Background: VTE is associated with considerable morbidity and mortality, in fact, as many as 10% of deaths of hospitalized patients have been contributed to pulmonary embolism.1 The ACP and AACP in their 2011 and 2012 guidelines, respectively, recommend that all hospitalized patients be evaluated for risk of VTE, and subsequent prophylaxis be initiated if benefits outweigh risks.2,3However, some studies have shown that excessive VTE prophylaxis was used in a majority of low-risk patients, with a significant annual cost to the health system4-7 .Our baseline data at our VA medical center in Aurora, CO indicated that 71% of patients at low risk for VTE were still receiving prophylaxis, usually in the form of subcutaneous heparin. We sought to address this problem with changes to our ordering pathways and with bedside interdisciplinary rounds (IDR), a collaborative inpatient model of care in which healthcare providers of different professions gather at the patient bedside to discuss plans of care. Bedside IDR have been shown to increase patient and healthcare provider satisfaction, and improve communication between healthcare providers. Due to collaborative workflow around bedside IDR, this structure can serve as a strong catalyst for interprofessional quality improvement projects.
Purpose: We aimed to reduce unnecessary VTE prophylaxis on our inpatient medicine units from 71% to 30% within 12 months, undertaking three simultaneous interventions to address three identified areas for improvement: 1) our VTE order sets included outdated recommendations and did not support prescribing prophylaxis guided by risk stratification; 2) providers defaulted to ordering, not refraining to order, VTE prophylaxis, and after busy admitting shifts this default decision was never revisited; 3) providers were not educated about the Padua score or other VTE risk stratification methods. Further, risk stratification is difficult to automate in the VA electronic medical record since it includes some subjective information such as the patient’s mobility.
Description: First, we removed redundant and outdated pathways to reduce confusion around VTE prophylaxis ordering and added a simple decision support tool to reduce erroneous ordering of VTE prophylaxis on low-risk patients. Second, we used bedside IDR to improve oversight over VTE prophylaxis ordering after admission. A group of interprofessional stakeholders, including pharmacists, met to discuss specific roles at the bedside for each profession. Inpatient pharmacists claimed accountability over VTE prophylaxis, using the Padua risk stratification score. We implemented a bedside IDR structure at our VAMC in June 2019 in which pharmacists used a standardized communication tool at bedside IDR to report the Padua score and make recommendations for VTE prophylaxis based on this risk stratification tool. Third, as an educational intervention, we disseminated information to VA attendings via noon lectures about VTE risk stratification to ensure everyone was familiar with the tools.Over a 2-month period, we saw a reduction in unnecessary VTE prophylaxis from 71% to 0% and plan to continue to collect data and refine our interventions.
Conclusions: We successfully used standardized bedside interdisciplinary rounding, order set redesign incorporating a decision support tool, and education to reduce over-prescription of VTE prophylaxis at a VA hospital.