Impact of a Clinical Decision-Support Tool on Venous Thromboembolism Prophylaxis in Acutely Ill Medical Patients

Abstract

Background: Adherence to guideline-based venous thromboembolism (VTE) prophylaxis recommendations is often inadequate. Effective improvement strategies are needed. Objective: The purpose of this quality improvement initiative was to increase use of the facility’s preferred pharmacologic VTE prophylaxis, reduce unnecessary VTE prophylaxis use, and reduce use of pharmacologic VTE prophylaxis in high bleeding risk patients, in accordance with guideline-based recommendations. Methods: Clinical pharmacists spearheaded the development and implementation of a clinical decision-support tool (CDST) integrated within a Veterans Health Administration electronic health record (EHR). The CDST focused on VTE prophylaxis in acutely ill medical patients and guided prescribers to guideline-based recommendations. Following review and approval, the CDST underwent activation in the EHR. A subsequent intervention occurred, year 2 post-intervention, which embedded this CDST into the EHR admission process and admission menus. A drug message was added in the EHR to alert prescribers that low-molecular-weight heparin was the preferred agent. Measures were evaluated pre-intervention, year 1 post-intervention, and year 2 post-intervention. Results: After intervention, there were statistically significant increases in the proportion of patients receiving the facility’s preferred pharmacologic VTE prophylaxis agent, enoxaparin, and a statistically significant decrease in the proportion of unwarranted VTE prophylaxis. The proportion of inappropriate pharmacologic VTE prophylaxis in high bleeding risk patients decreased, but this result did not reach statistical significance. Conclusion: The improvements observed suggest the beneficial role of CDSTs integrated into the EHR to increase adherence to guideline-based VTE prophylaxis recommendations.

Effect of Web-based Clinical Decision Support Systems on Adherence to Venous Thromboembolism Prophylaxis guideline among ICU Nonsurgical Patients: A Prospective Before and After Study

“…This nding was quite unexpected that the CDSS for recommendation VTE prophylaxis within the CPOE system has not affected ICU mortality rate and ICU length of stay. These results consist with other studies which have shown that CDSS for recommendation VTE prophylaxis within CPOE system improves tailored prophylaxis order in nonsurgical patients without effect on patient outcome (18, 30,35). An important implication of this nding is that an electronic CDSS for recommendation VTE prophylaxis within CPOE System can improve appropriate prophylaxis without effects on patient outcome.…”

“…Also, the main nding indicates that the CDSS for recommendation VTE prophylaxis within the CPOE system improves clinician adherence to VTE prophylaxis guidelines in nonsurgical patients at ICU. These results agreed with other studies which have shown that VTE prophylaxis CDSS for recommendation prophylaxis order set within CPOE system can improve appropriate VTE prophylaxis in nonsurgical patients at ICU, but the incidence of adherence to VTE prophylaxis guideline is a variety from country to country (29)(30)(31)(32)(33). In contrast to some reports in the literature, Eijgenraam and their colleagues found that after the introduction of VTE prophylaxis CDS did no signi cantly improve adherence in guideline VTE prophylaxis in nonsurgical patients (34).…”

The Impact of a Web-based Clinical Decision Support System on Adherence to Venous Thromboembolism Prophylaxis Guidelines in ICU Nonsurgical Patients: A Prospective Study

“…This nding was entirely unexpected that the CDSS for recommendation VTE prophylaxis within the CPOE system had not affected ICU mortality rate and ICU length of stay. These results consist of other studies showing that CDSS for recommendation VTE prophylaxis within the CPOE system improves tailored prophylaxis orders in nonsurgical patients without affecting the patient outcome [18,30,36,37]. An important implication of this nding is that an electronic CDSS for recommendation VTE prophylaxis within the CPOE System can improve appropriate prevention without affecting patient outcomes.…”

“…These results agreed with other studies showing that VTE prophylaxis CDSS for recommendation prophylaxis order set within the CPOE system can improve appropriate VTE prophylaxis in nonsurgical patients at ICU. Still, the incidence of adherence to VTE prophylaxis guidelines is a variety from country to country [29][30][31][32][33]. In contrast to some reports in the literature, Eijgenraam and their colleagues found that after the introduction of VTE prophylaxis, CDS did not signi cantly improve adherence in guideline VTE prophylaxis in nonsurgical patients [34,35].…”

COVID-19 and Venous Thromboembolism Pharmacologic Thromboprophylaxis

“…Per the VA Tennessee Valley Healthcare System (TVHS)-Nashville/Murfreesboro anticoagulation policy, we limit the ordering of parenteral anticoagulation to Computerized Patient Record System (CPRS) order sets in order to provide decision support (eFigure 1, available at doi:10.12788/fp.0063). Other fa-cilities have shown that embedded clinical decision support tools increase adherence to guideline VTE prophylaxis recommendations within the VA. 14 In April 2020, the TVHS anticoagulation clinical pharmacy leads developed a COVID-19 specific order set based on review of societal guidance and the evolving, supportive literature summarized in this review with consideration of provider familiarity (eFigure 2, available at doi:10.12788/fp.0063)). Between April and June 2020, the COVID-19 order set content consistently evolved with publication of each COVID-19 thromboprophylaxis guideline.…”