Getting Closer to Optimizing the Prevention and Detection of VTE in Hospitalized Children

Abstract

Symptomatic venous thromboembolism (VTE) in the general hospitalized pediatric population is increasing and is the second most common serious hospital-acquired condition for patients in children' s hospitals, causing significant harm and expense. 1-3 Unlike other hospital-acquired conditions in children and adult VTE, 4 however, there are no broadly accepted recommendations for the implementation of a standardized process of detection, prophylaxis, and treatment of VTE in hospitalized children. 5 In this issue of Hospital Pediatrics, Shaughnessy and colleagues report both on variable quality-improvement (QI) success in decreasing variability in risk screening 6 and in the detection of VTE events among hospitalized pediatric patients. 7 We comment below first on the improvement lessons from a comparative intervention around VTE and current algorithms and then discuss the active surveillance approach for quickly identifying VTEs in hospitalized patients. Finally, we discuss how these 2 studies, taken together, can help us develop robust, population-based pediatric algorithms for preventing and addressing healthcare-acquired pediatric VTE. INCREASING THE RELIABILITY OF VTE SCREENING: ARE SOME SURGICAL MICROSYSTEMS BETTER THAN OTHERS? In their first article in this issue, Shaughnessy et al 6 report on their variable success in significantly improving and sustaining the reliability of a VTE prophylaxis screening process 8 to 86% and 46% in hospitalized pediatric surgery and orthopedic patients, respectively. The authors found that in addition to leadership and engagement, linking to a computerized provider order entry system postoperatively was the most impactful approach to ensuring high reliability for completing VTE screening. At first glance, this tale of variable success in these 2 surgical specialties seems to be a culture or ownership issue, with general surgery outperforming orthopedics in screening reliability. Setting aside the question of different populations and risk patterns, the lack of success in the orthopedics unit is a true QI opportunity to re-evaluate through plan-do-study-act cycles and choosing to adapt, adopt, or abandon a given intervention. 9 Because neither initiative achieved sustainable .90% reliability, despite extensive engagement and computerized provider order entry, and some 38% of orthopedic patients were over-or undertreated, it may be worth abandoning the laborintensive interventions and instead revisiting the workflow for orthopedics by further engaging the frontline staff,