Category: Federal Forum Posters
Purpose: Patients hospitalized for acute medical illnesses are at increased risk for venous thromboembolism (VTE). Appropriate VTE prophylactic regimens, based on patient risk factors for VTE and bleeding, are often not prescribed in accordance with guideline recommendations. This project was conducted to assess appropriateness of VTE prophylaxis prescribing in acutely ill medical patients after the implementation of a VTE prophylaxis clinical decision-support tool. The tool aimed to assist prescribers in determining patient risk, need for VTE prophylaxis, and selection of guideline recommended and local facility preferred pharmacologic or nonpharmacologic therapies.
Methods: This quality improvement initiative was evaluated using a cross-sectional design. The appropriateness of VTE prophylaxis was determined using the Padua Prediction Score VTE risk assessment and risk factors for bleeding recommended in the American College of Chest Physician guidelines for prevention of VTE in nonsurgical patients, with review and concurrence of these factors by facility Hematology Service. Patients were included if they were nonsurgical patients admitted to the general medicine service. A one-day cross-sectional sample of patients was compared before (pre-intervention sample) and after (Year 1 and Year 2 post-intervention samples) the initiative. Patients were excluded if they were admitted to neurology or surgical service, or if they were admitted for stroke, decompensated heart failure, had history of spinal cord injury, or were receiving therapeutic anticoagulation. Using the computerized medical record, patient cases were reviewed for appropriateness of VTE prophylaxis in comparison to data from pre-intervention and Year 1 post-intervention samples.
Results: One-hundred-ninety-four patients were included, 50 from Year 2 post-intervention sample, 57 from Year 1 post-intervention sample, and 87 from pre-intervention sample. In Year 2 post-intervention sample, unwarranted VTE prophylaxis prescription was observed in 36 percent of patients, versus 56 percent in Year 1 post-intervention sample, and 59 percent in pre-intervention sample. In Year 2 post-intervention sample, 25 percent of high bleeding risk patients received pharmacologic VTE prophylaxis, versus 60 percent in Year 1 post-intervention sample, and 70 percent in pre-intervention sample. When VTE prophylaxis was prescribed in Year 2 post-intervention sample, 76 percent was pharmacologic, 10 percent was mechanical, and 14 percent received both. In pre-intervention and Year 1 post-intervention samples, 76 and 72 percent received pharmacologic, 21 and 11 percent received mechanical, and 3 and 17 percent received both, respectively. For Year 2 post-intervention sample pharmacologic prophylaxis, 52 percent were prescribed enoxaparin 40mg daily, 24 percent heparin 5000 units twice daily, and 24 percent heparin 5000 units thrice daily. In pre-intervention and Year 1 post-intervention samples, 3 percent and 41.5 percent were prescribed enoxaparin 40mg daily, 3 percent and 17 percent heparin 5000 units twice daily, and 94 percent and 41.5 percent heparin 5000 units thrice daily, respectively.
Conclusion: This evaluation found an improvement in prescribing practices following the implementation of the clinical decision-support tool. The use of the local facility’s preferred agent, enoxaparin, increased and use of thrice daily heparin decreased. Additionally, there was a substantial improvement in healthcare providers appropriately withholding VTE prophylaxis when it was not warranted and adjusting therapy with elevated bleeding risk. A secondary analysis to assess cost implications indicated if all patients who warranted pharmacologic prophylaxis received the preferred agent, this would have resulted in a potential yearly cost savings of approximately 46,000 dollars.
Samantha Gonzales– PGY2 Psychiatric Pharmacy Resident, VA North Texas Healthcare System, Forney, TX