Electronic alerts, comparative practitioner metrics, and education improve thromboprophylaxis and reduce venous thrombosis in community hospitals

Abstract

BackgroundVenous thromboembolism prophylaxis remains underutilized in hospitalized medical patients at high risk for venous thromboembolism. We previously reported that a multifaceted intervention was associated with a sustained increase in appropriate thromboprophylaxis and reduced symptomatic venous thromboembolism among medical patients hospitalized in two urban teaching hospitals. The effectiveness of this intervention in community hospitals is unknown.MethodsWe performed a prospective multicenter cohort study in three community hospitals. All medical patients admitted from February 1, 2011 to January 31, 2014 were eligible. Consecutive eligible patients were enrolled into the 12‐month “control,” 12‐month “intervention,” or 12‐month “maintenance” group. We provided electronic alerts, physician performance feedback, and targeted medical education for the intervention group. Only the alert component of the intervention continued in the maintenance group. The primary outcome was the rate of appropriate thromboprophylaxis among patients at high risk for venous thromboembolism defined as the prescription of guideline recommended chemoprophylaxis, or identification of a chemoprophylaxis contraindication. Secondary outcomes included rates of symptomatic venous thromboembolism, major bleeding, all‐cause mortality, heparin‐induced thrombocytopenia, physician satisfaction, and alert fatigue.ResultsAppropriate thromboprophylaxis when compared to the control group rate of 67% was higher for the intervention group (85%) and for the maintenance group (77%; P < .001 for each comparison). A reduction of 90‐day symptomatic venous thromboembolism accompanied the intervention (control 4.5%, intervention 3.4%, maintenance 3.0%, P = .04).ConclusionsThis multifaceted intervention was associated with an overall increase in appropriate thromboprophylaxis of medical patients compared with the control period. Hospital‐associated venous thrombosis rates decreased.

External validation of the simplified Geneva risk assessment model for hospital‐associated venous thromboembolism in the Padua cohort

“…While there may be several explanations, such as alert fatigue, one reason may be the complexity and therefore low applicability of the original Geneva RAM (19 items) . Other more comprehensive implementation efforts have had positive results, with greater adequate thromboprophylaxis and decreased VTE events . The now‐validated simplified Geneva RAM is somewhat simpler than the Padua RAM.…”

“…10 Other more comprehensive implementation efforts have had positive results, with greater adequate thromboprophylaxis and decreased VTE events. 11 The now-validated simplified Geneva RAM is somewhat simpler than the Padua RAM. It categorizes patients differently from the IMPROVE RAM, which identifies a greater proportion of lowrisk medical patients at the cost of a lower sensitivity and perhaps greater risks of VTE for low-risk patients.…”

Post‐discharge thrombosis and bleeding in medical patients: A novel risk score derived from ubiquitous biomarkers

“…Limitations of our work include that while derivation and validation encompassed many patients from five hospitals, all are part of an integrated 23 hospital health care network. Limitations inherent in using EMR interrogation to identify outcomes of thrombosis and bleeding events exist, although we have formerly published our ability to do so with a high degree of certainty 21 using these same techniques 32,33 . We are unable to account for missing outcome data that might arise from patients seeking care outside of our EMR catchment; however, we believe that this occurs rarely given our integrated health care system.…”

Predicting postdischarge hospital‐associated venous thromboembolism among medical patients using a validated mortality risk score derived from common biomarkers

“…This retrospective cohort study analyzed patients including those from the Intermountain Healthcare Venous Thromboembolism Reduction Initiative 1 (VRI‐1) and VRI‐2. These studies were part of a multifaceted health care quality improvement initiative and included all hospitalized medical patient admissions at 2 urban and 3 community Utah hospitals dating as we formerly described 31,32 . For this study, we considered eligible those patients from both studies and patients from 2 additional community hospitals who were hospitalized for >24 hours, discharged alive, did not have VTE detected on admission or during inpatient stay, had a complete blood cell count (CBC) and basic metabolic panel (BMP) obtained, and survived to 90 days from January 2010 through December 2014.…”