Background: On a daily basis, hospitalists prescribe Venous Thromboembolism (VTE) prophylaxis. While of benefit to certain populations, VTE prophylaxis has not been proven to benefit medical patients at low risk for VTE. Pharmacologic prophylaxis may increase the risk of serious bleeding, mechanical prophylaxis is associated with an increased risk of delirium, and both methods are expensive. Furthermore, combined use of mechanical and pharmacologic prophylaxis has not been shown to have any additive benefit in medical patients. We had noted a significant increase in all methods of VTE prophylaxis in our medical patients at Regions Hospital, a 454 bed urban teaching hospital in St. Paul, Minnesota.
Purpose: Our primary goal was to decrease the use of VTE prophylaxis in low risk individuals by creating an intuitive decision-making tool of risk stratification, while remaining compliant with Meaningful Use and the new VTE Core Measure.
Description: In February of 2013, the VTE prophylaxis section of our “General Admission Order Set” was modified in accordance with the 2012 ACCP guidelines (picture 1), such that each patient is individually assessed for risk of VTE. Within the order set, the provider is prompted to decide if the patient’s VTE risk is high or low. If the provider is uncertain, there is an embedded link leading to the Padua risk stratification scoring system for reference. If a patient is low risk, no prophylaxis is ordered. If a patient is high risk and has no contraindications to anticoagulation, pharmacologic prophylaxis is ordered. If a patient is high risk for VTE but also has bleeding risks, sequential compression devices are ordered. Patients already anti-coagulated receive no further VTE prophylaxis. Physician assessment of VTE risk, and subsequent orders for prophylaxis, are included as forcing functions or “hard stops” in the order set. We monitored the use of VTE prophylaxis and combined pharmacologic and mechanical VTE prophylaxis. We also monitored the incidence of in-hospital VTE.
Results: There was a 58.3% reduction in pharmacologic prophylaxis (figure 1, blue), and a 50.3% reduction in mechanical VTE prophylaxis (figure 1, green) in low-risk patients. There was a 91.0% reduction of patients with combined pharmacological and mechanical prophylaxis. Annual cost savings was $151,000. All physicians were more satisfied with the order set and 2/3 changed their VTE prophylaxis ordering practice (N=23). The incidence of in-hospital VTE did not significantly change (p=0.32) (Figure 1, purple).
Conclusions: Through the use of a decision making tool we were able to individualize VTE prophylaxis based on the ACCP guidelines and the Padua risk stratification scoring system. This led to decreased rates of low-risk VTE prophylaxis and decreased combined pharmacological and mechanical prophylaxis. It resulted in greater physician satisfaction, significant cost savings without a statistically significant increase in in-hospital VTE rates, and continued compliance with CMS guidelines for Meaningful Use of the Electronic Health Record and the VTE Core Measure. This innovation could be tailored to local EHRs and implemented at other institutions to more effectively utilize VTE prophylaxis based on individual patient risk.
