Appropriate Use of Pharmacologic VTE Prophylaxis in the Inpatient Setting

From the 2021 HVPAA National Conference

Kay Khine (UCF HCA Healthcare GME, Greater Orlando, FL), Anusha Ghaffar, Mays Zangana, Nima Hosseinian, Joshua Shultz, Ashwini Komarla, Kanya Rajagopalan

Background

Venous thromboembolism (VTE) occurs in 1.5% of hospitalized patients1. Despite a high incidence of VTE in hospitalized patients, pharmacologic prophylaxis is frequently inappropriately utilized (both overused and underused). The Padua score was developed to estimate risk of VTE in hospitalized medical patients and help guide decisions regarding the use of VTE prophylaxis. It has been shown that the use of appropriate VTE prophylaxis may have a cost saving of up to $6370 per discharge2. In the beginning of residency, we noticed a lack of awareness amongst residents regarding negative outcomes associate with inappropriate use of VTE prophylaxis. Therefore, our team was inspired to formulate a standardized protocol for ordering VTE prophylaxis. Our goal was primarily to improve patient safety as well as to reduce costs for patients and the hospital.

Objective

We developed a quality improvement (QI) project aimed to increase appropriate use of chemical VTE prophylaxis in the inpatient setting at our 400-bed hospital.

Methods

A retrospective chart review of non-surgical and non-ICU patients admitted to the medical resident service was done to determine incidence of appropriate use of pharmacologic VTE prophylaxis. Patients on therapeutic anticoagulation and patients who were admitted for acute thrombotic or bleeding events were excluded. The Padua score was used to assess risk of VTE in each patient and determine appropriate use of pharmacologic VTE prophylaxis. Overuse was defined as receiving prophylaxis with a Padua score <4, and underuse was defined as not receiving prophylaxis with a Padua score >4. A process map (figure 1) was created to reflect the common practice and workflow in our institution. A root cause analysis was performed by surveying the medicine residents on potential causes and sources for intervention. A questionnaire was distributed to 45 residents, and a Pareto chart (figure 2) was developed with this data.

Intervention

An Electronic Medical Record (EMR) “auto-populated order set” was introduced based on the Padua score to guide providers on the appropriate VTE prophylaxis, and we educated our fellow residents to increase awareness.

Results

Our pre-intervention data analysis in 12-2019 and 01-2020 showed 63% appropriate use (17/27 and 20/32 respectively). Following introduction of our order set, we noticed an increase in appropriate use of VTE prophylaxis as follows: 96.8% (62/64) in 9-2020, 93.68% (89/95) in 10-2020, 96.2% (76/79) in 11-2020, 89% (89/100) in 12-2020, 95.4% (82/86) in 01-2021 and 93.4% (71/76) in 02-2021. In addition to this we also noticed a steep decline in the under-use of VTE prophylaxis from 26% (7/27) and 34% (11/32) pre-intervention to 0% from 11-2020 to 01-21. (figure 3).

Conclusion

Our intervention successfully increased the appropriate use of VTE prophylaxis by 49.2% and showed a sustained change over time.

Clinical Implications

Inappropriate use of VTE prophylaxis is associated with increased major complications leading to poor outcomes for patients, including major bleeding and VTE (1.6% and 7.5%, respectively). These complications are associated with morbidity and mortality, decreased patient satisfaction, longer length of stay, and increased costs to patients and the healthcare system. Ensuring appropriate use of VTE prophylaxis by using tools such as the Padua score can help address this problem.

References

  1. Stein PD, Matta F. Acute Pulmonary Embolism. Curr Probl Cardiol. 2010;35(7):314-376. doi:https://doi.org/10.1016/j.cpcardiol.2010.03.002
  2. Amin AN, Lin J, Johnson BH, Schulman KL. Clinical and economic outcomes with appropriate or partial prophylaxis. Thromb Res. 2010;125(6):513-517. doi:10.1016/j.thromres.2009.10.018