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

Abstract

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. V enous thromboembolism (VTE), which encompasses both deep vein thrombosis (DVT) and pulmonary embolism (PE), is a major cause of the morbidity and mortality of hospitalized medical patients. CONCLUSIONS:1 Hospitalization for an acute medical illness has been associated with an 8-fold increase in the relative risk of VTE and is responsible for approximately a quarter of all VTE cases in the general population. 2,3Current evidence-based guidelines, including those from the American College of Chest Physicians (ACCP), recommend prophylaxis with low-dose unfractionated heparin (UFH) or lowmolecular-weight heparin (LMWH) for medical patients with risk factors for VTE. 4,5 Mechanical prophylaxis methods including graduated compression stockings and intermittent pneumatic compression are recommended for those patients for whom an- O R I G I N A L R E S E A R C H 331ticoagulant therapy is contraindicated because of a high risk of bleeding. 4,5 However, several studies have shown that adherence to these guidelines is suboptimal, with many at-risk patients receiving inadequate prophylaxis (range 32%-87%). 6 -10 Physician-related factors identified as potential barriers to guideline adherence include not being aware or familiar with the guidelines, not agreeing with the guidelines, or believing the guideline recommendations to be ineffective. 11 More specific studies have shown that some physicians may lack basic knowledge regarding the current treatment standards for VTE and may underestimate the significance of VTE.12-13 As distinct strategies, education aimed at disseminatin...

Reliability of a point‐based VTE risk assessment tool in the hands of medical residents

“…Previous studies that successfully improved VTE prophylaxis rates coupled a risk assessment tool with provider education as well as audit-and-feedback interventions. 25,26 In one study, provider education occurred on the first day of every month with an orientation to the hospital's recommended VTE prevention strategies. 26 Another study sought to improve the rates of VTE prophylaxis in medical intensive care (MICU) patients without performing individualized risk assessment.…”

“…25,26 In one study, provider education occurred on the first day of every month with an orientation to the hospital's recommended VTE prevention strategies. 26 Another study sought to improve the rates of VTE prophylaxis in medical intensive care (MICU) patients without performing individualized risk assessment. 27 Using only weekly graphic feedback and verbal reminders to the medical team, it showed an improvement in VTE prophylaxis for 1 year.…”

Bridging the Gap Between Evidence and Practice in Venous Thromboembolism Prophylaxis: The Quality Improvement Process

“…These studies generally show statistically significant increases in the proportion of patients receiving prophylaxis after the adoption of a QI strategy (Table 3). 13,[23][24][25][26][27][28][29][30] Provider Education…”

“…[26][27][28][29][30] A pharmacydriven educational program in a 493-bed US community hospital focusing on the importance of VTE prophylaxis in medically ill patients increased the use of prophylaxis from 43% to 58% (P<.001), of suitable prophylaxis from 38% to 49% (P=.006), and of optimal prophylaxis from 11% to 44% (P<.001). The educational program comprised live educational presentations and newsletters and involved nursing staff, house staff, pharmacists, and physicians.…”

“…Reminder posters can be used to reinforce information from educational sessions, 27,30 but the effectiveness of using this passive method alone has not been tested. An active reminder was a shared element of the most effective QI initiatives identified by Tooher et al 8 ; active reminders consist of either paper-based reminders or a computer-based alert.…”