Venous thromboembolism prophylaxis in medically ill patients and the development of strategies to improve prophylaxis rates

Abstract

Venous thromboembolism (VTE) is common but often unrecognized in medically ill patients. Over the past 5 years, three large-scale placebo-controlled trials enrolling a total of 5500 medically ill patients have highlighted the risk of VTE in this group. These trials have helped to define a specific at-risk patient profile, including those admitted to the hospital with severe congestive heart failure, respiratory illness, acute infection, and inflammatory bowel disease. We performed a retrospective review of patients admitted to the medical service at our tertiary care center to define how common the at-risk medical patient is and to evaluate and improve prophylaxis rates in this patient group. The study was conducted in two phases. Based on admission characteristics, patients were stratified into high-risk or low-risk groups for the development of VTE. During the pre-intervention phase, 75% of patients admitted to the medical service were characterized as increased risk for VTE, yet only 43% of these high-risk patients received prophylaxis of any sort. After interventions designed to increase awareness of VTE, we conducted a second review period. In this post-intervention phase, where 79% of patients were at risk for VTE, prophylaxis rates improved to 72%. Based on these results, we conclude that the majority of patients admitted to the medical service at our tertiary care center constitute a high-risk population that warrants consideration for VTE prophylaxis. Implementation of strategies to improve prophylaxis rates, including educational sessions and risk stratification guidelines, can be successful and improve identification and prophylaxis of this population. Am.

Preventing venous thromboembolism at a district hospital: a quality improvement study

“…Prospective analysis, however, would have required patient consent with the potential for bias as patients being aware of the intervention would have placed pressure on clinicians to prescribe thromboprophylaxis, which may have skewed the results. 15 …”

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

“…26,27 In a prospective registry of 5,451 patients with confirmed DVT, fewer medical patients received prophylaxis compared with surgical patients (32% versus 48%), 37 suggesting that QI interventions are particularly important for medical patients. A prospective study of the impact of continuing medical educa< tion and quality assurance programs on the use of VTE prophylaxis showed that statistically significant increases in the use of prophylaxis occurred in both medical and surgical patients in response to the interventions.…”

“…7 In the Tooher et al review, most of the QI studies were performed in surgical patients. 8 However, several more recently published initiatives have focused on medical patients [26][27][28][29][30] (Table 3). A highly successful multifaceted strategy for improving appropriate VTE prophylaxis in medical patients combined education, dissemination of a decision support tool, and regular audit-and-feedback for resident physicians.…”

“…[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.…”

“…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…”