Computerized Clinical Decision Support to Prevent Venous Thromboembolism Among Hospitalized Patients: Proximal Outcomes from a Multiyear Quality Improvement Project

Abstract:Despite venous thromboembolism (VTE) policy initiatives, gaps exist between guidelines and practice. In response, hospitals implement clinical decision support (CDS) systems to improve VTE prophylaxis. To assess the impact of a VTE CDS on reducing incidence of VTE, this study used a pretest/posttest, longitudinal, cohort design incorporating electronic health record (EHR) data from one urban tertiary and level 1 trauma center, and one suburban hospital. VTE CDS was embedded into the EHR system. The study included 45,046 admissions; 171,753 patient days; and 110 VTE events. The VTE rate declined from 0.954 per 1,000 patient days to 0.434 comparing baseline to full VTE CDS. Compared to baseline, patients benefitting from VTE CDS were 35% less likely to have a VTE. VTE CDS utilization achieved 78.4% patients assessed within 24 hr from admission, 64.0% patients identified at risk, and 47.7% patients at risk for VTE with an initiated VTE interdisciplinary plan of care. CDS systems with embedded algorithms, alerts, and notification capabilities enable physicians at the point of care to utilize guidelines and make impactful decisions to prevent VTE. This study demonstrates a phased‐in implementation of VTE CDS as an effective approach toward VTE prevention. Implications for future research and quality improvement are discussed as well.

[1]  M. Paterno,et al.  Multi-screen electronic alerts to augment venous thromboembolism prophylaxis , 2009, Thrombosis and Haemostasis.

[2]  Marilyn D Paterno,et al.  Electronic alerts to prevent venous thromboembolism among hospitalized patients. , 2005, The New England journal of medicine.

[3]  M Gent,et al.  Randomized clinical trial of postoperative fondaparinux versus perioperative dalteparin for prevention of venous thromboembolism in high‐risk abdominal surgery , 2005, The British journal of surgery.

[4]  P. Lindenauer,et al.  Venous Thromboembolism Prophylaxis among Medical Patients at US Hospitals , 2010, Journal of General Internal Medicine.

[5]  J. Collen,et al.  A simple reminder system improves venous thromboembolism prophylaxis rates and reduces thrombotic events for hospitalized patients 1 , 2012, Journal of thrombosis and haemostasis : JTH.

[6]  T. Cook,et al.  Quasi-experimentation: Design & analysis issues for field settings , 1979 .

[7]  Alessandro Liberati,et al.  Practice guidelines developed by specialty societies: the need for a critical appraisal , 2000, The Lancet.

[8]  Marilyn D Paterno,et al.  Physician Alerts to Prevent Symptomatic Venous Thromboembolism in Hospitalized Patients , 2009, Circulation.

[9]  S. Laporte,et al.  Prevention of venous thromboembolism in orthopedic surgery with vitamin K antagonists: a meta‐analysis , 2004, Journal of thrombosis and haemostasis : JTH.

[10]  Jay Lin,et al.  Direct medical costs of venous thromboembolism and subsequent hospital readmission rates: an administrative claims analysis from 30 managed care organizations. , 2015, Journal of managed care pharmacy : JMCP.

[11]  Clifford W Colwell,et al.  Prevention of Venous Thromboembolism* American College of Chest Physicians Evidence- Based Clinical Practice Guidelines (8th Edition) , 2008 .

[12]  Peter J Pronovost,et al.  Improved prophylaxis and decreased rates of preventable harm with the use of a mandatory computerized clinical decision support tool for prophylaxis for venous thromboembolism in trauma. , 2012, Archives of surgery.

[13]  Madison,et al.  Venous thromboembolism in adult hospitalizations - United States, 2007-2009. , 2012, MMWR. Morbidity and mortality weekly report.

[14]  lexander,et al.  Duration of Prophylaxis against Venous Thromboembolism with Enoxaparin after Surgery for Cancer , 2002 .

[15]  Matthew A. Berger,et al.  Improving hospital venous thromboembolism prophylaxis with electronic decision support. , 2013, Journal of hospital medicine.

[16]  Gordon H Guyatt,et al.  Executive Summary Antithrombotic Therapy and Prevention of Thrombosis , 9 th ed : American College of Chest Physicians Evidence-Based Clinical Practice Guidelines , 2012 .

[17]  H. McDonnell.  Enhancing the use of clinical guidelines: a social norms perspective. , 2006, Journal of the American College of Surgeons.

[18]  R. Dubois,et al.  Hospitals' compliance with prophylaxis guidelines for venous thromboembolism. , 2007, American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.

[19]  L. Jørgensen,et al.  Prolonged prophylaxis with dalteparin to prevent late thromboembolic complications in patients undergoing major abdominal surgery: a multicenter randomized open‐label study , 2006, Journal of thrombosis and haemostasis : JTH.

[20]  John A. Heit,et al.  The epidemiology of venous thromboembolism , 2003, Journal of Thrombosis and Thrombolysis.

[21]  C. Holzmueller,et al.  Lessons from the Johns Hopkins Multi-Disciplinary Venous Thromboembolism (VTE) Prevention Collaborative , 2012, BMJ : British Medical Journal.

[22]  Jay R Lieberman,et al.  Prevention of venous thromboembolic disease after total hip and knee arthroplasty. , 2013, The Journal of bone and joint surgery. American volume.

[23]  J. Paramo,et al.  Maintained effectiveness of an electronic alert system to prevent venous thromboembolism among hospitalized patients , 2008, Thrombosis and Haemostasis.

[24]  J. Grimshaw,et al.  Development and application of a generic methodology to assess the quality of clinical guidelines. , 1999, International journal for quality in health care : journal of the International Society for Quality in Health Care.