Marcia Frellick

May 10, 2017

LAS VEGAS — A quality-improvement protocol that combined a risk-assessment tool with a prevention strategy reduced hospital-acquired venous thromboembolism (VTE) rates by 22% in both medical and surgical patients, according to a new study.

"VTE is one of the most commonly recognized, dangerous, and potentially lethal, morbid, and expensive complications of hospitalization," said lead investigator Ian Jenkins, MD, from the University of California, San Diego.

Surprisingly, the reduction was greater in medical than in surgical patients, even though surgical patients generally have a much higher risk for venous thromboembolism, he reported here at the Society of Hospital Medicine 2017 Annual Meeting.

The protocol was implemented at 35 centers in the Dignity Health system, located throughout the Southwest United States.

"Although the system had a low VTE rate — only about 5 per 1000 — there was no single way to approach the assessment for risk of blood clots or to start a prevention strategy," Dr Jenkins told Medscape Medical News.

"This protocol adds a simple, low-cost way for all doctors to evaluate patients for clot risk and then implement a prevention strategy. It puts a risk-assessment tool and a menu of options in front of providers each time they admit or transfer a patient," he explained.

Three-Bucket Assessment Speeds Decision-Making

The three-bucket risk-assessment tool is used to categorize patients as being at low, medium, or high risk, in accordance with guidelines described in a protocol of pharmacologic and mechanical venous thromboembolism prophylaxis, which can be customized to individual hospital populations.

"Many other hospitals are using point-scoring systems that involve tallying 12 or more characteristics, assigning them point values, and adding up the result to see if patients qualify for prophylaxis. What we found is that doctors hate these point-value systems, and they don't use them," Dr Jenkins said.

The three-bucket assessment "is a decision a doctor can make in a split second. People actually do it," he added.

For this study, multidisciplinary teams identified lapses in venous thromboembolism prophylaxis and developed educational programs to address them. In addition, data management, order-set design, and webinar support were centralized.

At nine pilot sites, providers were mentored on the implementation of prophylactic best practices, patients were checked every day to make sure they were on the right prophylactic agent, and results were recorded.

The protocol was then rolled out to the other 26 "spread" sites, which did not have mentored implementation or the resources to carry out checks every day.

The investigators collected coding data on hospital-acquired venous thromboembolism events that occurred during hospitalizations from 2011 to 2014 or on readmissions in the 30 days after hospital discharge.

The year 2011 was used as the baseline, 2012 and 2013 were the intervention years, and 2014 was the comparison year.

Of the 1.16 million admissions during the study period, there were 5370 venous thromboembolism events.

There were 428 fewer hospital-acquired venous thromboembolism events in 2014 than in 2011 at the 35 sites (relative risk, 0.78; 95% confidence interval, 0.73 - 0.85). The reduction in events was greater at the pilot sites than at the spread sites (26% vs 20%).

In addition, the average annual rate of hospital-acquired venous thromboembolism was higher in surgical than in medical patients at both the pilot sites (5.7 vs 3.3 per 1000 patients) and the spread sites (7.3 vs 3.6per 1000 patients).

In medical patients, 2740 of the 3416 (80%) hospital-acquired events occurred after discharge, whereas in surgical patients, 1611 of the 2630 (61%) events occurred during the index admission.

"Measurevention," or real-time monitoring of the intervention, was a key part of the work, Dr Jenkins explained. It was funded at the pilot sites and encouraged at the spread sites.

Lack of Consensus

There is a lack of consensus in the literature about venous thromboembolism prophylaxis, particularly in medical patients, Dr Jenkins pointed out.

"Some authors feel it's not worth doing at all in the medical patient because the risk of VTE is low. But Dignity had a low VTE rate and was able to lower its rate using this strategy, from 5 per 1000 to 4 per 1000, and the benefit was unexpectedly greatest in medical patients," he said.

I hope this helps settle the controversy about whether VTE prophylaxis, particularly in medical patients, is worthwhile.

"I hope this helps settle the controversy about whether VTE prophylaxis, particularly in medical patients, is worthwhile," he added. Now, "I think we have to turn our attention to ask whether this is a hospital system's greatest priority."

This study shows that the strategy works in university settings, large hospitals, small hospitals, community teaching facilities, and nonteaching facilities, he added.

The small number of events — 5370 in 1.16 million admissions — speaks to the need for a large study like this on hospital-acquired venous thromboembolism, said Margaret Fang, MD, from the University of California, San Francisco, who is chair of the research, innovation, and vignettes section of the conference.

"It takes a study like this to see a significant change because, overall, VTEs are not super common," she told Medscape Medical News.

The results show that "you can move the needle and improve a hospital-acquired complication on a large scale," she explained. "The events are often preventable, in the sense that you can increase mobility or prescribe medications. But at the same time, you don't want to administer these anticoagulants to everybody."

This work was supported by a grant from the Gordon and Betty Moore Foundation. Dr Jenkins and Dr Fang have disclosed no relevant financial relationships.

Society of Hospital Medicine (HM) 2017 Annual Meeting. Presented May 2, 2017.

Follow Medscape Internal Medicine on Twitter @MedscapeIM and Marcia Frellick @mfrellick

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