophylaxis and Decreased Rates of Preventable Harm With the Use of a Mandatory Computerized Clinical Decision Support Tool for Prophylaxis for Venous Thromboembolism in Trauma

Venous thromboembolism is associated with substantial morbidity and mortality and is largely preventable. Despite this fact, appropriate prophylaxis is vastly underutilized. To improve compliance with best practice prophylaxis for VTE in hospitalized trauma patients, we implemented a mandatory computerized provider order entry-based clinical decision support tool. The system required completion of checklists of VTE risk factors and contraindications to pharmacologic prophylaxis. With this tool, we were able to determine a patient's risk stratification level and recommend appropriate prophylaxis. To evaluate the effect of our mandatory computerized provider order entry-based clinical decision support tool on compliance with prophylaxis guidelines for venous thromboembolism (VTE) and VTE outcomes among admitted adult trauma patients. Retrospective cohort study (from January 2007 through December 2010). University-based, state-designated level 1 adult trauma center. A total of 1599 hospitalized adult trauma patients with a hospital length of stay greater than 1 day. The primary outcome measure was the proportion of patients who were ordered risk-appropriate guideline-suggested VTE prophylaxis. The secondary outcome measure was the proportion of patients with any preventable VTE (defined as VTE in a patient not ordered guideline-appropriate VTE prophylaxis), pulmonary embolism, and/or deep vein thrombosis. Compliance with guideline-appropriate prophylaxis increased from 66.2% to 84.4% (P < .001). The rate of preventable harm from VTE decreased from 1.0% to 0.17% (P = .04). Implementation of a mandatory computerized provider order entry-based clinical decision support tool significantly improved compliance with VTE prophylaxis guidelines in hospitalized adult trauma patients. This improved compliance was associated with a significant decrease in the rate of preventable harm, which was defined as VTE events in patients not ordered appropriate prophylaxis.