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Barriers to Providing VTE Chemoprophylaxis to Hospitalized Patients: A Nursing-Focused Qualitative Evaluation
Venous thromboembolism (VTE), comprising deep venous thrombosis and pulmonary embolism (PE),1 is a serious medical condition that results in preventable morbidity and mortality.1-5 VTE affects all age groups, all races/ethnicities, and both genders, but there are known factors that increase the risk of developing VTE (eg, advanced age, undergoing surgery, hospitalization, and immobility).1-3,5-7 Prevention of VTE among hospitalized patients is of paramount importance to avoid preventable death, chronic illness/long-term complications,8 longer hospital stays, and increased hospital costs.9 Fortunately, there is clear evidence that provision of appropriate prophylaxis can decrease the risk of a VTE event occurring, and broadly accepted best-practice guidelines reflect this evidence.3,5
Given the inadequacy of current VTE-related quality measures to identify actionable failures in the provision of VTE prophylaxis, our group created a VTE process-of-care measure to assess adherence to the components of VTE prophylaxis: (1) early ambulation, (2) mechanical prophylaxis (sequential compression devices [SCDs]), and (3) chemoprophylaxis administered at the correct dose and frequency for the duration of the patient’s hospital stay.3,10,11 This quality measure was conceived, created, and iteratively revised to measure whether optimal care is provided to patients throughout their hospitalization and identify actionable areas in which failures of care occur, in order to decrease the risk of a VTE event. Data from our institution provided evidence that while ambulation and SCD component measure adherence is high, chemoprophylaxis adherence required significant improvement.10 When chemoprophylaxis process measure adherence data were analyzed further, a major failure mode was patient refusal of one or more doses. However, the drivers of patient refusal are not well defined in the literature, and previous studies have called for a greater focus on developing interventions to improve VTE chemoprophylaxis administration.12
Previous research has shown that nurses can influence patient compliance with VTE prophylaxis.13-15 A mixed-methods study by Elder et al. found that nurses in units with high rates of failure to provide optimal chemoprophylaxis offered the medication as optional, leading researchers to conclude that nurses perceived chemoprophylaxis as discretionary.13 Another study by Lee et al., conducted a survey of bedside registered nurses and identified nurses’ lack of education on VTE prevention as a significant barrier to providing care.14 These studies show that multiple levels of influence impact how nurses provide VTE chemoprophylaxis, particularly when they encounter patients who refuse chemoprophylaxis.
To explore the nuance and interplay of multiple influences, we used the Theoretical Domains Framework (TDF), an integrative framework that applies theoretical approaches to interventions aimed at behavior change.15-18 The framework contains 14 interrelated domains that characterize the behavior being studied, in this case, administration of VTE chemoprophylaxis. Consequently, we designed a nurse-focused, qualitative evaluation with the objective to identify nursing-related barriers to administration of VTE chemoprophylaxis.
METHODS
Inpatient Unit Selection
The study team accessed data from the hospital’s Enterprise Data Warehouse to review patient refusal rates of VTE chemoprophylaxis for each inpatient unit in the hospital. Patient refusal was utilized as a proxy measure for the behavior of nurses attempting to administer VTE chemoprophylaxis. Of the 14 medical and surgical units in the hospital, two medical and two surgical units were selected to participate in the qualitative evaluation based on having the highest patient refusal rates. One unit (surgical) was also selected to serve as a benchmark because it had the lowest patient refusal rate. Table 1 includes the refusal rates for the five units. Given the low refusal rate for the best performing unit, we suspected that it would be possible to decrease the patient refusal rate for other units with similar patient populations and interprofessional teams at the institution.
Observations
We observed chemoprophylaxis administration on the five units to understand the process for ordering and administering chemoprophylaxis. An observation protocol was utilized to document the date, time, and location of the observation as well as descriptive notes including accounts of particular events.19,20 Observations occurred in May 2016 and informed the creation of a process map outlining the procedure for ordering and administering VTE chemoprophylaxis. The process map was utilized to create the focus group interview guide and ensure the interview guide included pertinent questions for each step of the process (Appendix A).
Focus Group Interviews
We conducted focus group interviews with day and night shift nurses on the five units to assess nurses’ understanding of VTE chemoprophylaxis and nurses’ perceptions of barriers to administration of VTE chemoprophylaxis. The study team chose to conduct focus group interviews in an effort to maximize participation and to speak with multiple nurses within a shorter period of time. The focus group structure allowed the study team to speak with nurses during their shifts, as one could briefly step out, if required, for patient care and return to rejoin the discussion.
We developed a semistructured interview guide21 with questions focused on identifying nurses’ perceptions of guideline-recommended care for VTE chemoprophylaxis, where they learned these guidelines, how nurses discuss chemoprophylaxis with patients, how they handle the conversation with patients who refuse, and if there are times when chemoprophylaxis is not necessary. The interview guide was vetted by a multidisciplinary team consisting of clinical nursing coordinators and nurse managers from medical and surgical units, hospital quality leaders, surgeons and general internists, and qualitative research experts. The interview guide is included as Appendix B.
The unit clinical coordinators and nurse managers identified dates and times for the focus groups that would be minimally disruptive to the unit. For each of the four units with a high patient refusal rate, two focus groups were conducted during the lunch hour and one was conducted at the end of the night shift to ensure that both day and night shift nurses were included in the study. Two focus groups were conducted with the best-practice unit during the lunch hour. For each focus group, the clinical coordinator identified two to eight nurses who could step away from patient care to participate or who had completed their shifts. In total, approximately 67 nurses participated in the focus groups.
The focus groups (n = 14) lasted approximately 40 minutes during May and June 2016. Two members of the study team cofacilitated interviews, which were recorded and transcribed verbatim.
Coding and Data Analysis
To develop the code book, the study team, consisting of three qualitative researchers, independently read one focus group transcript and applied the TDF domains to the nurses’ perceptions of barriers to administration of VTE chemoprophylaxis.21-24 In addition to coding by domain, the study team also coded nursing perceptions as barriers or facilitators. The study team reviewed the coded transcript and reconciled any differences in coding. This process was repeated for a second transcript, and then all remaining transcripts were assigned to two out of three study team members for coding, with the entire study team meeting to reconcile any differences. If necessary, the team member who did not code a transcript acted as the tie-breaker if there were discrepancies in codes that could not be reconciled.
Once coding was completed, we identified the TDF domains that were most relevant to the administration of VTE chemoprophylaxis.16 Member checking (testing the analysis, interpretations, and conclusions with members of those groups from whom the data were originally obtained) was performed with the four clinical nursing coordinators and four nurse managers from the participating units to establish face validity of the themes identified from the focus group interviews.25
The study team used MaxQDA, V12 (Berlin, Germany) to support data coding and analysis.26 The Northwestern University institutional review board office deemed this project research on nonhuman-subjects because it focused on the process of providing VTE chemoprophylaxis and not about the patients themselves. The purpose of the study was explained at the beginning of each focus group, and nurses gave verbal consent to have the focus group recorded.
RESULTS
We conducted 14 focus groups with day and night shift nurses from five units (two medical and three surgical) at a single institution. All nurses invited to participate in a focus group agreed to participate. The data were coded and grouped by domain and identified as barriers or facilitators. The findings included below are for the domains most relevant to the provision of VTE prophylaxis. Table 2 provides illustrative verbatim quotes for each domain that was represented in the focus groups.
THEORETICAL DOMAINS FRAMEWORK DOMAINS
Knowledge
All interviewees recognized that providing some form of prophylaxis to mitigate the risk of a VTE event is essential. Some nurses stated that seeing a patient ambulating meant they would consider not administering prescribed chemoprophylaxis, while others would try to negotiate with patients by asking the patient to allow one dose of chemoprophylaxis prescribed two to three times daily because it was better than receiving no doses.
Environmental Context and Resources
Multiple barriers to providing optimal care were associated with the environmental context and a lack of resources. There was a lack of accessible, comprehensive, patient-centered education materials on VTE chemoprophylaxis to supplement a nurse’s explanation about the importance of chemoprophylaxis. Furthermore, many nurses cited the perceived patient pain of chemoprophylaxis injections as the main deterrent to patient compliance, especially subcutaneous heparin injections, which occur up to three times in 24 hours and often cause more pain at the site of injection than low-molecular-weight heparin. Nurses felt that transitioning patients from receiving subcutaneous heparin injections to receiving low-molecular-weight heparin could be a main driver to reduce patient refusals.
Skills
Nurses felt inadequately equipped to handle patient refusals. Many said that patient refusal of treatments was never discussed in nursing school. As a result, when patients refused treatments, the nurses did not know how to handle the situation. They felt that they lacked the tools and techniques to persuade the patient to comply.
Beliefs about Capabilities
Nurses did not know their own patient refusal rate or benchmarks of an acceptable refusal rate in contrast to one that is too high. Without this feedback, they were unable to assess their own behavior or performance related to providing VTE chemoprophylaxis.
DISCUSSION
Nurses play a critical role in providing VTE chemoprophylaxis to patients throughout their hospitalization. This study provided a unique opportunity to perform an in-depth, qualitative analysis of the barriers nurses face in providing patients with VTE chemoprophylaxis as part of their daily work caring for patients. We discovered several nursing-related barriers to the provision of VTE chemoprophylaxis, including lack of knowledge, resources, skill, and misconceptions of their capability to provide VTE chemoprophylaxis. We used a bottom-up approach by incorporating the voices of unit nurses, clinical coordinators, and nurse managers to understand potential barriers. Our findings brought to light the challenge of delivering standardized care in an area of care that is generally agreed upon, yet not fully followed. Some nurses display greater proficiency than others at communicating with patients who do not understand their risk for VTE and need for chemoprophylaxis. Furthermore, there is a pronounced misconception around the delivery of VTE chemoprophylaxis. Nurses have the inaccurate belief that even if ordered, chemoprophylaxis is not required. This misconception was widespread among nurses taking care of both medical and surgical patients. These factors appear to be modifiable targets for quality improvement and highlight the need for a skills-based education during the new hire onboarding process, as well as ongoing reeducation to ensure nursing staff have the skills to appropriately provide best-practice care for VTE chemoprophylaxis. Nurses felt ownership of the results of the qualitative evaluation because they were included in every aspect from the beginning.27 This sense of ownership will support future quality improvement efforts to develop a skills-based intervention to improve the provision of VTE chemoprophylaxis.18,27
This study has certain limitations. First, it was a qualitative study assessing nursing-related barriers to providing VTE chemoprophylaxis at a single institution, and the results cannot be generalized broadly. However, the techniques and results are transferable to other hospital settings and other clinical care situations. Thus, we believe that other institutions can utilize our methods and that similar lessons can be learned and applied. Furthermore, the validity of our study is bolstered by concordance between the results of this study and those of other studies conducted on the topic of provision of VTE prophylaxis by nurses.13-15,21 Other studies utilized observations and surveys to determine potential nurse-related barriers to the provision of VTE prophylaxis, such as lack of knowledge and the belief that the need for prophylaxis can be determined based on whether or not the patient is ambulating;13,14 however, by utilizing focus group interviews, we allowed nurses to speak in their own voices about their experiences with VTE prophylaxis, and we were able to delve deeper and identify additional barriers that emerged from discussions with nurses, such as the lack of skill and misconceptions of capability.28,29 Second, the study focused solely on nurses. Additional initiatives are underway to assess the roles of resident physicians, attending physicians, and patients in the provision of VTE prophylaxis.
Nursing-related barriers to the provision of VTE chemoprophylaxis include a lack of knowledge, resources, skills, and misconceptions of the consequences of missed elements of VTE prophylaxis. Future initiatives will focus on equipping nurses to have meaningful conversations with patients and engaging patients in their care through development of a multifaceted bundle of interventions. Furthermore, similar methods of qualitative inquiry will be used to identify the role of resident and attending physicians and patients in the provision of VTE chemoprophylaxis.
Acknowledgments
The authors thank Sonali Oberoi, Joanne Prinz, Nancy Tomaska, and Kate Paredes, as well as all the nurses who participated in focus group interviews for this study and the nurse managers and clinical coordinators who helped to schedule the focus group interviews.
Disclosures
The authors declare that they have no competing interests.
Funding
This study was funded by the Surgical Outcomes and Quality Improvement Center at Northwestern University.
1. Beckman MG, Hooper WC, Critchley SE, Ortel TL. Venous thromboembolism: a public health concern. Am J Prev Med. 2010;38(4):S495-S501. https://doi.org/10.1016/j.amepre.2009.12.017.
2. Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2):e278S-e325S. https://doi.org/10.1378/chest.11-2404.
3. Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2):e227S-e277S. https://doi.org/10.1378/chest.11-2297.
4. Guyatt GH, Akl EA, Crowther M, et al. Executive summary: antithrombotic therapy and prevention of thrombosis: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2):7S-47S. https://doi.org/10.1378/chest.1412S3.
5. Office of the Surgeon General. National Heart L, and Blood Institute. The Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism. Rockville, MD; 2008.
6. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(3):338S-400S. https://doi.org/10.1378/chest.126.3_suppl.338S.
7. Haut ER, Lau BD, Kraus PS, et al. Preventability of hospital-acquired venous thromboembolism. JAMA Surg. 2015;150(9):912-915. https://doi.org/10.1001/jamasurg.2015.1340.
8. Kahn SR, Solymoss S, Lamping DL, Abenhaim L. Long-term outcomes after deep vein thrombosis: postphlebitic syndrome and quality of life. J Gen Intern Med. 2000;15(6):425-429. https://doi.org/10.1046/j.1525-1497.2000.06419.x.
9. Mahan CE, Holdsworth MT, Welch SM, Borrego M, Spyropoulos AC. Deep-vein thrombosis: a United States cost model for a preventable and costly adverse event. Thromb Haemost. 2011;106(3):405-415. https://doi.org/10.1160/TH11-02-0132.
10. Kinnier CV, Ju MH, Kmiecik T, et al. Development of a novel composite process measure for venous thromboembolism prophylaxis. Med Care. 2016;54(2):210-217. https://doi.org/10.1097/MLR.0000000000000474.
11. Schünemann HJ, Cushman M, Burnett AE, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: prophylaxis for hospitalized and nonhospitalized medical patients. Blood Adv. 2018;2(22):3198-3225. https://doi.org/10.1182/bloodadvances.2018022954.
12. Lau BD, Streiff MB, Kraus PS, et al. Missed doses of venous thromboembolism (VTE) prophylaxis at community hospitals: cause for alarm. J Gen Intern Med. 2018;33(1):19-20. https://doi.org/10.1007/s11606-017-4203-y.
13. Elder S, Hobson DB, Rand CS, et al. Hidden barriers to delivery of pharmacological venous thromboembolism prophylaxis: the role of nursing beliefs and practices. J Patient Saf. 2016;12(2):63-68. https://doi.org/10.1097/PTS.0000000000000086.
14. Lee JA, Grochow D, Drake D, et al. Evaluation of hospital nurses’ perceived knowledge and practices of venous thromboembolism assessment and prevention. J Vasc Nurs. 2014;32(1):18-24. https://doi.org/10.1016/j.jvn.2013.06.001.
15. Shermock KM, Lau BD, Haut ER, et al. Patterns of non-administration of ordered doses of venous thromboembolism prophylaxis: implications for novel intervention strategies. PLOS ONE. 2013;8(6):e66311. https://doi.org/10.1371/journal.pone.0066311.
16. Lipworth W, Taylor N, Braithwaite J. Can the theoretical domains framework account for the implementation of clinical quality interventions? BMC Health Serv Res. 2013;13(1):530. https://doi.org/10.1186/1472-6963-13-530.
17. Taylor N, Lawton R, Moore S, et al. Collaborating with front-line healthcare professionals: the clinical and cost effectiveness of a theory based approach to the implementation of a national guideline. BMC Health Serv Res. 2014;14(1):648. https://doi.org/10.1186/s12913-014-0648-4.
18. Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7(1):37. https://doi.org/10.1186/1748-5908-7-37.
19. Bogdan R, Biklen S. Qualitative Research for Education: an Introduction to Theory and Methods. Boston: Allyn & Bacon; 1992.
20. Creswell J. Research Design: Qualitative and Quantitative Approaches. Thousand Oaks, CA: Sage Publications; 1994.
21. Patton M. Qualitative Research & Evaluation Methods: Integrating Theory and Practice. 4th ed. Thousand Oaks, CA: SAGE Publications, Inc.; 2014.
22. Alexander KE, Brijnath B, Mazza D. Barriers and enablers to delivery of the Healthy Kids Check: an analysis informed by the theoretical domains framework and COM-B model. Implement Sci. 2014;9(1):60. https://doi.org/10.1186/1748-5908-9-60.
23. Birken SA, Presseau J, Ellis SD, Gerstel AA, Mayer DK. Potential determinants of health-care professionals’ use of survivorship care plans: a qualitative study using the theoretical domains framework. Implement Sci. 2014;9(1):167. https://doi.org/10.1186/s13012-014-0167-z.
24. Atkins L, Francis J, Islam R, et al. A guide to using the theoretical domains framework of behaviour change to investigate implementation problems. Implement Sci. 2017;12(1):77. https://doi.org/10.1186/s13012-017-0605-9.
25. Lincoln YS, Guba EG. Naturalistic Inquiry. Newbury Park, CA: Sage Publications; 1985.
26. Berlin G. MAXQDA, Software for Qualitative Data Analysis. VERBI Software – Consult. Sozialforschung GmbH [computer program]; 1989-2016.
27. Lipmanowicz H. Buy-in v. ownership. Liberating Structures. http://www.liberatingstructures.com/hl-articles/. Accessed July 5, 2019.
28. Morgan D. Why Should You Use Focus Groups? and what focus groups are (and are not). In: The Focus Group Guidebook. Thousand Oaks, CA: Sage Publications; 1998:9-15, 29-35.
29. Sofaer S. Qualitative methods: what are they and why use them? Health Serv Res. 1999;34(5):1101-1118.
Venous thromboembolism (VTE), comprising deep venous thrombosis and pulmonary embolism (PE),1 is a serious medical condition that results in preventable morbidity and mortality.1-5 VTE affects all age groups, all races/ethnicities, and both genders, but there are known factors that increase the risk of developing VTE (eg, advanced age, undergoing surgery, hospitalization, and immobility).1-3,5-7 Prevention of VTE among hospitalized patients is of paramount importance to avoid preventable death, chronic illness/long-term complications,8 longer hospital stays, and increased hospital costs.9 Fortunately, there is clear evidence that provision of appropriate prophylaxis can decrease the risk of a VTE event occurring, and broadly accepted best-practice guidelines reflect this evidence.3,5
Given the inadequacy of current VTE-related quality measures to identify actionable failures in the provision of VTE prophylaxis, our group created a VTE process-of-care measure to assess adherence to the components of VTE prophylaxis: (1) early ambulation, (2) mechanical prophylaxis (sequential compression devices [SCDs]), and (3) chemoprophylaxis administered at the correct dose and frequency for the duration of the patient’s hospital stay.3,10,11 This quality measure was conceived, created, and iteratively revised to measure whether optimal care is provided to patients throughout their hospitalization and identify actionable areas in which failures of care occur, in order to decrease the risk of a VTE event. Data from our institution provided evidence that while ambulation and SCD component measure adherence is high, chemoprophylaxis adherence required significant improvement.10 When chemoprophylaxis process measure adherence data were analyzed further, a major failure mode was patient refusal of one or more doses. However, the drivers of patient refusal are not well defined in the literature, and previous studies have called for a greater focus on developing interventions to improve VTE chemoprophylaxis administration.12
Previous research has shown that nurses can influence patient compliance with VTE prophylaxis.13-15 A mixed-methods study by Elder et al. found that nurses in units with high rates of failure to provide optimal chemoprophylaxis offered the medication as optional, leading researchers to conclude that nurses perceived chemoprophylaxis as discretionary.13 Another study by Lee et al., conducted a survey of bedside registered nurses and identified nurses’ lack of education on VTE prevention as a significant barrier to providing care.14 These studies show that multiple levels of influence impact how nurses provide VTE chemoprophylaxis, particularly when they encounter patients who refuse chemoprophylaxis.
To explore the nuance and interplay of multiple influences, we used the Theoretical Domains Framework (TDF), an integrative framework that applies theoretical approaches to interventions aimed at behavior change.15-18 The framework contains 14 interrelated domains that characterize the behavior being studied, in this case, administration of VTE chemoprophylaxis. Consequently, we designed a nurse-focused, qualitative evaluation with the objective to identify nursing-related barriers to administration of VTE chemoprophylaxis.
METHODS
Inpatient Unit Selection
The study team accessed data from the hospital’s Enterprise Data Warehouse to review patient refusal rates of VTE chemoprophylaxis for each inpatient unit in the hospital. Patient refusal was utilized as a proxy measure for the behavior of nurses attempting to administer VTE chemoprophylaxis. Of the 14 medical and surgical units in the hospital, two medical and two surgical units were selected to participate in the qualitative evaluation based on having the highest patient refusal rates. One unit (surgical) was also selected to serve as a benchmark because it had the lowest patient refusal rate. Table 1 includes the refusal rates for the five units. Given the low refusal rate for the best performing unit, we suspected that it would be possible to decrease the patient refusal rate for other units with similar patient populations and interprofessional teams at the institution.
Observations
We observed chemoprophylaxis administration on the five units to understand the process for ordering and administering chemoprophylaxis. An observation protocol was utilized to document the date, time, and location of the observation as well as descriptive notes including accounts of particular events.19,20 Observations occurred in May 2016 and informed the creation of a process map outlining the procedure for ordering and administering VTE chemoprophylaxis. The process map was utilized to create the focus group interview guide and ensure the interview guide included pertinent questions for each step of the process (Appendix A).
Focus Group Interviews
We conducted focus group interviews with day and night shift nurses on the five units to assess nurses’ understanding of VTE chemoprophylaxis and nurses’ perceptions of barriers to administration of VTE chemoprophylaxis. The study team chose to conduct focus group interviews in an effort to maximize participation and to speak with multiple nurses within a shorter period of time. The focus group structure allowed the study team to speak with nurses during their shifts, as one could briefly step out, if required, for patient care and return to rejoin the discussion.
We developed a semistructured interview guide21 with questions focused on identifying nurses’ perceptions of guideline-recommended care for VTE chemoprophylaxis, where they learned these guidelines, how nurses discuss chemoprophylaxis with patients, how they handle the conversation with patients who refuse, and if there are times when chemoprophylaxis is not necessary. The interview guide was vetted by a multidisciplinary team consisting of clinical nursing coordinators and nurse managers from medical and surgical units, hospital quality leaders, surgeons and general internists, and qualitative research experts. The interview guide is included as Appendix B.
The unit clinical coordinators and nurse managers identified dates and times for the focus groups that would be minimally disruptive to the unit. For each of the four units with a high patient refusal rate, two focus groups were conducted during the lunch hour and one was conducted at the end of the night shift to ensure that both day and night shift nurses were included in the study. Two focus groups were conducted with the best-practice unit during the lunch hour. For each focus group, the clinical coordinator identified two to eight nurses who could step away from patient care to participate or who had completed their shifts. In total, approximately 67 nurses participated in the focus groups.
The focus groups (n = 14) lasted approximately 40 minutes during May and June 2016. Two members of the study team cofacilitated interviews, which were recorded and transcribed verbatim.
Coding and Data Analysis
To develop the code book, the study team, consisting of three qualitative researchers, independently read one focus group transcript and applied the TDF domains to the nurses’ perceptions of barriers to administration of VTE chemoprophylaxis.21-24 In addition to coding by domain, the study team also coded nursing perceptions as barriers or facilitators. The study team reviewed the coded transcript and reconciled any differences in coding. This process was repeated for a second transcript, and then all remaining transcripts were assigned to two out of three study team members for coding, with the entire study team meeting to reconcile any differences. If necessary, the team member who did not code a transcript acted as the tie-breaker if there were discrepancies in codes that could not be reconciled.
Once coding was completed, we identified the TDF domains that were most relevant to the administration of VTE chemoprophylaxis.16 Member checking (testing the analysis, interpretations, and conclusions with members of those groups from whom the data were originally obtained) was performed with the four clinical nursing coordinators and four nurse managers from the participating units to establish face validity of the themes identified from the focus group interviews.25
The study team used MaxQDA, V12 (Berlin, Germany) to support data coding and analysis.26 The Northwestern University institutional review board office deemed this project research on nonhuman-subjects because it focused on the process of providing VTE chemoprophylaxis and not about the patients themselves. The purpose of the study was explained at the beginning of each focus group, and nurses gave verbal consent to have the focus group recorded.
RESULTS
We conducted 14 focus groups with day and night shift nurses from five units (two medical and three surgical) at a single institution. All nurses invited to participate in a focus group agreed to participate. The data were coded and grouped by domain and identified as barriers or facilitators. The findings included below are for the domains most relevant to the provision of VTE prophylaxis. Table 2 provides illustrative verbatim quotes for each domain that was represented in the focus groups.
THEORETICAL DOMAINS FRAMEWORK DOMAINS
Knowledge
All interviewees recognized that providing some form of prophylaxis to mitigate the risk of a VTE event is essential. Some nurses stated that seeing a patient ambulating meant they would consider not administering prescribed chemoprophylaxis, while others would try to negotiate with patients by asking the patient to allow one dose of chemoprophylaxis prescribed two to three times daily because it was better than receiving no doses.
Environmental Context and Resources
Multiple barriers to providing optimal care were associated with the environmental context and a lack of resources. There was a lack of accessible, comprehensive, patient-centered education materials on VTE chemoprophylaxis to supplement a nurse’s explanation about the importance of chemoprophylaxis. Furthermore, many nurses cited the perceived patient pain of chemoprophylaxis injections as the main deterrent to patient compliance, especially subcutaneous heparin injections, which occur up to three times in 24 hours and often cause more pain at the site of injection than low-molecular-weight heparin. Nurses felt that transitioning patients from receiving subcutaneous heparin injections to receiving low-molecular-weight heparin could be a main driver to reduce patient refusals.
Skills
Nurses felt inadequately equipped to handle patient refusals. Many said that patient refusal of treatments was never discussed in nursing school. As a result, when patients refused treatments, the nurses did not know how to handle the situation. They felt that they lacked the tools and techniques to persuade the patient to comply.
Beliefs about Capabilities
Nurses did not know their own patient refusal rate or benchmarks of an acceptable refusal rate in contrast to one that is too high. Without this feedback, they were unable to assess their own behavior or performance related to providing VTE chemoprophylaxis.
DISCUSSION
Nurses play a critical role in providing VTE chemoprophylaxis to patients throughout their hospitalization. This study provided a unique opportunity to perform an in-depth, qualitative analysis of the barriers nurses face in providing patients with VTE chemoprophylaxis as part of their daily work caring for patients. We discovered several nursing-related barriers to the provision of VTE chemoprophylaxis, including lack of knowledge, resources, skill, and misconceptions of their capability to provide VTE chemoprophylaxis. We used a bottom-up approach by incorporating the voices of unit nurses, clinical coordinators, and nurse managers to understand potential barriers. Our findings brought to light the challenge of delivering standardized care in an area of care that is generally agreed upon, yet not fully followed. Some nurses display greater proficiency than others at communicating with patients who do not understand their risk for VTE and need for chemoprophylaxis. Furthermore, there is a pronounced misconception around the delivery of VTE chemoprophylaxis. Nurses have the inaccurate belief that even if ordered, chemoprophylaxis is not required. This misconception was widespread among nurses taking care of both medical and surgical patients. These factors appear to be modifiable targets for quality improvement and highlight the need for a skills-based education during the new hire onboarding process, as well as ongoing reeducation to ensure nursing staff have the skills to appropriately provide best-practice care for VTE chemoprophylaxis. Nurses felt ownership of the results of the qualitative evaluation because they were included in every aspect from the beginning.27 This sense of ownership will support future quality improvement efforts to develop a skills-based intervention to improve the provision of VTE chemoprophylaxis.18,27
This study has certain limitations. First, it was a qualitative study assessing nursing-related barriers to providing VTE chemoprophylaxis at a single institution, and the results cannot be generalized broadly. However, the techniques and results are transferable to other hospital settings and other clinical care situations. Thus, we believe that other institutions can utilize our methods and that similar lessons can be learned and applied. Furthermore, the validity of our study is bolstered by concordance between the results of this study and those of other studies conducted on the topic of provision of VTE prophylaxis by nurses.13-15,21 Other studies utilized observations and surveys to determine potential nurse-related barriers to the provision of VTE prophylaxis, such as lack of knowledge and the belief that the need for prophylaxis can be determined based on whether or not the patient is ambulating;13,14 however, by utilizing focus group interviews, we allowed nurses to speak in their own voices about their experiences with VTE prophylaxis, and we were able to delve deeper and identify additional barriers that emerged from discussions with nurses, such as the lack of skill and misconceptions of capability.28,29 Second, the study focused solely on nurses. Additional initiatives are underway to assess the roles of resident physicians, attending physicians, and patients in the provision of VTE prophylaxis.
Nursing-related barriers to the provision of VTE chemoprophylaxis include a lack of knowledge, resources, skills, and misconceptions of the consequences of missed elements of VTE prophylaxis. Future initiatives will focus on equipping nurses to have meaningful conversations with patients and engaging patients in their care through development of a multifaceted bundle of interventions. Furthermore, similar methods of qualitative inquiry will be used to identify the role of resident and attending physicians and patients in the provision of VTE chemoprophylaxis.
Acknowledgments
The authors thank Sonali Oberoi, Joanne Prinz, Nancy Tomaska, and Kate Paredes, as well as all the nurses who participated in focus group interviews for this study and the nurse managers and clinical coordinators who helped to schedule the focus group interviews.
Disclosures
The authors declare that they have no competing interests.
Funding
This study was funded by the Surgical Outcomes and Quality Improvement Center at Northwestern University.
Venous thromboembolism (VTE), comprising deep venous thrombosis and pulmonary embolism (PE),1 is a serious medical condition that results in preventable morbidity and mortality.1-5 VTE affects all age groups, all races/ethnicities, and both genders, but there are known factors that increase the risk of developing VTE (eg, advanced age, undergoing surgery, hospitalization, and immobility).1-3,5-7 Prevention of VTE among hospitalized patients is of paramount importance to avoid preventable death, chronic illness/long-term complications,8 longer hospital stays, and increased hospital costs.9 Fortunately, there is clear evidence that provision of appropriate prophylaxis can decrease the risk of a VTE event occurring, and broadly accepted best-practice guidelines reflect this evidence.3,5
Given the inadequacy of current VTE-related quality measures to identify actionable failures in the provision of VTE prophylaxis, our group created a VTE process-of-care measure to assess adherence to the components of VTE prophylaxis: (1) early ambulation, (2) mechanical prophylaxis (sequential compression devices [SCDs]), and (3) chemoprophylaxis administered at the correct dose and frequency for the duration of the patient’s hospital stay.3,10,11 This quality measure was conceived, created, and iteratively revised to measure whether optimal care is provided to patients throughout their hospitalization and identify actionable areas in which failures of care occur, in order to decrease the risk of a VTE event. Data from our institution provided evidence that while ambulation and SCD component measure adherence is high, chemoprophylaxis adherence required significant improvement.10 When chemoprophylaxis process measure adherence data were analyzed further, a major failure mode was patient refusal of one or more doses. However, the drivers of patient refusal are not well defined in the literature, and previous studies have called for a greater focus on developing interventions to improve VTE chemoprophylaxis administration.12
Previous research has shown that nurses can influence patient compliance with VTE prophylaxis.13-15 A mixed-methods study by Elder et al. found that nurses in units with high rates of failure to provide optimal chemoprophylaxis offered the medication as optional, leading researchers to conclude that nurses perceived chemoprophylaxis as discretionary.13 Another study by Lee et al., conducted a survey of bedside registered nurses and identified nurses’ lack of education on VTE prevention as a significant barrier to providing care.14 These studies show that multiple levels of influence impact how nurses provide VTE chemoprophylaxis, particularly when they encounter patients who refuse chemoprophylaxis.
To explore the nuance and interplay of multiple influences, we used the Theoretical Domains Framework (TDF), an integrative framework that applies theoretical approaches to interventions aimed at behavior change.15-18 The framework contains 14 interrelated domains that characterize the behavior being studied, in this case, administration of VTE chemoprophylaxis. Consequently, we designed a nurse-focused, qualitative evaluation with the objective to identify nursing-related barriers to administration of VTE chemoprophylaxis.
METHODS
Inpatient Unit Selection
The study team accessed data from the hospital’s Enterprise Data Warehouse to review patient refusal rates of VTE chemoprophylaxis for each inpatient unit in the hospital. Patient refusal was utilized as a proxy measure for the behavior of nurses attempting to administer VTE chemoprophylaxis. Of the 14 medical and surgical units in the hospital, two medical and two surgical units were selected to participate in the qualitative evaluation based on having the highest patient refusal rates. One unit (surgical) was also selected to serve as a benchmark because it had the lowest patient refusal rate. Table 1 includes the refusal rates for the five units. Given the low refusal rate for the best performing unit, we suspected that it would be possible to decrease the patient refusal rate for other units with similar patient populations and interprofessional teams at the institution.
Observations
We observed chemoprophylaxis administration on the five units to understand the process for ordering and administering chemoprophylaxis. An observation protocol was utilized to document the date, time, and location of the observation as well as descriptive notes including accounts of particular events.19,20 Observations occurred in May 2016 and informed the creation of a process map outlining the procedure for ordering and administering VTE chemoprophylaxis. The process map was utilized to create the focus group interview guide and ensure the interview guide included pertinent questions for each step of the process (Appendix A).
Focus Group Interviews
We conducted focus group interviews with day and night shift nurses on the five units to assess nurses’ understanding of VTE chemoprophylaxis and nurses’ perceptions of barriers to administration of VTE chemoprophylaxis. The study team chose to conduct focus group interviews in an effort to maximize participation and to speak with multiple nurses within a shorter period of time. The focus group structure allowed the study team to speak with nurses during their shifts, as one could briefly step out, if required, for patient care and return to rejoin the discussion.
We developed a semistructured interview guide21 with questions focused on identifying nurses’ perceptions of guideline-recommended care for VTE chemoprophylaxis, where they learned these guidelines, how nurses discuss chemoprophylaxis with patients, how they handle the conversation with patients who refuse, and if there are times when chemoprophylaxis is not necessary. The interview guide was vetted by a multidisciplinary team consisting of clinical nursing coordinators and nurse managers from medical and surgical units, hospital quality leaders, surgeons and general internists, and qualitative research experts. The interview guide is included as Appendix B.
The unit clinical coordinators and nurse managers identified dates and times for the focus groups that would be minimally disruptive to the unit. For each of the four units with a high patient refusal rate, two focus groups were conducted during the lunch hour and one was conducted at the end of the night shift to ensure that both day and night shift nurses were included in the study. Two focus groups were conducted with the best-practice unit during the lunch hour. For each focus group, the clinical coordinator identified two to eight nurses who could step away from patient care to participate or who had completed their shifts. In total, approximately 67 nurses participated in the focus groups.
The focus groups (n = 14) lasted approximately 40 minutes during May and June 2016. Two members of the study team cofacilitated interviews, which were recorded and transcribed verbatim.
Coding and Data Analysis
To develop the code book, the study team, consisting of three qualitative researchers, independently read one focus group transcript and applied the TDF domains to the nurses’ perceptions of barriers to administration of VTE chemoprophylaxis.21-24 In addition to coding by domain, the study team also coded nursing perceptions as barriers or facilitators. The study team reviewed the coded transcript and reconciled any differences in coding. This process was repeated for a second transcript, and then all remaining transcripts were assigned to two out of three study team members for coding, with the entire study team meeting to reconcile any differences. If necessary, the team member who did not code a transcript acted as the tie-breaker if there were discrepancies in codes that could not be reconciled.
Once coding was completed, we identified the TDF domains that were most relevant to the administration of VTE chemoprophylaxis.16 Member checking (testing the analysis, interpretations, and conclusions with members of those groups from whom the data were originally obtained) was performed with the four clinical nursing coordinators and four nurse managers from the participating units to establish face validity of the themes identified from the focus group interviews.25
The study team used MaxQDA, V12 (Berlin, Germany) to support data coding and analysis.26 The Northwestern University institutional review board office deemed this project research on nonhuman-subjects because it focused on the process of providing VTE chemoprophylaxis and not about the patients themselves. The purpose of the study was explained at the beginning of each focus group, and nurses gave verbal consent to have the focus group recorded.
RESULTS
We conducted 14 focus groups with day and night shift nurses from five units (two medical and three surgical) at a single institution. All nurses invited to participate in a focus group agreed to participate. The data were coded and grouped by domain and identified as barriers or facilitators. The findings included below are for the domains most relevant to the provision of VTE prophylaxis. Table 2 provides illustrative verbatim quotes for each domain that was represented in the focus groups.
THEORETICAL DOMAINS FRAMEWORK DOMAINS
Knowledge
All interviewees recognized that providing some form of prophylaxis to mitigate the risk of a VTE event is essential. Some nurses stated that seeing a patient ambulating meant they would consider not administering prescribed chemoprophylaxis, while others would try to negotiate with patients by asking the patient to allow one dose of chemoprophylaxis prescribed two to three times daily because it was better than receiving no doses.
Environmental Context and Resources
Multiple barriers to providing optimal care were associated with the environmental context and a lack of resources. There was a lack of accessible, comprehensive, patient-centered education materials on VTE chemoprophylaxis to supplement a nurse’s explanation about the importance of chemoprophylaxis. Furthermore, many nurses cited the perceived patient pain of chemoprophylaxis injections as the main deterrent to patient compliance, especially subcutaneous heparin injections, which occur up to three times in 24 hours and often cause more pain at the site of injection than low-molecular-weight heparin. Nurses felt that transitioning patients from receiving subcutaneous heparin injections to receiving low-molecular-weight heparin could be a main driver to reduce patient refusals.
Skills
Nurses felt inadequately equipped to handle patient refusals. Many said that patient refusal of treatments was never discussed in nursing school. As a result, when patients refused treatments, the nurses did not know how to handle the situation. They felt that they lacked the tools and techniques to persuade the patient to comply.
Beliefs about Capabilities
Nurses did not know their own patient refusal rate or benchmarks of an acceptable refusal rate in contrast to one that is too high. Without this feedback, they were unable to assess their own behavior or performance related to providing VTE chemoprophylaxis.
DISCUSSION
Nurses play a critical role in providing VTE chemoprophylaxis to patients throughout their hospitalization. This study provided a unique opportunity to perform an in-depth, qualitative analysis of the barriers nurses face in providing patients with VTE chemoprophylaxis as part of their daily work caring for patients. We discovered several nursing-related barriers to the provision of VTE chemoprophylaxis, including lack of knowledge, resources, skill, and misconceptions of their capability to provide VTE chemoprophylaxis. We used a bottom-up approach by incorporating the voices of unit nurses, clinical coordinators, and nurse managers to understand potential barriers. Our findings brought to light the challenge of delivering standardized care in an area of care that is generally agreed upon, yet not fully followed. Some nurses display greater proficiency than others at communicating with patients who do not understand their risk for VTE and need for chemoprophylaxis. Furthermore, there is a pronounced misconception around the delivery of VTE chemoprophylaxis. Nurses have the inaccurate belief that even if ordered, chemoprophylaxis is not required. This misconception was widespread among nurses taking care of both medical and surgical patients. These factors appear to be modifiable targets for quality improvement and highlight the need for a skills-based education during the new hire onboarding process, as well as ongoing reeducation to ensure nursing staff have the skills to appropriately provide best-practice care for VTE chemoprophylaxis. Nurses felt ownership of the results of the qualitative evaluation because they were included in every aspect from the beginning.27 This sense of ownership will support future quality improvement efforts to develop a skills-based intervention to improve the provision of VTE chemoprophylaxis.18,27
This study has certain limitations. First, it was a qualitative study assessing nursing-related barriers to providing VTE chemoprophylaxis at a single institution, and the results cannot be generalized broadly. However, the techniques and results are transferable to other hospital settings and other clinical care situations. Thus, we believe that other institutions can utilize our methods and that similar lessons can be learned and applied. Furthermore, the validity of our study is bolstered by concordance between the results of this study and those of other studies conducted on the topic of provision of VTE prophylaxis by nurses.13-15,21 Other studies utilized observations and surveys to determine potential nurse-related barriers to the provision of VTE prophylaxis, such as lack of knowledge and the belief that the need for prophylaxis can be determined based on whether or not the patient is ambulating;13,14 however, by utilizing focus group interviews, we allowed nurses to speak in their own voices about their experiences with VTE prophylaxis, and we were able to delve deeper and identify additional barriers that emerged from discussions with nurses, such as the lack of skill and misconceptions of capability.28,29 Second, the study focused solely on nurses. Additional initiatives are underway to assess the roles of resident physicians, attending physicians, and patients in the provision of VTE prophylaxis.
Nursing-related barriers to the provision of VTE chemoprophylaxis include a lack of knowledge, resources, skills, and misconceptions of the consequences of missed elements of VTE prophylaxis. Future initiatives will focus on equipping nurses to have meaningful conversations with patients and engaging patients in their care through development of a multifaceted bundle of interventions. Furthermore, similar methods of qualitative inquiry will be used to identify the role of resident and attending physicians and patients in the provision of VTE chemoprophylaxis.
Acknowledgments
The authors thank Sonali Oberoi, Joanne Prinz, Nancy Tomaska, and Kate Paredes, as well as all the nurses who participated in focus group interviews for this study and the nurse managers and clinical coordinators who helped to schedule the focus group interviews.
Disclosures
The authors declare that they have no competing interests.
Funding
This study was funded by the Surgical Outcomes and Quality Improvement Center at Northwestern University.
1. Beckman MG, Hooper WC, Critchley SE, Ortel TL. Venous thromboembolism: a public health concern. Am J Prev Med. 2010;38(4):S495-S501. https://doi.org/10.1016/j.amepre.2009.12.017.
2. Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2):e278S-e325S. https://doi.org/10.1378/chest.11-2404.
3. Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2):e227S-e277S. https://doi.org/10.1378/chest.11-2297.
4. Guyatt GH, Akl EA, Crowther M, et al. Executive summary: antithrombotic therapy and prevention of thrombosis: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2):7S-47S. https://doi.org/10.1378/chest.1412S3.
5. Office of the Surgeon General. National Heart L, and Blood Institute. The Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism. Rockville, MD; 2008.
6. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(3):338S-400S. https://doi.org/10.1378/chest.126.3_suppl.338S.
7. Haut ER, Lau BD, Kraus PS, et al. Preventability of hospital-acquired venous thromboembolism. JAMA Surg. 2015;150(9):912-915. https://doi.org/10.1001/jamasurg.2015.1340.
8. Kahn SR, Solymoss S, Lamping DL, Abenhaim L. Long-term outcomes after deep vein thrombosis: postphlebitic syndrome and quality of life. J Gen Intern Med. 2000;15(6):425-429. https://doi.org/10.1046/j.1525-1497.2000.06419.x.
9. Mahan CE, Holdsworth MT, Welch SM, Borrego M, Spyropoulos AC. Deep-vein thrombosis: a United States cost model for a preventable and costly adverse event. Thromb Haemost. 2011;106(3):405-415. https://doi.org/10.1160/TH11-02-0132.
10. Kinnier CV, Ju MH, Kmiecik T, et al. Development of a novel composite process measure for venous thromboembolism prophylaxis. Med Care. 2016;54(2):210-217. https://doi.org/10.1097/MLR.0000000000000474.
11. Schünemann HJ, Cushman M, Burnett AE, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: prophylaxis for hospitalized and nonhospitalized medical patients. Blood Adv. 2018;2(22):3198-3225. https://doi.org/10.1182/bloodadvances.2018022954.
12. Lau BD, Streiff MB, Kraus PS, et al. Missed doses of venous thromboembolism (VTE) prophylaxis at community hospitals: cause for alarm. J Gen Intern Med. 2018;33(1):19-20. https://doi.org/10.1007/s11606-017-4203-y.
13. Elder S, Hobson DB, Rand CS, et al. Hidden barriers to delivery of pharmacological venous thromboembolism prophylaxis: the role of nursing beliefs and practices. J Patient Saf. 2016;12(2):63-68. https://doi.org/10.1097/PTS.0000000000000086.
14. Lee JA, Grochow D, Drake D, et al. Evaluation of hospital nurses’ perceived knowledge and practices of venous thromboembolism assessment and prevention. J Vasc Nurs. 2014;32(1):18-24. https://doi.org/10.1016/j.jvn.2013.06.001.
15. Shermock KM, Lau BD, Haut ER, et al. Patterns of non-administration of ordered doses of venous thromboembolism prophylaxis: implications for novel intervention strategies. PLOS ONE. 2013;8(6):e66311. https://doi.org/10.1371/journal.pone.0066311.
16. Lipworth W, Taylor N, Braithwaite J. Can the theoretical domains framework account for the implementation of clinical quality interventions? BMC Health Serv Res. 2013;13(1):530. https://doi.org/10.1186/1472-6963-13-530.
17. Taylor N, Lawton R, Moore S, et al. Collaborating with front-line healthcare professionals: the clinical and cost effectiveness of a theory based approach to the implementation of a national guideline. BMC Health Serv Res. 2014;14(1):648. https://doi.org/10.1186/s12913-014-0648-4.
18. Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7(1):37. https://doi.org/10.1186/1748-5908-7-37.
19. Bogdan R, Biklen S. Qualitative Research for Education: an Introduction to Theory and Methods. Boston: Allyn & Bacon; 1992.
20. Creswell J. Research Design: Qualitative and Quantitative Approaches. Thousand Oaks, CA: Sage Publications; 1994.
21. Patton M. Qualitative Research & Evaluation Methods: Integrating Theory and Practice. 4th ed. Thousand Oaks, CA: SAGE Publications, Inc.; 2014.
22. Alexander KE, Brijnath B, Mazza D. Barriers and enablers to delivery of the Healthy Kids Check: an analysis informed by the theoretical domains framework and COM-B model. Implement Sci. 2014;9(1):60. https://doi.org/10.1186/1748-5908-9-60.
23. Birken SA, Presseau J, Ellis SD, Gerstel AA, Mayer DK. Potential determinants of health-care professionals’ use of survivorship care plans: a qualitative study using the theoretical domains framework. Implement Sci. 2014;9(1):167. https://doi.org/10.1186/s13012-014-0167-z.
24. Atkins L, Francis J, Islam R, et al. A guide to using the theoretical domains framework of behaviour change to investigate implementation problems. Implement Sci. 2017;12(1):77. https://doi.org/10.1186/s13012-017-0605-9.
25. Lincoln YS, Guba EG. Naturalistic Inquiry. Newbury Park, CA: Sage Publications; 1985.
26. Berlin G. MAXQDA, Software for Qualitative Data Analysis. VERBI Software – Consult. Sozialforschung GmbH [computer program]; 1989-2016.
27. Lipmanowicz H. Buy-in v. ownership. Liberating Structures. http://www.liberatingstructures.com/hl-articles/. Accessed July 5, 2019.
28. Morgan D. Why Should You Use Focus Groups? and what focus groups are (and are not). In: The Focus Group Guidebook. Thousand Oaks, CA: Sage Publications; 1998:9-15, 29-35.
29. Sofaer S. Qualitative methods: what are they and why use them? Health Serv Res. 1999;34(5):1101-1118.
1. Beckman MG, Hooper WC, Critchley SE, Ortel TL. Venous thromboembolism: a public health concern. Am J Prev Med. 2010;38(4):S495-S501. https://doi.org/10.1016/j.amepre.2009.12.017.
2. Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2):e278S-e325S. https://doi.org/10.1378/chest.11-2404.
3. Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2):e227S-e277S. https://doi.org/10.1378/chest.11-2297.
4. Guyatt GH, Akl EA, Crowther M, et al. Executive summary: antithrombotic therapy and prevention of thrombosis: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2):7S-47S. https://doi.org/10.1378/chest.1412S3.
5. Office of the Surgeon General. National Heart L, and Blood Institute. The Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism. Rockville, MD; 2008.
6. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(3):338S-400S. https://doi.org/10.1378/chest.126.3_suppl.338S.
7. Haut ER, Lau BD, Kraus PS, et al. Preventability of hospital-acquired venous thromboembolism. JAMA Surg. 2015;150(9):912-915. https://doi.org/10.1001/jamasurg.2015.1340.
8. Kahn SR, Solymoss S, Lamping DL, Abenhaim L. Long-term outcomes after deep vein thrombosis: postphlebitic syndrome and quality of life. J Gen Intern Med. 2000;15(6):425-429. https://doi.org/10.1046/j.1525-1497.2000.06419.x.
9. Mahan CE, Holdsworth MT, Welch SM, Borrego M, Spyropoulos AC. Deep-vein thrombosis: a United States cost model for a preventable and costly adverse event. Thromb Haemost. 2011;106(3):405-415. https://doi.org/10.1160/TH11-02-0132.
10. Kinnier CV, Ju MH, Kmiecik T, et al. Development of a novel composite process measure for venous thromboembolism prophylaxis. Med Care. 2016;54(2):210-217. https://doi.org/10.1097/MLR.0000000000000474.
11. Schünemann HJ, Cushman M, Burnett AE, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: prophylaxis for hospitalized and nonhospitalized medical patients. Blood Adv. 2018;2(22):3198-3225. https://doi.org/10.1182/bloodadvances.2018022954.
12. Lau BD, Streiff MB, Kraus PS, et al. Missed doses of venous thromboembolism (VTE) prophylaxis at community hospitals: cause for alarm. J Gen Intern Med. 2018;33(1):19-20. https://doi.org/10.1007/s11606-017-4203-y.
13. Elder S, Hobson DB, Rand CS, et al. Hidden barriers to delivery of pharmacological venous thromboembolism prophylaxis: the role of nursing beliefs and practices. J Patient Saf. 2016;12(2):63-68. https://doi.org/10.1097/PTS.0000000000000086.
14. Lee JA, Grochow D, Drake D, et al. Evaluation of hospital nurses’ perceived knowledge and practices of venous thromboembolism assessment and prevention. J Vasc Nurs. 2014;32(1):18-24. https://doi.org/10.1016/j.jvn.2013.06.001.
15. Shermock KM, Lau BD, Haut ER, et al. Patterns of non-administration of ordered doses of venous thromboembolism prophylaxis: implications for novel intervention strategies. PLOS ONE. 2013;8(6):e66311. https://doi.org/10.1371/journal.pone.0066311.
16. Lipworth W, Taylor N, Braithwaite J. Can the theoretical domains framework account for the implementation of clinical quality interventions? BMC Health Serv Res. 2013;13(1):530. https://doi.org/10.1186/1472-6963-13-530.
17. Taylor N, Lawton R, Moore S, et al. Collaborating with front-line healthcare professionals: the clinical and cost effectiveness of a theory based approach to the implementation of a national guideline. BMC Health Serv Res. 2014;14(1):648. https://doi.org/10.1186/s12913-014-0648-4.
18. Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7(1):37. https://doi.org/10.1186/1748-5908-7-37.
19. Bogdan R, Biklen S. Qualitative Research for Education: an Introduction to Theory and Methods. Boston: Allyn & Bacon; 1992.
20. Creswell J. Research Design: Qualitative and Quantitative Approaches. Thousand Oaks, CA: Sage Publications; 1994.
21. Patton M. Qualitative Research & Evaluation Methods: Integrating Theory and Practice. 4th ed. Thousand Oaks, CA: SAGE Publications, Inc.; 2014.
22. Alexander KE, Brijnath B, Mazza D. Barriers and enablers to delivery of the Healthy Kids Check: an analysis informed by the theoretical domains framework and COM-B model. Implement Sci. 2014;9(1):60. https://doi.org/10.1186/1748-5908-9-60.
23. Birken SA, Presseau J, Ellis SD, Gerstel AA, Mayer DK. Potential determinants of health-care professionals’ use of survivorship care plans: a qualitative study using the theoretical domains framework. Implement Sci. 2014;9(1):167. https://doi.org/10.1186/s13012-014-0167-z.
24. Atkins L, Francis J, Islam R, et al. A guide to using the theoretical domains framework of behaviour change to investigate implementation problems. Implement Sci. 2017;12(1):77. https://doi.org/10.1186/s13012-017-0605-9.
25. Lincoln YS, Guba EG. Naturalistic Inquiry. Newbury Park, CA: Sage Publications; 1985.
26. Berlin G. MAXQDA, Software for Qualitative Data Analysis. VERBI Software – Consult. Sozialforschung GmbH [computer program]; 1989-2016.
27. Lipmanowicz H. Buy-in v. ownership. Liberating Structures. http://www.liberatingstructures.com/hl-articles/. Accessed July 5, 2019.
28. Morgan D. Why Should You Use Focus Groups? and what focus groups are (and are not). In: The Focus Group Guidebook. Thousand Oaks, CA: Sage Publications; 1998:9-15, 29-35.
29. Sofaer S. Qualitative methods: what are they and why use them? Health Serv Res. 1999;34(5):1101-1118.
© 2019 Society of Hospital Medicine
Improving VTE Prevention
Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism, is a significant cause of morbidity and mortality in the United States among hospitalized patients.[1, 2, 3, 4, 5, 6] Although it may not be possible to completely eradicate VTE events,[7] chemical and/or mechanical prophylaxis can reduce VTE rates by up to 74% to 86%,[8, 9, 10] and meta‐analyses have demonstrated the benefit of VTE prophylaxis in the inpatient population.[11, 12] Despite evidence‐based guidelines regarding the appropriate type, duration, and dosing of prophylaxis, thromboprophylaxis has been found to be underutilized in the inpatient setting.[13, 14, 15]
Northwestern Memorial Hospital (NMH) historically performed poorly on VTE outcome measures. VTE in the surgical patient population was an especially glaring problem, as NMH was persistently found to be a risk‐adjusted poor performer in the American College of Surgeons National Surgical Quality Improvement Project (ACS‐NSQIP).
However, VTE outcome measures have been shown to be problematic due to their susceptibility to surveillance bias; that is, variation in the ordering of screening or diagnostic VTE imaging studies between hospitals leads to variable VTE rates (the more you look, the more you find).[16, 17, 18, 19] More vigilant hospitals that have a lower threshold to order an imaging study may find higher occurrences of VTE, and paradoxically be deemed a poor performer. Surveillance bias and the lack of validity of the VTE outcome measurement highlighted the importance of utilizing process‐of‐care measures in assessing hospital VTE prevention efforts.[20, 21] Thus, when the Joint Commission enacted 6 new VTE core process‐of‐care measures on January 1, 2013 to monitor hospital performance on VTE prophylaxis administration and VTE treatment (Table 1), NMH undertook a hospital‐wide quality‐improvement (QI) project utilizing the define‐measure‐analyze‐improve‐control (DMAIC) process improvement (PI) methodology to optimize their performance on these core measures as well as the Surgical Care Improvement Project (SCIP) SCIP‐VTE‐2 measure. In this article, we describe the QI effort undertaken at NMH to improve hospital‐level measure performance and the outcomes of this effort.
| VTE Measure | Measure Calculation | Description of Issues | Interventions | Preintervention Performance, % (N)* | Postintervention Performance, % (N) |
|---|---|---|---|---|---|
| |||||
| VTE‐1: VTE PPX | Patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given | Missing documentation (both chemical and mechanical); prophylaxis ordered, but not administered; patient refusals and opportunity to increase patient education regarding prophylaxis | 1. Enhanced, individualized VTE prophylaxis alert: alert incorporated order, administration, mechanical PPX, lab exclusion and contraindication details | NMH: 86.6% (174) | NMH: 93.6% (162) |
| All patients | Undocumented contraindication reasons | 2. Nursing education initiative: back‐to‐basics VTE education initiative to help increase the administration of VTE prophylaxis and improve patient education resulting in fewer patient refusals and missed doses | NMH general surgery: 94.4% (34) | NMH general surgery: 97.6% (41) | |
| Inconsistent monitoring and patient education | 3. Updated VTE prophylaxis surgical and medicine order set: updated order listing, heparin TID setting and contraindications | NMH general medicine: 82.5% (115) | NMH general medicine: 90.2% (85) | ||
| VTE‐2: ICU VTE PPX | Patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given | See interventions 1 through 3 | NMH: 100% (58) | NMH: 95.8% (69) | |
| Patients directly admitted or transferred to the ICU | NMH general surgery: 100% (11) | NMH general surgery: 100% (10) | |||
| NMH general medicine: 100% (40) | NMH general medicine: 100% (51) | ||||
| VTE‐3: VTE patients with anticoagulation overlap therapy | Patients who received overlap therapy of parenteral anticoagulation and warfarin therapy | Gaps in documentation and administration of overlap therapy for 5 days | 4. Overlap therapy alert at discharge: document VTE on diagnosis list with alert to either (1) document reason for discontinuation of parental therapy or (2) prescribe parental anticoagulation during hospitalization or at discharge | NMH: 95.8% (159) | NMH: 100% (105) |
| Patients with confirmed VTE who received warfarin | 5. Overlap therapy alert during hospitalization: documentation alert on the day therapy discontinued | NMH general surgery: 85.7% (12) | NMH general surgery: 100% (16) | ||
| NMH general medicine: 97.0% (129) | NMH general medicine: 100% (79) | ||||
| VTE‐4: VTE patients receiving unfractionated dosages/platelet count monitoring by protocol or nomogram | Patients who have IV UFH therapy dosages and platelet counts monitored according to defined parameters such as a nomogram or protocol | Missing required language on IV UFH orders and order may not include preselected CBC order | 6. Updated heparin order sets: reminder to monitor platelet counts per nomogram and preselect CBC order | NMH: 73.7% (98) | NMH: 100% (74) |
| Patients with confirmed VTE receiving IV UFH therapy | NMH general surgery: 56.3% (7) | NMH general surgery: 100% (9) | |||
| NMH general medicine: 83.8% (88) | NMH general medicine: 100% (52) | ||||
| VTE‐5: VTE warfarin discharge instructions | Patients with documentation that they or their caregivers were given written discharge instructions or other educational material about warfarin | Discharge process is not standardized | 7. Warfarin Patient Education Task: automate nursing task for warfarin order set, check individual warfarin education excluding consult orders | NMH: 9.6% (12) | NMH: 87.5% (63) |
| Patients with confirmed VTE discharged on warfarin therapy | Patient education during hospitalization varies | 8. Warfarin dotphrase: new warfarin/Coumadin dotphrase aligned with department and core measure requirements | NMH general surgery: 0% (0) | NMH general surgery: 100% (11) | |
| No standardized process for initiating and tracking warfarin education during hospitalization | 9. Department Warfarin Instructions Phase II: update department warfarin language, automate warfarin education task | NMH general medicine: 11.3% (12) | NMH general medicine: 85.5% (50) | ||
| Warfarin special instructions for discharge is not aligned with the EMR dotphrase | 10. Physician Referral Order Update: Add follow‐up reason to order | ||||
| Follow‐up appointments are inconsistent | |||||
| VTE‐6: Incidence of potentially preventable VTE | Patients who received no VTE PPX prior to the VTE diagnostic test order date | Failure reasons related to other measures | NMH: 8% (8) | NMH: 2.4% (2) | |
| Patients who developed confirmed VTE during hospitalization | NMH general surgery: 6.7% (1) | NMH general surgery: 0% (0) | |||
| NMH general medicine: 13.5% (7) | NMH general medicine: 0% (0) | ||||
| SCIP‐VTE‐2 | Surgery patients who receive appropriate VTE prophylaxis within 24 hours prior to anesthesia start time to 24 hours after anesthesia end time | Standard enoxaparin administration time is 1300 and there is a gap between surgery end time to enoxaparin administration (i.e. patient may wait up to 23 hours for prophylaxis) | 11. Updated VTE prophylaxis‐surgical and medicine order set: added 1‐time and 2‐time heparin doses to enoxaparin order section | NMH: 99.5% (202) | NMH: 100% (104) |
| All selected surgery patients | NMH General Surgery: 98.5% (67) | NMH General Surgery: 100% (100) | |||
| NMH General Medicine: N/A | NMH General Medicine: N/A | ||||
| Additional interventions | Incomplete VTE prophylaxis information | 12. Updated IPC view | |||
| Inconsistent documentation across forms | 13. Updated ADL forms and iView nursing responses updated | ||||
| 14. Updated unit snapshot to mirror IPC view | |||||
| 15. Updated MPET: updated nursing task: standardize Not Given and Not Done Nursing Responses | |||||
METHODS
Setting
NMH is a tertiary referral and teaching hospital affiliated with the Feinberg School of Medicine of Northwestern University. It is the flagship of Northwestern Medicine, which also includes 4 community hospitals, a dedicated women's hospital, and outpatient and urgent care centers.[22] NMH is an 885‐bed hospital with approximately 50,000 inpatients admitted annually. This project, to evaluate the outcomes of the NMH VTE QI initiative, was reviewed and approved by the Northwestern University Institutional Review Board as an exempt activity.
Measures
The Joint Commission VTE measures were a product of the National Consensus Standards for the Prevention and Care of Deep Vein Thrombosis project between the Joint Commission and National Quality Forum (NQF). These 6 measures are endorsed by the NQF and aligned with the Centers of Medicare and Medicaid Services.[23] SCIP also has measures focusing on VTE prophylaxis. SCIP‐VTE‐2 focuses on prophylaxis in the perioperative period (the 24 hours prior to anesthesia start time to 24 hours postanesthesia end time). Specific measure definitions are in Table 1. All patients hospitalized at NMH were eligible for case abstraction; specific inclusion and exclusion criteria were based on measure specifics set forth by The Joint Commission and SCIP, and random cases were selected for abstraction utilizing the standard sampling methodology required for these measures. Case abstraction was performed by a nurse and validated by physicians.
The Intervention
Review of baseline performance on the core measures began in January 2013. Common failure points were identified first by electronic medical record (EMR) evaluation. Subsequently, focus groups with front‐line staff, close examination of EMR ordering logic for chemical and mechanical prophylaxis with the IT department, hospital floor observations, and evaluation of the patient education process during discharge were performed to further define the reasons for common failure points.
Fifteen data‐driven, focused interventions were then designed, pilot tested, and implemented throughout the hospital in May 2013, with iterative improvement of each component over the next 18 months (Table 1). This project utilized DMAIC PI methodology, and was carried out by a multidisciplinary team with representatives from the departments of surgery, internal medicine, anesthesia, gynecology, PI, clinical quality, pharmacy, analytics, information technology (IT), and nursing. Broadly, the 15 interventions consisted of (1) EMR alerts, (2) education initiatives, (3) new EMR order sets, and (4) other EMR changes.
EMR Alerts
Novel provider alerts were built into NMH's inpatient EMR platform (Cerner PowerChart; Cerner Corp., North Kansas City, MO) to address common mistakes contributing to failures on VTE‐1 (chemoprophylaxis) and VTE‐3 (overlap therapy). Although VTE‐1 failures were often multifactorial, missing documentation regarding reasons for no chemoprophylaxis given and failures to order chemoprophylaxis were 2 common drivers of failures. To address these 2 problems, a logic‐driven alert to force patient‐specific ordering of appropriate VTE prophylaxis was developed (Figure 1). VTE‐3 (overlap therapy) failures occurred due to clinician failure to order a full 5 days of overlap therapy when switching from parenteral anticoagulation to warfarin therapy; hence, to target VTE‐3 performance, new alerts reminding clinicians to meticulously order and document the overlap of parenteral VTE therapy and warfarin were developed. As part of the logic‐driven alert to improve patient‐specific ordering of appropriate VTE prophylaxis, we allowed for the inclusion of documentation of a contraindication to explain why VTE prophylaxis was not ordered.
Educational Initiatives
After consulting with attending physicians, residents, nurses, and practice managers at NMH to understand the potential drivers of VTE‐1 (chemoprophylaxis) failures, a team of clinicians and PI experts held 2‐part interactive educational sessions with nurses to address knowledge deficits. The first part focused on general VTE education (eg, the significance of the problem nationwide as well as at NMH, general signs and symptoms of VTE, risk factors for VTE, and NMH‐specific failure rates for mechanical and chemoprophylaxis). The second portion used a myth‐busting approach, in which common misunderstandings that frequently impede VTE prophylaxis (eg, a patient capable of ambulating does not need sequential compression devices (SCDs), or SCDs cannot be applied to a patient with acute or chronic DVT) were discussed. Educational efforts also addressed VTE‐5 (warfarin discharge instructions) performance; although nurses provided patient education with regard to home warfarin use, the timing was inconsistent. The VTE‐5 education provided nurses with a standardized method and time for educating patients about postdischarge warfarin use. EMR changes ensured that when warfarin was ordered, warfarin education automatically populated the nurse's task list, reminding them to educate their patients prior to discharge.
New EMR Order Sets
Previously existing order sets often made it difficult for physicians to order the correct dosing and timing of VTE prophylaxis, document contraindications to prophylaxis, and lacked the appropriate laboratory orders with therapy orders. New order sets were designed to facilitate compliance with VTE‐1 (chemoprophylaxis), VTE‐4 (platelet monitoring), VTE‐5 (warfarin discharge instructions), and SCIP‐VTE‐2 (perioperative prophylaxis) by updating lab and medication order listings, dosing choices, prophylaxis contraindications, reminders to monitor platelet counts per nomogram, and physician follow‐up reasons. When we considered our hospital's specific local factors, we came to the conclusion that risk stratification would be a difficult strategy to apply effectively as a component of the new order sets, mainly due to barriers related to buy‐in from physicians and nurses.
Other EMR Changes
Other interventions targeted at specific issues were programmed into the EMR. For example, a shortcut (known as a dotphrase in Cerner PowerChart) for inserting warfarin instructions into patient care documentation was available to physicians, but was misaligned to the standard warfarin instructions. In addition, the physician responsible for following up on a patient's first outpatient international normalized ratio was often omitted from the discharge instructions, potentially leaving patients without a physician to adjust their dosing appropriately. Adding this physician information, as well as aligning and updating all discharge instructions, allowed for clear, consistent patient instructions for home warfarin use. Moreover, EMR forms used by physicians and forms used by nurses to check for VTE prophylaxis were inconsistent, thus leading to potential confusion between physicians and nurses. Accordingly, regularly used EMR forms (eg, the interdisciplinary plan of care, and the unit summary page or unit snapshot) were updated and standardized.
Control Mechanisms
Concurrent with the implementation of the 15 interventions was the development of several control mechanisms to ensure sustained improvement. These mechanisms consisted of (1) an electronic proxy measure for VTE‐1 (chemoprophylaxis) and (2) monitoring of clinician (including physicians, nurses, and midlevel providers) responses to the EMR alerts, and (3) a comprehensive EMR unit report (Figure 2).
Proxy Measure
Because the Joint Commission core measures are abstracted from only a sample of cases, and a time lag existed between each failure on VTE‐1 (chemoprophylaxis) to the time the QI team learned of the failure, a proxy measure was created. This proxy measure is used as a stand‐in for actual VTE‐1 measure performance, but is generated in real time and reflects performance throughout the entire hospital instead of a random sample of cases. Using the Northwestern Electronic Data Warehouse (EDW), the NMH analytics team created a report reflecting thromboprophylaxis administration on each hospital unit currently and over time. Performance could also be examined for each individual hospital service line. Being able to track longitudinal performance by unit and by service line enabled the QI team to understand trends in performance. Having the ability to examine patients who missed doses over the preceding few hours allowed unit leadership to proactively act upon the failures in a timely fashion, instead of waiting to receive their performance on the Joint Commission core measures.
Physician Alert Response Monitoring
Monitoring of clinical responses to EMR alerts was embedded as standard practice. Because alert fatigue is a documented unintended consequence of heavy reliance on EMR alerts,[24, 25] physicians and nurses who failed to respond to alerts regarding VTE prophylaxis were identified. Interventions targeted toward this group of nonresponders are currently being developed and tested.
EDW Unit Report
This report allows unit managers to track potential failures real time and act prior to a failure occurring (eg, missed chemoprophylaxis dose) through the NMH EDW (Figure 2). These reports contained detailed order and administration data at the individual patient, nurse, and physician levels. Missed doses of VTE chemoprophylaxis were immediately fed back to unit nursing managers who utilized the report to perform a rapid drilldown to identify the root cause(s) of the failure, and then rectify the failure while the patient was still hospitalized.
Statistical Analyses
Hospital performance on the VTE core measures and SCIP‐VTE‐2 was determined by trained nurse abstractors, who abstract cases randomly sampled by the University of HealthCare Consortium, and adjudicate findings as per the Specifications Manual for National Hospital Inpatient Quality Measures. Performance in the period prior to the QI intervention and in the period following the QI intervention was documented as proportions of abstracted cases found to be compliant with measure specifications. Differences between the pre‐ and postintervention periods were compared using a binomial test, with a P value <0.05 considered significant. All analyses were performed using Stata version 13 (StataCorp, College Station, TX).
RESULTS
A total of 1679 cases were abstracted to obtain core measure performance in the time period before the DMAIC intervention phase (January 1, 2013May 1, 2013), and 1424 cases were abstracted to obtain core measure performance in the time period after the DMAIC intervention phase (October 1, 2014April 1, 2015).
Overall NMH performance on measures VTE‐1 (chemoprophylaxis) and VTE36 (overlap therapy, platelet monitoring, warfarin discharge instructions, hospital‐acquired [HA]‐VTE) improved significantly (P < 0.05) (Table 1). No improvement was seen on VTE‐2 (intensive care unit chemoprophylaxis) given that pre‐ and postintervention performance was 100%, which likely reflects previous hospital efforts to improve adherence to this measure. The percentage of patients who failed measure VTE‐6 (number of patients with HA‐VTE who did not have VTE prophylaxis ordered prior to diagnosis of their VTE) decreased from 8% to 2.4%, demonstrating improved VTE prevention prescribing habits in NMH providers rather than a change in VTE event rates (ie, if more patients receive prophylaxis, they cannot be included in the numerator). Performance on SCIP‐VTE‐2 (perioperative chemoprophylaxis) increased from 99.5% to 100% as well but did not reach significance given the baseline high performance.
Measure performance on the general surgery services was comparable to the general medical services, with 1 exception. VTE‐1 (chemoprophylaxis) performance was lower both prior to and following the QI intervention on general medicine services (medicine: 82.5% to 90.2% vs surgery: 94.4% to 97.6%). Recent performance on the VTE‐1 proxy measure has proven to be stable between 95% and 97% on surgery services. Physician response to alerts has increased slightly among the NMH general medicine practitioners (15.2%19.1%) but has been stable among NMH general surgery providers.
DISCUSSION
Our study demonstrates that a formal DMAIC QI project taken on by a multidisciplinary team (including clinicians from multiple specialties as well as personnel from IT, nursing, analytics, and PI) can be successfully implemented and can result in marked improvement in VTE core process measure performance. We used a multifaceted approach undertaken by the NMH VTE QI team, utilizing 15 data‐driven interventions including EMR alerts, education initiatives, and new EMR order sets. These were combined with strong control mechanisms to sustain gains.
Previously published studies on VTE prophylaxis practices found that projects combining both passive (ie, helping clinicians to remember to risk‐assess their patients' for VTE) and active (ie, assisting clinicians in appropriate prescribing practices) strategies are the most successful.[26] Our improvement on VTE‐1 can be compared to previous studies examining changes in ordering rates of VTE prophylaxis. Other QI projects that featured a combination of interventions observed similar significant increases in prophylaxis ordering.[27, 28] Our improvement on VTE‐1 (chemoprophylaxis) was significant, although the difference between pre‐ and postintervention performance varied by service type (general surgery vs general medicine vs other). The small increment of improvement on surgical services was likely attributable to a high baseline performance. Prior to 2013, surgically focused VTE prophylaxis QI efforts spurred by poor ACS‐NSQIP performance proved to be successful, thus resulting in high surgical prophylaxis rates at the outset of the hospital‐wide VTE DMAIC project.
One of the most significant unanticipated barriers to improving performance on VTE‐1 (chemoprophylaxis) included the different hospital subcultures on the medical floors as compared to the surgical floors. The surgical floors had higher rates of compliance with VTE‐1 than the general medicine floors both before and after the QI interventions. When the root causes were explored, the medical floors were found to have different ordering and administration patterns. These, in part, stemmed from differing guidelines[29] and standards in the literature regarding VTE prophylaxis for medical and surgical patients. Multiple discussions within the multidisciplinary QI team and with each involved department were held, focusing on the data regarding safe care in medical patients at low risk for a VTE. Subsequent EMR alerts alterations reflected the internal medicine VTE prophylaxis recommendations for medical patients, allowing that low‐risk patients could be assessed by the provider and given as a reason for foregoing VTE prophylaxis.
Barriers to VTE prophylaxis administration were encountered on the nursing front as well. Floor observations illustrated that chemoprophylaxis injections were often offered as an optional medication. Patients, when given the choice of receiving an injection or not, would understandably choose to forgo their heparin or enoxaparin shot. This missed dose was then documented as a patient refusal. This may not be a problem unique to NMH; 1 study demonstrated that almost 12% of chemoprophylaxis doses may not be administered, and a frequent reason may be due to patient refusal.[30] The lack of patient education regarding the importance of receiving chemical prophylaxis was an improvement opportunity at both the nursing and physician level. Not only did physicians and nurses take the responsibility to educate patients on the importance of receiving the proper prophylaxis, but nursing managers were made responsible for acting on missed doses that were listed on the real‐time performance reports for their units. Missed prophylaxis doses thus became an actionable item instead of an acceptable occurrence.
Culture change in an organization is difficult and necessitates sustained efforts. An important component of our project is our control mechanism, in which a real‐time, continuously updated unit report leverages data from our EDW to generate ongoing performance reports that are regularly reviewed by hospital leadership, clinical process owners, and, most importantly, frontline nurse managers. The unit‐specific reports allow nurse managers and clinical project owners to review prophylaxis failures on a case‐by‐case basis daily and to address and rectify the cause. In addition, the QI team tracks individual physician action taken in response to EMR alerts. As performance feedback to surgical trainees has been demonstrated to have a positive effect on ordering practices,[31] efforts to improve resident alert response rates by means of feedback and education are underway.
Limitations
Our results have to be interpreted within certain limitations. First, given that hospital performance on the VTE core measures is determined by abstracting only a sample of eligible cases, it is possible that our results were affected by sampling error. Second, because of problems with the VTE outcome measure due to surveillance bias, we are unable to draw any valid conclusions about changes in VTE event rates as a result of this QI project. Third, because many of our interventions were tailored to NMH's EMR platform and local hospital culture, it is possible that parts of our project are not readily generalizable to other hospitals; however, we believe that many components, such as the alert logics, can be easily tailored to other EMR platforms.
CONCLUSION
This institutional project was a large, multidisciplinary, and sustained undertaking that improved our performance on the VTE core measures. We believe that our bundle of EMR modifications, alerts (particularly the underlying alert logics), order sets, and standardization of summary EMR view can be adopted in other settings with appropriate adaptations to each hospital's specific local environment. Our focused educational interventions can also be easily adapted to other hospital settings. Perhaps the most important part of the project was the construction of novel control mechanisms that allow for tracking of physical alert response and for real‐time evaluation, audit, and feedback of prophylaxis ordering and administration practices at NMH. Taken as a whole, this bundle of resources to improve adherence to optimal VTE prophylaxis will facilitate future interventions targeted at reaching defect‐free care.
Disclosures: Nothing to report.
- , , , , . Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence‐Based Clinical Practice Guidelines. Chest. 2012;141:7S–47S.
- , , , , . Estimated annual numbers of US acute‐care hospital patients at risk for venous thromboembolism. Am J Hematol. 2007;82:777–782.
- , , , et al. All‐cause and potentially disease‐related health care costs associated with venous thromboembolism in commercial, Medicare, and Medicaid beneficiaries. J Manag Care Pharm. 2012;18:363–374.
- , . Pulmonary embolism and deep vein thrombosis. Lancet. 2012;379:1835–1846.
- , , , . Long‐term outcomes after deep vein thrombosis: postphlebitic syndrome and quality of life. J Gen Intern Med. 2000;15:425–429.
- , , , et al. The long‐term clinical course of acute deep venous thrombosis. Ann Intern Med. 1996;125:1–7.
- , . The CMS ruling on venous thromboembolism after total knee or hip arthroplasty: weighing risks and benefits. JAMA. 2009;301:1063–1065.
- , , , et al. Hidden costs associated with venous thromboembolism: impact of lost productivity on employers and employees. J Occup Environ Med. 2014;56(9):979–985.
- , . Designing and implementing effective venous thromboembolism prevention protocols: lessons from collaborative efforts. J Thromb Thrombolysis. 2010;29:159–166.
- , , , . Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin. Overview of results of randomized trials in general, orthopedic, and urologic surgery. N Engl J Med. 1988;318:1162–1173.
- , , , , . Meta‐analysis: anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalized medical patients. Ann Intern Med. 2007;146:278–288.
- , , , , . Meta‐analysis of low molecular weight heparin in the prevention of venous thromboembolism in general surgery. Br J Surg. 2001;88:913–930.
- , , , et al. Preventability of hospital‐acquired venous thromboembolism. JAMA Surg. 2015;150(9):912–915.
- , , , et al. Venous thromboembolism risk and prophylaxis in the acute care hospital setting (ENDORSE survey): findings in surgical patients. Ann Surg. 2010;251:330–338.
- , , , . Are surgical patients at risk of venous thromboembolism currently meeting the Surgical Care Improvement Project performance measure for appropriate and timely prophylaxis? J Thromb Thrombolysis. 2010;30:55–66.
- , , , et al. Evaluation of surveillance bias and the validity of the venous thromboembolism quality measure. JAMA. 2013;310:1482–1489.
- , , , , , . Evaluation of hospital factors associated with hospital postoperative venous thromboembolism imaging utilisation practices. BMJ Qual Saf. 2014;23(11):947–956.
- , , , et al. Association between hospital imaging use and venous thromboembolism events rates based on clinical data. Ann Surg. 2014;260:558–564; discussion 64–66.
- , , , , . Postoperative venous thromboembolism outcomes measure: analytic exploration of potential misclassification of hospital quality due to surveillance bias. Ann Surg. 2015;261(3):443–444.
- , , . The need to revisit VTE quality measures. JAMA. 2014;312:286–287.
- . Facilitating quality improvement: pushing the pendulum back toward process measures. JAMA. 2015;314:1333–1334.
- Northwestern Medicine website. Available at: https://www.nm.org/locations‐at‐northwestern‐medicine. Accessed February 23, 2016.
- Venous thromboembolism. The Joint Commission website. Available at: http://www.jointcommission.org/venous_thromboembolism. Accessed February 23, 2016.
- , , , , . Some unintended consequences of clinical decision support systems. AMIA Annu Symp Proc. 2007:26–30.
- , , , . Overriding of drug safety alerts in computerized physician order entry. J Am Med Inform Assoc. 2006;13:138–147.
- , , , et al. A systematic review of strategies to improve prophylaxis for venous thromboembolism in hospitals. Ann Surg. 2005;241:397–415.
- , , , et al. Optimizing prevention of hospital‐acquired venous thromboembolism (VTE): prospective validation of a VTE risk assessment model. J Hosp Med. 2010;5:10–18.
- , , . Improving the use of venous thromboembolism prophylaxis in an Australian teaching hospital. Qual Saf Health Care. 2009;18:408–412.
- , , , , . Venous thromboembolism prophylaxis in hospitalized patients: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2011;155:625–632.
- , , , et al. Patterns of non‐administration of ordered doses of venous thromboembolism prophylaxis: implications for novel intervention strategies. PLoS One. 2013;8:e66311.
- , , , et al. Individualized performance feedback to surgical residents improves appropriate venous thromboembolism prophylaxis prescription and reduces potentially preventable VTE: a prospective cohort study [published online November 25, 2015]. Ann Surg. doi: 10.1097/SLA.0000000000001512.
Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism, is a significant cause of morbidity and mortality in the United States among hospitalized patients.[1, 2, 3, 4, 5, 6] Although it may not be possible to completely eradicate VTE events,[7] chemical and/or mechanical prophylaxis can reduce VTE rates by up to 74% to 86%,[8, 9, 10] and meta‐analyses have demonstrated the benefit of VTE prophylaxis in the inpatient population.[11, 12] Despite evidence‐based guidelines regarding the appropriate type, duration, and dosing of prophylaxis, thromboprophylaxis has been found to be underutilized in the inpatient setting.[13, 14, 15]
Northwestern Memorial Hospital (NMH) historically performed poorly on VTE outcome measures. VTE in the surgical patient population was an especially glaring problem, as NMH was persistently found to be a risk‐adjusted poor performer in the American College of Surgeons National Surgical Quality Improvement Project (ACS‐NSQIP).
However, VTE outcome measures have been shown to be problematic due to their susceptibility to surveillance bias; that is, variation in the ordering of screening or diagnostic VTE imaging studies between hospitals leads to variable VTE rates (the more you look, the more you find).[16, 17, 18, 19] More vigilant hospitals that have a lower threshold to order an imaging study may find higher occurrences of VTE, and paradoxically be deemed a poor performer. Surveillance bias and the lack of validity of the VTE outcome measurement highlighted the importance of utilizing process‐of‐care measures in assessing hospital VTE prevention efforts.[20, 21] Thus, when the Joint Commission enacted 6 new VTE core process‐of‐care measures on January 1, 2013 to monitor hospital performance on VTE prophylaxis administration and VTE treatment (Table 1), NMH undertook a hospital‐wide quality‐improvement (QI) project utilizing the define‐measure‐analyze‐improve‐control (DMAIC) process improvement (PI) methodology to optimize their performance on these core measures as well as the Surgical Care Improvement Project (SCIP) SCIP‐VTE‐2 measure. In this article, we describe the QI effort undertaken at NMH to improve hospital‐level measure performance and the outcomes of this effort.
| VTE Measure | Measure Calculation | Description of Issues | Interventions | Preintervention Performance, % (N)* | Postintervention Performance, % (N) |
|---|---|---|---|---|---|
| |||||
| VTE‐1: VTE PPX | Patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given | Missing documentation (both chemical and mechanical); prophylaxis ordered, but not administered; patient refusals and opportunity to increase patient education regarding prophylaxis | 1. Enhanced, individualized VTE prophylaxis alert: alert incorporated order, administration, mechanical PPX, lab exclusion and contraindication details | NMH: 86.6% (174) | NMH: 93.6% (162) |
| All patients | Undocumented contraindication reasons | 2. Nursing education initiative: back‐to‐basics VTE education initiative to help increase the administration of VTE prophylaxis and improve patient education resulting in fewer patient refusals and missed doses | NMH general surgery: 94.4% (34) | NMH general surgery: 97.6% (41) | |
| Inconsistent monitoring and patient education | 3. Updated VTE prophylaxis surgical and medicine order set: updated order listing, heparin TID setting and contraindications | NMH general medicine: 82.5% (115) | NMH general medicine: 90.2% (85) | ||
| VTE‐2: ICU VTE PPX | Patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given | See interventions 1 through 3 | NMH: 100% (58) | NMH: 95.8% (69) | |
| Patients directly admitted or transferred to the ICU | NMH general surgery: 100% (11) | NMH general surgery: 100% (10) | |||
| NMH general medicine: 100% (40) | NMH general medicine: 100% (51) | ||||
| VTE‐3: VTE patients with anticoagulation overlap therapy | Patients who received overlap therapy of parenteral anticoagulation and warfarin therapy | Gaps in documentation and administration of overlap therapy for 5 days | 4. Overlap therapy alert at discharge: document VTE on diagnosis list with alert to either (1) document reason for discontinuation of parental therapy or (2) prescribe parental anticoagulation during hospitalization or at discharge | NMH: 95.8% (159) | NMH: 100% (105) |
| Patients with confirmed VTE who received warfarin | 5. Overlap therapy alert during hospitalization: documentation alert on the day therapy discontinued | NMH general surgery: 85.7% (12) | NMH general surgery: 100% (16) | ||
| NMH general medicine: 97.0% (129) | NMH general medicine: 100% (79) | ||||
| VTE‐4: VTE patients receiving unfractionated dosages/platelet count monitoring by protocol or nomogram | Patients who have IV UFH therapy dosages and platelet counts monitored according to defined parameters such as a nomogram or protocol | Missing required language on IV UFH orders and order may not include preselected CBC order | 6. Updated heparin order sets: reminder to monitor platelet counts per nomogram and preselect CBC order | NMH: 73.7% (98) | NMH: 100% (74) |
| Patients with confirmed VTE receiving IV UFH therapy | NMH general surgery: 56.3% (7) | NMH general surgery: 100% (9) | |||
| NMH general medicine: 83.8% (88) | NMH general medicine: 100% (52) | ||||
| VTE‐5: VTE warfarin discharge instructions | Patients with documentation that they or their caregivers were given written discharge instructions or other educational material about warfarin | Discharge process is not standardized | 7. Warfarin Patient Education Task: automate nursing task for warfarin order set, check individual warfarin education excluding consult orders | NMH: 9.6% (12) | NMH: 87.5% (63) |
| Patients with confirmed VTE discharged on warfarin therapy | Patient education during hospitalization varies | 8. Warfarin dotphrase: new warfarin/Coumadin dotphrase aligned with department and core measure requirements | NMH general surgery: 0% (0) | NMH general surgery: 100% (11) | |
| No standardized process for initiating and tracking warfarin education during hospitalization | 9. Department Warfarin Instructions Phase II: update department warfarin language, automate warfarin education task | NMH general medicine: 11.3% (12) | NMH general medicine: 85.5% (50) | ||
| Warfarin special instructions for discharge is not aligned with the EMR dotphrase | 10. Physician Referral Order Update: Add follow‐up reason to order | ||||
| Follow‐up appointments are inconsistent | |||||
| VTE‐6: Incidence of potentially preventable VTE | Patients who received no VTE PPX prior to the VTE diagnostic test order date | Failure reasons related to other measures | NMH: 8% (8) | NMH: 2.4% (2) | |
| Patients who developed confirmed VTE during hospitalization | NMH general surgery: 6.7% (1) | NMH general surgery: 0% (0) | |||
| NMH general medicine: 13.5% (7) | NMH general medicine: 0% (0) | ||||
| SCIP‐VTE‐2 | Surgery patients who receive appropriate VTE prophylaxis within 24 hours prior to anesthesia start time to 24 hours after anesthesia end time | Standard enoxaparin administration time is 1300 and there is a gap between surgery end time to enoxaparin administration (i.e. patient may wait up to 23 hours for prophylaxis) | 11. Updated VTE prophylaxis‐surgical and medicine order set: added 1‐time and 2‐time heparin doses to enoxaparin order section | NMH: 99.5% (202) | NMH: 100% (104) |
| All selected surgery patients | NMH General Surgery: 98.5% (67) | NMH General Surgery: 100% (100) | |||
| NMH General Medicine: N/A | NMH General Medicine: N/A | ||||
| Additional interventions | Incomplete VTE prophylaxis information | 12. Updated IPC view | |||
| Inconsistent documentation across forms | 13. Updated ADL forms and iView nursing responses updated | ||||
| 14. Updated unit snapshot to mirror IPC view | |||||
| 15. Updated MPET: updated nursing task: standardize Not Given and Not Done Nursing Responses | |||||
METHODS
Setting
NMH is a tertiary referral and teaching hospital affiliated with the Feinberg School of Medicine of Northwestern University. It is the flagship of Northwestern Medicine, which also includes 4 community hospitals, a dedicated women's hospital, and outpatient and urgent care centers.[22] NMH is an 885‐bed hospital with approximately 50,000 inpatients admitted annually. This project, to evaluate the outcomes of the NMH VTE QI initiative, was reviewed and approved by the Northwestern University Institutional Review Board as an exempt activity.
Measures
The Joint Commission VTE measures were a product of the National Consensus Standards for the Prevention and Care of Deep Vein Thrombosis project between the Joint Commission and National Quality Forum (NQF). These 6 measures are endorsed by the NQF and aligned with the Centers of Medicare and Medicaid Services.[23] SCIP also has measures focusing on VTE prophylaxis. SCIP‐VTE‐2 focuses on prophylaxis in the perioperative period (the 24 hours prior to anesthesia start time to 24 hours postanesthesia end time). Specific measure definitions are in Table 1. All patients hospitalized at NMH were eligible for case abstraction; specific inclusion and exclusion criteria were based on measure specifics set forth by The Joint Commission and SCIP, and random cases were selected for abstraction utilizing the standard sampling methodology required for these measures. Case abstraction was performed by a nurse and validated by physicians.
The Intervention
Review of baseline performance on the core measures began in January 2013. Common failure points were identified first by electronic medical record (EMR) evaluation. Subsequently, focus groups with front‐line staff, close examination of EMR ordering logic for chemical and mechanical prophylaxis with the IT department, hospital floor observations, and evaluation of the patient education process during discharge were performed to further define the reasons for common failure points.
Fifteen data‐driven, focused interventions were then designed, pilot tested, and implemented throughout the hospital in May 2013, with iterative improvement of each component over the next 18 months (Table 1). This project utilized DMAIC PI methodology, and was carried out by a multidisciplinary team with representatives from the departments of surgery, internal medicine, anesthesia, gynecology, PI, clinical quality, pharmacy, analytics, information technology (IT), and nursing. Broadly, the 15 interventions consisted of (1) EMR alerts, (2) education initiatives, (3) new EMR order sets, and (4) other EMR changes.
EMR Alerts
Novel provider alerts were built into NMH's inpatient EMR platform (Cerner PowerChart; Cerner Corp., North Kansas City, MO) to address common mistakes contributing to failures on VTE‐1 (chemoprophylaxis) and VTE‐3 (overlap therapy). Although VTE‐1 failures were often multifactorial, missing documentation regarding reasons for no chemoprophylaxis given and failures to order chemoprophylaxis were 2 common drivers of failures. To address these 2 problems, a logic‐driven alert to force patient‐specific ordering of appropriate VTE prophylaxis was developed (Figure 1). VTE‐3 (overlap therapy) failures occurred due to clinician failure to order a full 5 days of overlap therapy when switching from parenteral anticoagulation to warfarin therapy; hence, to target VTE‐3 performance, new alerts reminding clinicians to meticulously order and document the overlap of parenteral VTE therapy and warfarin were developed. As part of the logic‐driven alert to improve patient‐specific ordering of appropriate VTE prophylaxis, we allowed for the inclusion of documentation of a contraindication to explain why VTE prophylaxis was not ordered.
Educational Initiatives
After consulting with attending physicians, residents, nurses, and practice managers at NMH to understand the potential drivers of VTE‐1 (chemoprophylaxis) failures, a team of clinicians and PI experts held 2‐part interactive educational sessions with nurses to address knowledge deficits. The first part focused on general VTE education (eg, the significance of the problem nationwide as well as at NMH, general signs and symptoms of VTE, risk factors for VTE, and NMH‐specific failure rates for mechanical and chemoprophylaxis). The second portion used a myth‐busting approach, in which common misunderstandings that frequently impede VTE prophylaxis (eg, a patient capable of ambulating does not need sequential compression devices (SCDs), or SCDs cannot be applied to a patient with acute or chronic DVT) were discussed. Educational efforts also addressed VTE‐5 (warfarin discharge instructions) performance; although nurses provided patient education with regard to home warfarin use, the timing was inconsistent. The VTE‐5 education provided nurses with a standardized method and time for educating patients about postdischarge warfarin use. EMR changes ensured that when warfarin was ordered, warfarin education automatically populated the nurse's task list, reminding them to educate their patients prior to discharge.
New EMR Order Sets
Previously existing order sets often made it difficult for physicians to order the correct dosing and timing of VTE prophylaxis, document contraindications to prophylaxis, and lacked the appropriate laboratory orders with therapy orders. New order sets were designed to facilitate compliance with VTE‐1 (chemoprophylaxis), VTE‐4 (platelet monitoring), VTE‐5 (warfarin discharge instructions), and SCIP‐VTE‐2 (perioperative prophylaxis) by updating lab and medication order listings, dosing choices, prophylaxis contraindications, reminders to monitor platelet counts per nomogram, and physician follow‐up reasons. When we considered our hospital's specific local factors, we came to the conclusion that risk stratification would be a difficult strategy to apply effectively as a component of the new order sets, mainly due to barriers related to buy‐in from physicians and nurses.
Other EMR Changes
Other interventions targeted at specific issues were programmed into the EMR. For example, a shortcut (known as a dotphrase in Cerner PowerChart) for inserting warfarin instructions into patient care documentation was available to physicians, but was misaligned to the standard warfarin instructions. In addition, the physician responsible for following up on a patient's first outpatient international normalized ratio was often omitted from the discharge instructions, potentially leaving patients without a physician to adjust their dosing appropriately. Adding this physician information, as well as aligning and updating all discharge instructions, allowed for clear, consistent patient instructions for home warfarin use. Moreover, EMR forms used by physicians and forms used by nurses to check for VTE prophylaxis were inconsistent, thus leading to potential confusion between physicians and nurses. Accordingly, regularly used EMR forms (eg, the interdisciplinary plan of care, and the unit summary page or unit snapshot) were updated and standardized.
Control Mechanisms
Concurrent with the implementation of the 15 interventions was the development of several control mechanisms to ensure sustained improvement. These mechanisms consisted of (1) an electronic proxy measure for VTE‐1 (chemoprophylaxis) and (2) monitoring of clinician (including physicians, nurses, and midlevel providers) responses to the EMR alerts, and (3) a comprehensive EMR unit report (Figure 2).
Proxy Measure
Because the Joint Commission core measures are abstracted from only a sample of cases, and a time lag existed between each failure on VTE‐1 (chemoprophylaxis) to the time the QI team learned of the failure, a proxy measure was created. This proxy measure is used as a stand‐in for actual VTE‐1 measure performance, but is generated in real time and reflects performance throughout the entire hospital instead of a random sample of cases. Using the Northwestern Electronic Data Warehouse (EDW), the NMH analytics team created a report reflecting thromboprophylaxis administration on each hospital unit currently and over time. Performance could also be examined for each individual hospital service line. Being able to track longitudinal performance by unit and by service line enabled the QI team to understand trends in performance. Having the ability to examine patients who missed doses over the preceding few hours allowed unit leadership to proactively act upon the failures in a timely fashion, instead of waiting to receive their performance on the Joint Commission core measures.
Physician Alert Response Monitoring
Monitoring of clinical responses to EMR alerts was embedded as standard practice. Because alert fatigue is a documented unintended consequence of heavy reliance on EMR alerts,[24, 25] physicians and nurses who failed to respond to alerts regarding VTE prophylaxis were identified. Interventions targeted toward this group of nonresponders are currently being developed and tested.
EDW Unit Report
This report allows unit managers to track potential failures real time and act prior to a failure occurring (eg, missed chemoprophylaxis dose) through the NMH EDW (Figure 2). These reports contained detailed order and administration data at the individual patient, nurse, and physician levels. Missed doses of VTE chemoprophylaxis were immediately fed back to unit nursing managers who utilized the report to perform a rapid drilldown to identify the root cause(s) of the failure, and then rectify the failure while the patient was still hospitalized.
Statistical Analyses
Hospital performance on the VTE core measures and SCIP‐VTE‐2 was determined by trained nurse abstractors, who abstract cases randomly sampled by the University of HealthCare Consortium, and adjudicate findings as per the Specifications Manual for National Hospital Inpatient Quality Measures. Performance in the period prior to the QI intervention and in the period following the QI intervention was documented as proportions of abstracted cases found to be compliant with measure specifications. Differences between the pre‐ and postintervention periods were compared using a binomial test, with a P value <0.05 considered significant. All analyses were performed using Stata version 13 (StataCorp, College Station, TX).
RESULTS
A total of 1679 cases were abstracted to obtain core measure performance in the time period before the DMAIC intervention phase (January 1, 2013May 1, 2013), and 1424 cases were abstracted to obtain core measure performance in the time period after the DMAIC intervention phase (October 1, 2014April 1, 2015).
Overall NMH performance on measures VTE‐1 (chemoprophylaxis) and VTE36 (overlap therapy, platelet monitoring, warfarin discharge instructions, hospital‐acquired [HA]‐VTE) improved significantly (P < 0.05) (Table 1). No improvement was seen on VTE‐2 (intensive care unit chemoprophylaxis) given that pre‐ and postintervention performance was 100%, which likely reflects previous hospital efforts to improve adherence to this measure. The percentage of patients who failed measure VTE‐6 (number of patients with HA‐VTE who did not have VTE prophylaxis ordered prior to diagnosis of their VTE) decreased from 8% to 2.4%, demonstrating improved VTE prevention prescribing habits in NMH providers rather than a change in VTE event rates (ie, if more patients receive prophylaxis, they cannot be included in the numerator). Performance on SCIP‐VTE‐2 (perioperative chemoprophylaxis) increased from 99.5% to 100% as well but did not reach significance given the baseline high performance.
Measure performance on the general surgery services was comparable to the general medical services, with 1 exception. VTE‐1 (chemoprophylaxis) performance was lower both prior to and following the QI intervention on general medicine services (medicine: 82.5% to 90.2% vs surgery: 94.4% to 97.6%). Recent performance on the VTE‐1 proxy measure has proven to be stable between 95% and 97% on surgery services. Physician response to alerts has increased slightly among the NMH general medicine practitioners (15.2%19.1%) but has been stable among NMH general surgery providers.
DISCUSSION
Our study demonstrates that a formal DMAIC QI project taken on by a multidisciplinary team (including clinicians from multiple specialties as well as personnel from IT, nursing, analytics, and PI) can be successfully implemented and can result in marked improvement in VTE core process measure performance. We used a multifaceted approach undertaken by the NMH VTE QI team, utilizing 15 data‐driven interventions including EMR alerts, education initiatives, and new EMR order sets. These were combined with strong control mechanisms to sustain gains.
Previously published studies on VTE prophylaxis practices found that projects combining both passive (ie, helping clinicians to remember to risk‐assess their patients' for VTE) and active (ie, assisting clinicians in appropriate prescribing practices) strategies are the most successful.[26] Our improvement on VTE‐1 can be compared to previous studies examining changes in ordering rates of VTE prophylaxis. Other QI projects that featured a combination of interventions observed similar significant increases in prophylaxis ordering.[27, 28] Our improvement on VTE‐1 (chemoprophylaxis) was significant, although the difference between pre‐ and postintervention performance varied by service type (general surgery vs general medicine vs other). The small increment of improvement on surgical services was likely attributable to a high baseline performance. Prior to 2013, surgically focused VTE prophylaxis QI efforts spurred by poor ACS‐NSQIP performance proved to be successful, thus resulting in high surgical prophylaxis rates at the outset of the hospital‐wide VTE DMAIC project.
One of the most significant unanticipated barriers to improving performance on VTE‐1 (chemoprophylaxis) included the different hospital subcultures on the medical floors as compared to the surgical floors. The surgical floors had higher rates of compliance with VTE‐1 than the general medicine floors both before and after the QI interventions. When the root causes were explored, the medical floors were found to have different ordering and administration patterns. These, in part, stemmed from differing guidelines[29] and standards in the literature regarding VTE prophylaxis for medical and surgical patients. Multiple discussions within the multidisciplinary QI team and with each involved department were held, focusing on the data regarding safe care in medical patients at low risk for a VTE. Subsequent EMR alerts alterations reflected the internal medicine VTE prophylaxis recommendations for medical patients, allowing that low‐risk patients could be assessed by the provider and given as a reason for foregoing VTE prophylaxis.
Barriers to VTE prophylaxis administration were encountered on the nursing front as well. Floor observations illustrated that chemoprophylaxis injections were often offered as an optional medication. Patients, when given the choice of receiving an injection or not, would understandably choose to forgo their heparin or enoxaparin shot. This missed dose was then documented as a patient refusal. This may not be a problem unique to NMH; 1 study demonstrated that almost 12% of chemoprophylaxis doses may not be administered, and a frequent reason may be due to patient refusal.[30] The lack of patient education regarding the importance of receiving chemical prophylaxis was an improvement opportunity at both the nursing and physician level. Not only did physicians and nurses take the responsibility to educate patients on the importance of receiving the proper prophylaxis, but nursing managers were made responsible for acting on missed doses that were listed on the real‐time performance reports for their units. Missed prophylaxis doses thus became an actionable item instead of an acceptable occurrence.
Culture change in an organization is difficult and necessitates sustained efforts. An important component of our project is our control mechanism, in which a real‐time, continuously updated unit report leverages data from our EDW to generate ongoing performance reports that are regularly reviewed by hospital leadership, clinical process owners, and, most importantly, frontline nurse managers. The unit‐specific reports allow nurse managers and clinical project owners to review prophylaxis failures on a case‐by‐case basis daily and to address and rectify the cause. In addition, the QI team tracks individual physician action taken in response to EMR alerts. As performance feedback to surgical trainees has been demonstrated to have a positive effect on ordering practices,[31] efforts to improve resident alert response rates by means of feedback and education are underway.
Limitations
Our results have to be interpreted within certain limitations. First, given that hospital performance on the VTE core measures is determined by abstracting only a sample of eligible cases, it is possible that our results were affected by sampling error. Second, because of problems with the VTE outcome measure due to surveillance bias, we are unable to draw any valid conclusions about changes in VTE event rates as a result of this QI project. Third, because many of our interventions were tailored to NMH's EMR platform and local hospital culture, it is possible that parts of our project are not readily generalizable to other hospitals; however, we believe that many components, such as the alert logics, can be easily tailored to other EMR platforms.
CONCLUSION
This institutional project was a large, multidisciplinary, and sustained undertaking that improved our performance on the VTE core measures. We believe that our bundle of EMR modifications, alerts (particularly the underlying alert logics), order sets, and standardization of summary EMR view can be adopted in other settings with appropriate adaptations to each hospital's specific local environment. Our focused educational interventions can also be easily adapted to other hospital settings. Perhaps the most important part of the project was the construction of novel control mechanisms that allow for tracking of physical alert response and for real‐time evaluation, audit, and feedback of prophylaxis ordering and administration practices at NMH. Taken as a whole, this bundle of resources to improve adherence to optimal VTE prophylaxis will facilitate future interventions targeted at reaching defect‐free care.
Disclosures: Nothing to report.
Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism, is a significant cause of morbidity and mortality in the United States among hospitalized patients.[1, 2, 3, 4, 5, 6] Although it may not be possible to completely eradicate VTE events,[7] chemical and/or mechanical prophylaxis can reduce VTE rates by up to 74% to 86%,[8, 9, 10] and meta‐analyses have demonstrated the benefit of VTE prophylaxis in the inpatient population.[11, 12] Despite evidence‐based guidelines regarding the appropriate type, duration, and dosing of prophylaxis, thromboprophylaxis has been found to be underutilized in the inpatient setting.[13, 14, 15]
Northwestern Memorial Hospital (NMH) historically performed poorly on VTE outcome measures. VTE in the surgical patient population was an especially glaring problem, as NMH was persistently found to be a risk‐adjusted poor performer in the American College of Surgeons National Surgical Quality Improvement Project (ACS‐NSQIP).
However, VTE outcome measures have been shown to be problematic due to their susceptibility to surveillance bias; that is, variation in the ordering of screening or diagnostic VTE imaging studies between hospitals leads to variable VTE rates (the more you look, the more you find).[16, 17, 18, 19] More vigilant hospitals that have a lower threshold to order an imaging study may find higher occurrences of VTE, and paradoxically be deemed a poor performer. Surveillance bias and the lack of validity of the VTE outcome measurement highlighted the importance of utilizing process‐of‐care measures in assessing hospital VTE prevention efforts.[20, 21] Thus, when the Joint Commission enacted 6 new VTE core process‐of‐care measures on January 1, 2013 to monitor hospital performance on VTE prophylaxis administration and VTE treatment (Table 1), NMH undertook a hospital‐wide quality‐improvement (QI) project utilizing the define‐measure‐analyze‐improve‐control (DMAIC) process improvement (PI) methodology to optimize their performance on these core measures as well as the Surgical Care Improvement Project (SCIP) SCIP‐VTE‐2 measure. In this article, we describe the QI effort undertaken at NMH to improve hospital‐level measure performance and the outcomes of this effort.
| VTE Measure | Measure Calculation | Description of Issues | Interventions | Preintervention Performance, % (N)* | Postintervention Performance, % (N) |
|---|---|---|---|---|---|
| |||||
| VTE‐1: VTE PPX | Patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given | Missing documentation (both chemical and mechanical); prophylaxis ordered, but not administered; patient refusals and opportunity to increase patient education regarding prophylaxis | 1. Enhanced, individualized VTE prophylaxis alert: alert incorporated order, administration, mechanical PPX, lab exclusion and contraindication details | NMH: 86.6% (174) | NMH: 93.6% (162) |
| All patients | Undocumented contraindication reasons | 2. Nursing education initiative: back‐to‐basics VTE education initiative to help increase the administration of VTE prophylaxis and improve patient education resulting in fewer patient refusals and missed doses | NMH general surgery: 94.4% (34) | NMH general surgery: 97.6% (41) | |
| Inconsistent monitoring and patient education | 3. Updated VTE prophylaxis surgical and medicine order set: updated order listing, heparin TID setting and contraindications | NMH general medicine: 82.5% (115) | NMH general medicine: 90.2% (85) | ||
| VTE‐2: ICU VTE PPX | Patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given | See interventions 1 through 3 | NMH: 100% (58) | NMH: 95.8% (69) | |
| Patients directly admitted or transferred to the ICU | NMH general surgery: 100% (11) | NMH general surgery: 100% (10) | |||
| NMH general medicine: 100% (40) | NMH general medicine: 100% (51) | ||||
| VTE‐3: VTE patients with anticoagulation overlap therapy | Patients who received overlap therapy of parenteral anticoagulation and warfarin therapy | Gaps in documentation and administration of overlap therapy for 5 days | 4. Overlap therapy alert at discharge: document VTE on diagnosis list with alert to either (1) document reason for discontinuation of parental therapy or (2) prescribe parental anticoagulation during hospitalization or at discharge | NMH: 95.8% (159) | NMH: 100% (105) |
| Patients with confirmed VTE who received warfarin | 5. Overlap therapy alert during hospitalization: documentation alert on the day therapy discontinued | NMH general surgery: 85.7% (12) | NMH general surgery: 100% (16) | ||
| NMH general medicine: 97.0% (129) | NMH general medicine: 100% (79) | ||||
| VTE‐4: VTE patients receiving unfractionated dosages/platelet count monitoring by protocol or nomogram | Patients who have IV UFH therapy dosages and platelet counts monitored according to defined parameters such as a nomogram or protocol | Missing required language on IV UFH orders and order may not include preselected CBC order | 6. Updated heparin order sets: reminder to monitor platelet counts per nomogram and preselect CBC order | NMH: 73.7% (98) | NMH: 100% (74) |
| Patients with confirmed VTE receiving IV UFH therapy | NMH general surgery: 56.3% (7) | NMH general surgery: 100% (9) | |||
| NMH general medicine: 83.8% (88) | NMH general medicine: 100% (52) | ||||
| VTE‐5: VTE warfarin discharge instructions | Patients with documentation that they or their caregivers were given written discharge instructions or other educational material about warfarin | Discharge process is not standardized | 7. Warfarin Patient Education Task: automate nursing task for warfarin order set, check individual warfarin education excluding consult orders | NMH: 9.6% (12) | NMH: 87.5% (63) |
| Patients with confirmed VTE discharged on warfarin therapy | Patient education during hospitalization varies | 8. Warfarin dotphrase: new warfarin/Coumadin dotphrase aligned with department and core measure requirements | NMH general surgery: 0% (0) | NMH general surgery: 100% (11) | |
| No standardized process for initiating and tracking warfarin education during hospitalization | 9. Department Warfarin Instructions Phase II: update department warfarin language, automate warfarin education task | NMH general medicine: 11.3% (12) | NMH general medicine: 85.5% (50) | ||
| Warfarin special instructions for discharge is not aligned with the EMR dotphrase | 10. Physician Referral Order Update: Add follow‐up reason to order | ||||
| Follow‐up appointments are inconsistent | |||||
| VTE‐6: Incidence of potentially preventable VTE | Patients who received no VTE PPX prior to the VTE diagnostic test order date | Failure reasons related to other measures | NMH: 8% (8) | NMH: 2.4% (2) | |
| Patients who developed confirmed VTE during hospitalization | NMH general surgery: 6.7% (1) | NMH general surgery: 0% (0) | |||
| NMH general medicine: 13.5% (7) | NMH general medicine: 0% (0) | ||||
| SCIP‐VTE‐2 | Surgery patients who receive appropriate VTE prophylaxis within 24 hours prior to anesthesia start time to 24 hours after anesthesia end time | Standard enoxaparin administration time is 1300 and there is a gap between surgery end time to enoxaparin administration (i.e. patient may wait up to 23 hours for prophylaxis) | 11. Updated VTE prophylaxis‐surgical and medicine order set: added 1‐time and 2‐time heparin doses to enoxaparin order section | NMH: 99.5% (202) | NMH: 100% (104) |
| All selected surgery patients | NMH General Surgery: 98.5% (67) | NMH General Surgery: 100% (100) | |||
| NMH General Medicine: N/A | NMH General Medicine: N/A | ||||
| Additional interventions | Incomplete VTE prophylaxis information | 12. Updated IPC view | |||
| Inconsistent documentation across forms | 13. Updated ADL forms and iView nursing responses updated | ||||
| 14. Updated unit snapshot to mirror IPC view | |||||
| 15. Updated MPET: updated nursing task: standardize Not Given and Not Done Nursing Responses | |||||
METHODS
Setting
NMH is a tertiary referral and teaching hospital affiliated with the Feinberg School of Medicine of Northwestern University. It is the flagship of Northwestern Medicine, which also includes 4 community hospitals, a dedicated women's hospital, and outpatient and urgent care centers.[22] NMH is an 885‐bed hospital with approximately 50,000 inpatients admitted annually. This project, to evaluate the outcomes of the NMH VTE QI initiative, was reviewed and approved by the Northwestern University Institutional Review Board as an exempt activity.
Measures
The Joint Commission VTE measures were a product of the National Consensus Standards for the Prevention and Care of Deep Vein Thrombosis project between the Joint Commission and National Quality Forum (NQF). These 6 measures are endorsed by the NQF and aligned with the Centers of Medicare and Medicaid Services.[23] SCIP also has measures focusing on VTE prophylaxis. SCIP‐VTE‐2 focuses on prophylaxis in the perioperative period (the 24 hours prior to anesthesia start time to 24 hours postanesthesia end time). Specific measure definitions are in Table 1. All patients hospitalized at NMH were eligible for case abstraction; specific inclusion and exclusion criteria were based on measure specifics set forth by The Joint Commission and SCIP, and random cases were selected for abstraction utilizing the standard sampling methodology required for these measures. Case abstraction was performed by a nurse and validated by physicians.
The Intervention
Review of baseline performance on the core measures began in January 2013. Common failure points were identified first by electronic medical record (EMR) evaluation. Subsequently, focus groups with front‐line staff, close examination of EMR ordering logic for chemical and mechanical prophylaxis with the IT department, hospital floor observations, and evaluation of the patient education process during discharge were performed to further define the reasons for common failure points.
Fifteen data‐driven, focused interventions were then designed, pilot tested, and implemented throughout the hospital in May 2013, with iterative improvement of each component over the next 18 months (Table 1). This project utilized DMAIC PI methodology, and was carried out by a multidisciplinary team with representatives from the departments of surgery, internal medicine, anesthesia, gynecology, PI, clinical quality, pharmacy, analytics, information technology (IT), and nursing. Broadly, the 15 interventions consisted of (1) EMR alerts, (2) education initiatives, (3) new EMR order sets, and (4) other EMR changes.
EMR Alerts
Novel provider alerts were built into NMH's inpatient EMR platform (Cerner PowerChart; Cerner Corp., North Kansas City, MO) to address common mistakes contributing to failures on VTE‐1 (chemoprophylaxis) and VTE‐3 (overlap therapy). Although VTE‐1 failures were often multifactorial, missing documentation regarding reasons for no chemoprophylaxis given and failures to order chemoprophylaxis were 2 common drivers of failures. To address these 2 problems, a logic‐driven alert to force patient‐specific ordering of appropriate VTE prophylaxis was developed (Figure 1). VTE‐3 (overlap therapy) failures occurred due to clinician failure to order a full 5 days of overlap therapy when switching from parenteral anticoagulation to warfarin therapy; hence, to target VTE‐3 performance, new alerts reminding clinicians to meticulously order and document the overlap of parenteral VTE therapy and warfarin were developed. As part of the logic‐driven alert to improve patient‐specific ordering of appropriate VTE prophylaxis, we allowed for the inclusion of documentation of a contraindication to explain why VTE prophylaxis was not ordered.
Educational Initiatives
After consulting with attending physicians, residents, nurses, and practice managers at NMH to understand the potential drivers of VTE‐1 (chemoprophylaxis) failures, a team of clinicians and PI experts held 2‐part interactive educational sessions with nurses to address knowledge deficits. The first part focused on general VTE education (eg, the significance of the problem nationwide as well as at NMH, general signs and symptoms of VTE, risk factors for VTE, and NMH‐specific failure rates for mechanical and chemoprophylaxis). The second portion used a myth‐busting approach, in which common misunderstandings that frequently impede VTE prophylaxis (eg, a patient capable of ambulating does not need sequential compression devices (SCDs), or SCDs cannot be applied to a patient with acute or chronic DVT) were discussed. Educational efforts also addressed VTE‐5 (warfarin discharge instructions) performance; although nurses provided patient education with regard to home warfarin use, the timing was inconsistent. The VTE‐5 education provided nurses with a standardized method and time for educating patients about postdischarge warfarin use. EMR changes ensured that when warfarin was ordered, warfarin education automatically populated the nurse's task list, reminding them to educate their patients prior to discharge.
New EMR Order Sets
Previously existing order sets often made it difficult for physicians to order the correct dosing and timing of VTE prophylaxis, document contraindications to prophylaxis, and lacked the appropriate laboratory orders with therapy orders. New order sets were designed to facilitate compliance with VTE‐1 (chemoprophylaxis), VTE‐4 (platelet monitoring), VTE‐5 (warfarin discharge instructions), and SCIP‐VTE‐2 (perioperative prophylaxis) by updating lab and medication order listings, dosing choices, prophylaxis contraindications, reminders to monitor platelet counts per nomogram, and physician follow‐up reasons. When we considered our hospital's specific local factors, we came to the conclusion that risk stratification would be a difficult strategy to apply effectively as a component of the new order sets, mainly due to barriers related to buy‐in from physicians and nurses.
Other EMR Changes
Other interventions targeted at specific issues were programmed into the EMR. For example, a shortcut (known as a dotphrase in Cerner PowerChart) for inserting warfarin instructions into patient care documentation was available to physicians, but was misaligned to the standard warfarin instructions. In addition, the physician responsible for following up on a patient's first outpatient international normalized ratio was often omitted from the discharge instructions, potentially leaving patients without a physician to adjust their dosing appropriately. Adding this physician information, as well as aligning and updating all discharge instructions, allowed for clear, consistent patient instructions for home warfarin use. Moreover, EMR forms used by physicians and forms used by nurses to check for VTE prophylaxis were inconsistent, thus leading to potential confusion between physicians and nurses. Accordingly, regularly used EMR forms (eg, the interdisciplinary plan of care, and the unit summary page or unit snapshot) were updated and standardized.
Control Mechanisms
Concurrent with the implementation of the 15 interventions was the development of several control mechanisms to ensure sustained improvement. These mechanisms consisted of (1) an electronic proxy measure for VTE‐1 (chemoprophylaxis) and (2) monitoring of clinician (including physicians, nurses, and midlevel providers) responses to the EMR alerts, and (3) a comprehensive EMR unit report (Figure 2).
Proxy Measure
Because the Joint Commission core measures are abstracted from only a sample of cases, and a time lag existed between each failure on VTE‐1 (chemoprophylaxis) to the time the QI team learned of the failure, a proxy measure was created. This proxy measure is used as a stand‐in for actual VTE‐1 measure performance, but is generated in real time and reflects performance throughout the entire hospital instead of a random sample of cases. Using the Northwestern Electronic Data Warehouse (EDW), the NMH analytics team created a report reflecting thromboprophylaxis administration on each hospital unit currently and over time. Performance could also be examined for each individual hospital service line. Being able to track longitudinal performance by unit and by service line enabled the QI team to understand trends in performance. Having the ability to examine patients who missed doses over the preceding few hours allowed unit leadership to proactively act upon the failures in a timely fashion, instead of waiting to receive their performance on the Joint Commission core measures.
Physician Alert Response Monitoring
Monitoring of clinical responses to EMR alerts was embedded as standard practice. Because alert fatigue is a documented unintended consequence of heavy reliance on EMR alerts,[24, 25] physicians and nurses who failed to respond to alerts regarding VTE prophylaxis were identified. Interventions targeted toward this group of nonresponders are currently being developed and tested.
EDW Unit Report
This report allows unit managers to track potential failures real time and act prior to a failure occurring (eg, missed chemoprophylaxis dose) through the NMH EDW (Figure 2). These reports contained detailed order and administration data at the individual patient, nurse, and physician levels. Missed doses of VTE chemoprophylaxis were immediately fed back to unit nursing managers who utilized the report to perform a rapid drilldown to identify the root cause(s) of the failure, and then rectify the failure while the patient was still hospitalized.
Statistical Analyses
Hospital performance on the VTE core measures and SCIP‐VTE‐2 was determined by trained nurse abstractors, who abstract cases randomly sampled by the University of HealthCare Consortium, and adjudicate findings as per the Specifications Manual for National Hospital Inpatient Quality Measures. Performance in the period prior to the QI intervention and in the period following the QI intervention was documented as proportions of abstracted cases found to be compliant with measure specifications. Differences between the pre‐ and postintervention periods were compared using a binomial test, with a P value <0.05 considered significant. All analyses were performed using Stata version 13 (StataCorp, College Station, TX).
RESULTS
A total of 1679 cases were abstracted to obtain core measure performance in the time period before the DMAIC intervention phase (January 1, 2013May 1, 2013), and 1424 cases were abstracted to obtain core measure performance in the time period after the DMAIC intervention phase (October 1, 2014April 1, 2015).
Overall NMH performance on measures VTE‐1 (chemoprophylaxis) and VTE36 (overlap therapy, platelet monitoring, warfarin discharge instructions, hospital‐acquired [HA]‐VTE) improved significantly (P < 0.05) (Table 1). No improvement was seen on VTE‐2 (intensive care unit chemoprophylaxis) given that pre‐ and postintervention performance was 100%, which likely reflects previous hospital efforts to improve adherence to this measure. The percentage of patients who failed measure VTE‐6 (number of patients with HA‐VTE who did not have VTE prophylaxis ordered prior to diagnosis of their VTE) decreased from 8% to 2.4%, demonstrating improved VTE prevention prescribing habits in NMH providers rather than a change in VTE event rates (ie, if more patients receive prophylaxis, they cannot be included in the numerator). Performance on SCIP‐VTE‐2 (perioperative chemoprophylaxis) increased from 99.5% to 100% as well but did not reach significance given the baseline high performance.
Measure performance on the general surgery services was comparable to the general medical services, with 1 exception. VTE‐1 (chemoprophylaxis) performance was lower both prior to and following the QI intervention on general medicine services (medicine: 82.5% to 90.2% vs surgery: 94.4% to 97.6%). Recent performance on the VTE‐1 proxy measure has proven to be stable between 95% and 97% on surgery services. Physician response to alerts has increased slightly among the NMH general medicine practitioners (15.2%19.1%) but has been stable among NMH general surgery providers.
DISCUSSION
Our study demonstrates that a formal DMAIC QI project taken on by a multidisciplinary team (including clinicians from multiple specialties as well as personnel from IT, nursing, analytics, and PI) can be successfully implemented and can result in marked improvement in VTE core process measure performance. We used a multifaceted approach undertaken by the NMH VTE QI team, utilizing 15 data‐driven interventions including EMR alerts, education initiatives, and new EMR order sets. These were combined with strong control mechanisms to sustain gains.
Previously published studies on VTE prophylaxis practices found that projects combining both passive (ie, helping clinicians to remember to risk‐assess their patients' for VTE) and active (ie, assisting clinicians in appropriate prescribing practices) strategies are the most successful.[26] Our improvement on VTE‐1 can be compared to previous studies examining changes in ordering rates of VTE prophylaxis. Other QI projects that featured a combination of interventions observed similar significant increases in prophylaxis ordering.[27, 28] Our improvement on VTE‐1 (chemoprophylaxis) was significant, although the difference between pre‐ and postintervention performance varied by service type (general surgery vs general medicine vs other). The small increment of improvement on surgical services was likely attributable to a high baseline performance. Prior to 2013, surgically focused VTE prophylaxis QI efforts spurred by poor ACS‐NSQIP performance proved to be successful, thus resulting in high surgical prophylaxis rates at the outset of the hospital‐wide VTE DMAIC project.
One of the most significant unanticipated barriers to improving performance on VTE‐1 (chemoprophylaxis) included the different hospital subcultures on the medical floors as compared to the surgical floors. The surgical floors had higher rates of compliance with VTE‐1 than the general medicine floors both before and after the QI interventions. When the root causes were explored, the medical floors were found to have different ordering and administration patterns. These, in part, stemmed from differing guidelines[29] and standards in the literature regarding VTE prophylaxis for medical and surgical patients. Multiple discussions within the multidisciplinary QI team and with each involved department were held, focusing on the data regarding safe care in medical patients at low risk for a VTE. Subsequent EMR alerts alterations reflected the internal medicine VTE prophylaxis recommendations for medical patients, allowing that low‐risk patients could be assessed by the provider and given as a reason for foregoing VTE prophylaxis.
Barriers to VTE prophylaxis administration were encountered on the nursing front as well. Floor observations illustrated that chemoprophylaxis injections were often offered as an optional medication. Patients, when given the choice of receiving an injection or not, would understandably choose to forgo their heparin or enoxaparin shot. This missed dose was then documented as a patient refusal. This may not be a problem unique to NMH; 1 study demonstrated that almost 12% of chemoprophylaxis doses may not be administered, and a frequent reason may be due to patient refusal.[30] The lack of patient education regarding the importance of receiving chemical prophylaxis was an improvement opportunity at both the nursing and physician level. Not only did physicians and nurses take the responsibility to educate patients on the importance of receiving the proper prophylaxis, but nursing managers were made responsible for acting on missed doses that were listed on the real‐time performance reports for their units. Missed prophylaxis doses thus became an actionable item instead of an acceptable occurrence.
Culture change in an organization is difficult and necessitates sustained efforts. An important component of our project is our control mechanism, in which a real‐time, continuously updated unit report leverages data from our EDW to generate ongoing performance reports that are regularly reviewed by hospital leadership, clinical process owners, and, most importantly, frontline nurse managers. The unit‐specific reports allow nurse managers and clinical project owners to review prophylaxis failures on a case‐by‐case basis daily and to address and rectify the cause. In addition, the QI team tracks individual physician action taken in response to EMR alerts. As performance feedback to surgical trainees has been demonstrated to have a positive effect on ordering practices,[31] efforts to improve resident alert response rates by means of feedback and education are underway.
Limitations
Our results have to be interpreted within certain limitations. First, given that hospital performance on the VTE core measures is determined by abstracting only a sample of eligible cases, it is possible that our results were affected by sampling error. Second, because of problems with the VTE outcome measure due to surveillance bias, we are unable to draw any valid conclusions about changes in VTE event rates as a result of this QI project. Third, because many of our interventions were tailored to NMH's EMR platform and local hospital culture, it is possible that parts of our project are not readily generalizable to other hospitals; however, we believe that many components, such as the alert logics, can be easily tailored to other EMR platforms.
CONCLUSION
This institutional project was a large, multidisciplinary, and sustained undertaking that improved our performance on the VTE core measures. We believe that our bundle of EMR modifications, alerts (particularly the underlying alert logics), order sets, and standardization of summary EMR view can be adopted in other settings with appropriate adaptations to each hospital's specific local environment. Our focused educational interventions can also be easily adapted to other hospital settings. Perhaps the most important part of the project was the construction of novel control mechanisms that allow for tracking of physical alert response and for real‐time evaluation, audit, and feedback of prophylaxis ordering and administration practices at NMH. Taken as a whole, this bundle of resources to improve adherence to optimal VTE prophylaxis will facilitate future interventions targeted at reaching defect‐free care.
Disclosures: Nothing to report.
- , , , , . Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence‐Based Clinical Practice Guidelines. Chest. 2012;141:7S–47S.
- , , , , . Estimated annual numbers of US acute‐care hospital patients at risk for venous thromboembolism. Am J Hematol. 2007;82:777–782.
- , , , et al. All‐cause and potentially disease‐related health care costs associated with venous thromboembolism in commercial, Medicare, and Medicaid beneficiaries. J Manag Care Pharm. 2012;18:363–374.
- , . Pulmonary embolism and deep vein thrombosis. Lancet. 2012;379:1835–1846.
- , , , . Long‐term outcomes after deep vein thrombosis: postphlebitic syndrome and quality of life. J Gen Intern Med. 2000;15:425–429.
- , , , et al. The long‐term clinical course of acute deep venous thrombosis. Ann Intern Med. 1996;125:1–7.
- , . The CMS ruling on venous thromboembolism after total knee or hip arthroplasty: weighing risks and benefits. JAMA. 2009;301:1063–1065.
- , , , et al. Hidden costs associated with venous thromboembolism: impact of lost productivity on employers and employees. J Occup Environ Med. 2014;56(9):979–985.
- , . Designing and implementing effective venous thromboembolism prevention protocols: lessons from collaborative efforts. J Thromb Thrombolysis. 2010;29:159–166.
- , , , . Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin. Overview of results of randomized trials in general, orthopedic, and urologic surgery. N Engl J Med. 1988;318:1162–1173.
- , , , , . Meta‐analysis: anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalized medical patients. Ann Intern Med. 2007;146:278–288.
- , , , , . Meta‐analysis of low molecular weight heparin in the prevention of venous thromboembolism in general surgery. Br J Surg. 2001;88:913–930.
- , , , et al. Preventability of hospital‐acquired venous thromboembolism. JAMA Surg. 2015;150(9):912–915.
- , , , et al. Venous thromboembolism risk and prophylaxis in the acute care hospital setting (ENDORSE survey): findings in surgical patients. Ann Surg. 2010;251:330–338.
- , , , . Are surgical patients at risk of venous thromboembolism currently meeting the Surgical Care Improvement Project performance measure for appropriate and timely prophylaxis? J Thromb Thrombolysis. 2010;30:55–66.
- , , , et al. Evaluation of surveillance bias and the validity of the venous thromboembolism quality measure. JAMA. 2013;310:1482–1489.
- , , , , , . Evaluation of hospital factors associated with hospital postoperative venous thromboembolism imaging utilisation practices. BMJ Qual Saf. 2014;23(11):947–956.
- , , , et al. Association between hospital imaging use and venous thromboembolism events rates based on clinical data. Ann Surg. 2014;260:558–564; discussion 64–66.
- , , , , . Postoperative venous thromboembolism outcomes measure: analytic exploration of potential misclassification of hospital quality due to surveillance bias. Ann Surg. 2015;261(3):443–444.
- , , . The need to revisit VTE quality measures. JAMA. 2014;312:286–287.
- . Facilitating quality improvement: pushing the pendulum back toward process measures. JAMA. 2015;314:1333–1334.
- Northwestern Medicine website. Available at: https://www.nm.org/locations‐at‐northwestern‐medicine. Accessed February 23, 2016.
- Venous thromboembolism. The Joint Commission website. Available at: http://www.jointcommission.org/venous_thromboembolism. Accessed February 23, 2016.
- , , , , . Some unintended consequences of clinical decision support systems. AMIA Annu Symp Proc. 2007:26–30.
- , , , . Overriding of drug safety alerts in computerized physician order entry. J Am Med Inform Assoc. 2006;13:138–147.
- , , , et al. A systematic review of strategies to improve prophylaxis for venous thromboembolism in hospitals. Ann Surg. 2005;241:397–415.
- , , , et al. Optimizing prevention of hospital‐acquired venous thromboembolism (VTE): prospective validation of a VTE risk assessment model. J Hosp Med. 2010;5:10–18.
- , , . Improving the use of venous thromboembolism prophylaxis in an Australian teaching hospital. Qual Saf Health Care. 2009;18:408–412.
- , , , , . Venous thromboembolism prophylaxis in hospitalized patients: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2011;155:625–632.
- , , , et al. Patterns of non‐administration of ordered doses of venous thromboembolism prophylaxis: implications for novel intervention strategies. PLoS One. 2013;8:e66311.
- , , , et al. Individualized performance feedback to surgical residents improves appropriate venous thromboembolism prophylaxis prescription and reduces potentially preventable VTE: a prospective cohort study [published online November 25, 2015]. Ann Surg. doi: 10.1097/SLA.0000000000001512.
- , , , , . Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence‐Based Clinical Practice Guidelines. Chest. 2012;141:7S–47S.
- , , , , . Estimated annual numbers of US acute‐care hospital patients at risk for venous thromboembolism. Am J Hematol. 2007;82:777–782.
- , , , et al. All‐cause and potentially disease‐related health care costs associated with venous thromboembolism in commercial, Medicare, and Medicaid beneficiaries. J Manag Care Pharm. 2012;18:363–374.
- , . Pulmonary embolism and deep vein thrombosis. Lancet. 2012;379:1835–1846.
- , , , . Long‐term outcomes after deep vein thrombosis: postphlebitic syndrome and quality of life. J Gen Intern Med. 2000;15:425–429.
- , , , et al. The long‐term clinical course of acute deep venous thrombosis. Ann Intern Med. 1996;125:1–7.
- , . The CMS ruling on venous thromboembolism after total knee or hip arthroplasty: weighing risks and benefits. JAMA. 2009;301:1063–1065.
- , , , et al. Hidden costs associated with venous thromboembolism: impact of lost productivity on employers and employees. J Occup Environ Med. 2014;56(9):979–985.
- , . Designing and implementing effective venous thromboembolism prevention protocols: lessons from collaborative efforts. J Thromb Thrombolysis. 2010;29:159–166.
- , , , . Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin. Overview of results of randomized trials in general, orthopedic, and urologic surgery. N Engl J Med. 1988;318:1162–1173.
- , , , , . Meta‐analysis: anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalized medical patients. Ann Intern Med. 2007;146:278–288.
- , , , , . Meta‐analysis of low molecular weight heparin in the prevention of venous thromboembolism in general surgery. Br J Surg. 2001;88:913–930.
- , , , et al. Preventability of hospital‐acquired venous thromboembolism. JAMA Surg. 2015;150(9):912–915.
- , , , et al. Venous thromboembolism risk and prophylaxis in the acute care hospital setting (ENDORSE survey): findings in surgical patients. Ann Surg. 2010;251:330–338.
- , , , . Are surgical patients at risk of venous thromboembolism currently meeting the Surgical Care Improvement Project performance measure for appropriate and timely prophylaxis? J Thromb Thrombolysis. 2010;30:55–66.
- , , , et al. Evaluation of surveillance bias and the validity of the venous thromboembolism quality measure. JAMA. 2013;310:1482–1489.
- , , , , , . Evaluation of hospital factors associated with hospital postoperative venous thromboembolism imaging utilisation practices. BMJ Qual Saf. 2014;23(11):947–956.
- , , , et al. Association between hospital imaging use and venous thromboembolism events rates based on clinical data. Ann Surg. 2014;260:558–564; discussion 64–66.
- , , , , . Postoperative venous thromboembolism outcomes measure: analytic exploration of potential misclassification of hospital quality due to surveillance bias. Ann Surg. 2015;261(3):443–444.
- , , . The need to revisit VTE quality measures. JAMA. 2014;312:286–287.
- . Facilitating quality improvement: pushing the pendulum back toward process measures. JAMA. 2015;314:1333–1334.
- Northwestern Medicine website. Available at: https://www.nm.org/locations‐at‐northwestern‐medicine. Accessed February 23, 2016.
- Venous thromboembolism. The Joint Commission website. Available at: http://www.jointcommission.org/venous_thromboembolism. Accessed February 23, 2016.
- , , , , . Some unintended consequences of clinical decision support systems. AMIA Annu Symp Proc. 2007:26–30.
- , , , . Overriding of drug safety alerts in computerized physician order entry. J Am Med Inform Assoc. 2006;13:138–147.
- , , , et al. A systematic review of strategies to improve prophylaxis for venous thromboembolism in hospitals. Ann Surg. 2005;241:397–415.
- , , , et al. Optimizing prevention of hospital‐acquired venous thromboembolism (VTE): prospective validation of a VTE risk assessment model. J Hosp Med. 2010;5:10–18.
- , , . Improving the use of venous thromboembolism prophylaxis in an Australian teaching hospital. Qual Saf Health Care. 2009;18:408–412.
- , , , , . Venous thromboembolism prophylaxis in hospitalized patients: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2011;155:625–632.
- , , , et al. Patterns of non‐administration of ordered doses of venous thromboembolism prophylaxis: implications for novel intervention strategies. PLoS One. 2013;8:e66311.
- , , , et al. Individualized performance feedback to surgical residents improves appropriate venous thromboembolism prophylaxis prescription and reduces potentially preventable VTE: a prospective cohort study [published online November 25, 2015]. Ann Surg. doi: 10.1097/SLA.0000000000001512.
© 2016 Society of Hospital Medicine
