Prevention of perioperative venous thromboembolism and coronary events: differential responsiveness to an intervention program to improve guidelines adherence

Abstract

Adherence to guidelines for prevention of surgical complications was found to be low in our institution. A multifaceted intervention significantly increased use of prophylaxis for venous thromboembolism but not for coronary events. This differential response suggests that the success of a quality improvement project strongly depends on topic content and its phase of acceptance.

Barriers to the Implementation of Practice Guidelines in Managing Patients with Nonvariceal Upper Gastrointestinal Bleeding: A Qualitative Approach

“…Precursors to development of an intervention include defining best evidence, the determination of clinical practice gap and barrier analyses (39), which can stem from many sources (37) including the individual practitioner, policy, other health care practitioners, patients, family members, social contexts and the health care system(s) (37,(40)(41)(42). Several systematic reviews have stressed the need to understand the forces and variables influencing practice through the use of methods that are practice-or community-based and interactive (41) rather than didactic (43,44), and have concluded that 'magic bullets' to change professional behaviour do not exist, and that the likely best approach is to combine one or more strategies listed above in a manner that is contextsensitive and responsive to feedback and changing needs (41,45,46) while recognizing that the optimal approach may be dependent on the specific topic, patients, professionals or specialty to be addressed (47)(48)(49).…”

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

“…13 However, in this same population, the same intervention initiatives had no effect on the use of beta-blockers to prevent peri-operative cardiac events and beta-blocker use remained very low.…”

“…11,12 In addition, responses to a QI initiative may depend on factors related to the practice, such as the issue being studied and the level of acceptance it has achieved among health care professionals. 13 A study of surgical patients in a 1,200-bed medical center showed that before intervention initiatives (staff meetings, local protocols, etc), only 29% of eligible patients and/or adopt established evidence-based protocols Have in place a documented system for ongoing QI that demonstrates acting on evidence-based guidelines/practices (rationale for departing from guidelines should be documented unless documentation itself is for some reason contraindicated) Include provision for risk assessment/stratification, prophylaxis, diagnosis, and treatment Include appropriate QI activity/monitoring for all phases of care with periodic (as defined by institutional policy) assessment of compliance with policies and measures Provide for a system of provider education that encompasses all aspects of VTE prevention and care including primary and secondary prevention, risk assessment and stratification, prophylaxis, diagnosis, treatment and monitoring. Risk assessment/stratification recommendations Provide for risk assessments on all patients based on evidence-based institutional policy (institutions have the flexibility to determine how patient risks are assessed/stratified) Require documentation in the patient's health record that risk assessment/stratification was completed Prophylaxis recommendations…”

“…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…”

Prophylaxis of venous thromboembolism in the US: improving hospital performance

“…In this regard, the use of objective individualized VTE risk‐assessment models [17,53] or computerized decision‐support software can improve the accuracy of prophylaxis prescribing [54]. It has also been shown that guidelines recommending a change to established physician behaviors encounter greater resistance than those recommending new practices [50,55].…”