Venous thromboembolism (VTE)—consisting of pulmonary embolism (PE) and DVT—is one of the most common and deadliest complications experienced by trauma patients admitted to hospitals. According to recent estimates, trauma is the leading killer of young people in the United States. Other studies suggest that at least 100,000 people die from PE alone every year. In light of the incidence of these events, the AHRQ recently placed interventions to improve VTE prophylaxis on its top 10 list of patient safety practices that are strongly encouraged.
Changing the Approach of VTE Prophylaxis
“Currently, healthcare practitioners use a complex flow diagram for determining the most appropriate strategies when providing VTE prophylaxis,” explains Elliott R. Haut, MD, FACS. For a study, Dr. Haut and colleagues converted the complex algorithm into a shorter clinical decision support-enabled VTE order set that was built into a computerized provider order entry system (CPOE). The converted algorithm was used at the point of care by trauma services providers at the Johns Hopkins Hospital in the analysis.
For the intervention, clinicians checked off appropriate boxes on a short checklist (Table) based on patients’ VTE risk factors and contraindications to pharmacologic VTE prophylaxis. The CPOE system integrated this information into an evidence-based algorithm to stratify patients’ VTE risk. The system then suggested the optimal decision for an appropriate VTE prophylaxis regimen.
“Using the order set was mandatory for all adult trauma patients in our study,” adds Dr. Haut, whose research was published in JAMA Surgery. The study team compared compliance with guideline-appropriate VTE prophylaxis during the year prior to implementing the order set with the 3 years after implementation.
Increased Compliance of VTE Prophylaxis
Prior to implementing the order set, only 3% of charts for adult trauma patients in the study included documentation of VTE risk stratification within the first 24 hours of admission, according to Dr. Haut. After implementing the computerized algorithm, the rate increased to about 98%. “While this may not translate directly into improved outcomes,” says Dr. Haut, “it does represent an important first step to improving quality of care.”
Previous investigations have shown that compliance with evidence-based VTE prophylaxis ranges from about 40% to 60% in medical and surgical patients. Dr. Haut says the trauma service at his institution was at about 66% before implementing the CPOE system, but this rate improved to about 85% after implementing the intervention (Figure). “Other studies have shown a link between computerized decision support tools and prophylaxis, but we observed a more direct link with hard outcomes,” Dr. Haut says. The number of all VTEs trended downward throughout the investigation, although not statistically significantly. When comparing the pre- and post-implementation periods, the rate of preventable VTE events dropped significantly.
The Big Picture Leveraging Health IT
Dr. Haut acknowledges that implementing system changes like the one used in his study relies heavily on buy-in at the hospital administrative level. “It takes the daily experiences of physicians to see where problems occur and to determine the best approaches for making improvements,” he says. “It starts with clinicians identifying that there is a problem at their institution and then working with information technology (IT), the hospital administration, and others to evoke change.”
These changes, according to Dr. Haut, are more easily attainable when health IT is leveraged and computerized systems are scaled appropriately, based on the hospital’s needs. “In our study, we used a single checklist for helping prevent one common type of complication during trauma care. This strategy can be helpful when managing patients with standardized protocols. We should be able to build it into a CPOE and make it easy to bring those data to clinicians at the moment they need them.”
Formal cost-effective analyses of mandatory CPOE-based, clinical decision support-enabled VTE order sets are still needed. However, Dr. Haut believes these types of systems should be implemented on a larger scale throughout the country. “These order sets don’t force clinicians to give all patients a dangerous drug,” he says. “Instead, they force clinicians to complete a short checklist to determine whether patients are appropriate candidates for a given therapy. When we make efforts to increase the number of patients receiving the most appropriate prophylaxis, we will improve the quality of care we provide while bringing little to no harm to patients.”
Readings & Resources (click to view)
Haut E, Lau B, Kraenzlin F, et al. Improved prophylaxis and decreased rates of preventable harm with the use of mandatory computerized clinical decision support tool for prophylaxis for venous thromboembolism in trauma. Arch Surg. 2012;147:901-907. Available at: http://archsurg.jamanetwork.com/article.aspx?articleid=1380449.
Haut E, Lau B. Chapter 28: Prevention of venous thromboembolism: brief update review. In “Making health care safer II: an updated critical analysis of the evidence for patient safety practices.” March 2013. Agency for Healthcare Research and Quality, Available at www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyuptp.html.
Kardooni S, Haut E, Chang D, et al. Hazards of benchmarking complications with the National Trauma Data Bank: numerators in search of denominators. J Trauma. 2008;64:273-279.
Streiff M, Haut E. The CMS ruling on venous thromboembolism after total knee or hip arthroplasty: weighing risks and benefits. JAMA. 2009;301:1063-1065.
Haut E, Pronovost P. Surveillance Bias in Outcomes Reporting. JAMA. 2011; 305(23):2462-3.
Cohen A, Tapson V, Bergmann J, et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet. 2008;371:387-394.
Liu D, Lee M, Spelman T, et al. Medication chart intervention improves inpatient thromboembolism prophylaxis. Chest. 2012;141:632-641.
O’Connor C, Adhikari N, DeCaire K, Friedrich J. Medical admission order sets to improve deep vein thrombosis prophylaxis rates and other outcomes. J Hosp Med. 2009;4:81-89.