Background: Venous thromboembolism (VTE) is a preventable and potentially fatal condition for which hospitalized medical patients are at risk. Compared with the more traditional option of unfractionated heparin, low molecular weight heparin (LMWH) has been shown to be superior for VTE prophylaxis with regard to both efficacy and bleeding risk, and to have a lower risk of heparin-induced thrombocytopenia. Our institution uses the LMWH enoxaparin, which also provides the advantage of once daily dosing and thus fewer injections for patients. There is also less cost associated with once daily dosing, in terms of nursing time expenditure and physical resources necessary to provide the injection itself.
Despite the benefits of LMWH, baseline data at our institution revealed that only approximately 1 in 10 hospitalized patients received enoxaparin for VTE prophylaxis. Therefore, a quality improvement (QI) project was initiated to increase the use of LMWH for VTE prophylaxis among medical patients hospitalized on four inpatient general medical resident teaching services at Mayo Clinic Hospital, Saint Mary’s Campus during April through August, 2015.
Methods: To improve the utilization of LMWH for VTE prophylaxis, an interprofessional QI team was formed, consisting of resident and attending physicians with nursing and pharmacy leadership. A systems analysis was performed, with stakeholder interviews revealing prescriber knowledge regarding the use of LMWH for VTE prophylaxis as the largest barrier to its utilization. Several Plan-Do-Study-Act (PDSA) cycles were performed, with interventions including peer-to-peer education, pharmacist-to-resident education, educational posters, educational emails, and performance feedback.
Results: Data analysis demonstrated a significant increase in LMWH use among hospitalized medical patients from 10.5% in April to 71.2% in August (p<0.00001). Process measure evaluation revealed that while peer-to-peer education and feedback resulted in some improvement in resident knowledge, pharmacist education lead to an even greater improvement. In an effort to promote sustainability, a recurring pharmacist-led educational session has now been incorporated into the monthly unit orientation for new residents rotating on the inpatient general medicine services.
Conclusions: This QI project has shown that a multifaceted, interprofessional intervention can lead to a significant improvement in high-value VTE prophylaxis. Sustained over a one month period, we estimate that this improvement will conserve over 450 injections and nearly 80 total hours of nursing time. In this manner, usage of LMWH for VTE prophylaxis rather than unfractionated heparin improves the quality, patient satisfaction, cost and efficiency of healthcare, and is a ‘win’ for patients, nursing staff, and providers.