|Year : 2014 | Volume
| Issue : 1 | Page : 6-9
Translating venous thromboembolism prevention guidelines into practice through system redesign
Ali Al-Aklabi1, Mohammad Bo Saeed2, Imad Hassan1, Mohammad Al-Qahtani1, Adel Al-Othman1, A Al-Theaby2, M Al-Ammari2, M Al Firm2, Fahad Al-Hameed3
1 Department of Medicine, King Abdulaziz Medical City; College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
2 Department of Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
3 Department of Intensive Care, King Abdulaziz Medical City, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah; Saudi Association for Venous Thrombo Embolism, Saudi Arabia
|Date of Web Publication||2-May-2014|
Department of Medicine, King Abdulaziz Medical City, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh-11426
Source of Support: None, Conflict of Interest: None
Background: Venous thromboembolism (VTE) is a major public health problem, which is a primary concern of hospitalized or recently hospitalized patients. Pulmonary embolism resulting from deep vein thrombosis (DVT) is the most common preventable cause of death occurring in the hospital. System redesign is suggested to improve in compliance with practice guidelines. This study assessed the impact of ward-based Knowledge Translation (KT) monitor on the implementations of evidence-based thromboprophylaxis guidelines and its compliance. Materials and Methods: The study was conducted at the Department of Medicine, in a tertiary-care hospital. In addition to staff education, a risk-scoring template and employment of a Knowledge Translation (KT) monitor were undertaken. The KT monitor was specifically trained to assess the risk of venous thromboembolism (VTE) for all medical in-patients. Patients on no, suboptimal or contraindicated prophylaxis interventions were identified by the monitor. The treating team is immediately contacted to initiate the recommended corrective measures. The monitor will subsequently follow these patients to guarantee the commencement of action for treatment. Results: After eliminating the non-eligible patients, 602 individuals were eligible for prophylactic anticoagulation. Four hundred and thirty (71%) of these patients were receiving appropriate VTE prophylaxis, 124 patients (21%) were receiving suboptimal doses of subcutaneous heparin and 48 eligible patients (8%) were not receiving any intervention for prophylaxis. All those 48 patients (not on prophylaxis) were subsequently commenced on the appropriate method and dose of VTE prophylaxis after contacting the primary physicians. Patients on suboptimal prophylaxis were referred to the teams and 82 of these patients thromboprophylaxis were adjusted to the optimal dose. Conclusion: Implementation of multifaceted interventions with system redesign and employment of a ward-based Knowledge Translation (KT) monitor resulted in significant improvements in appropriate VTE prophylaxis.
Keywords: Continuing medical staff education, clinical practice guidelines, deep vein thrombosis, knowledge translation monitor, risk-scoring template, venous thromboembolism
|How to cite this article:|
Al-Aklabi A, Saeed MB, Hassan I, Al-Qahtani M, Al-Othman A, Al-Theaby A, Al-Ammari M, Al Firm M, Al-Hameed F. Translating venous thromboembolism prevention guidelines into practice through system redesign. J Appl Hematol 2014;5:6-9
|How to cite this URL:|
Al-Aklabi A, Saeed MB, Hassan I, Al-Qahtani M, Al-Othman A, Al-Theaby A, Al-Ammari M, Al Firm M, Al-Hameed F. Translating venous thromboembolism prevention guidelines into practice through system redesign. J Appl Hematol [serial online] 2014 [cited 2020 Sep 27];5:6-9. Available from: http://www.jahjournal.org/text.asp?2014/5/1/6/131818
| Introduction|| |
Venous thromboembolism (VTE) comprising deep vein thrombosis (DVT) and pulmonary embolism (PE) represent a major public health problem. VTE is a primary problem in hospitalized or recently hospitalized patients. The incidence of VTE has been shown to be more than 100 times greater among hospitalized patients than those in the community.  Pulmonary embolism resulting from DVT is the most common preventable cause of hospital death. ,, Fortunately, pharmacologic methods to prevent VTE are safe, efficient, cost-effective, and advocated by authoritative guidelines. 
The American College of Chest Physicians (ACCP) currently recommends that every hospital develops specific strategies for assessing VTE risk and also plan for implementation of appropriate prophylaxis. The ACCP currently recommends unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) for prevention of VTE in medically ill-patients. 
Despite the fact that hospitalized medical and surgical patients regularly have multiple risk factors for VTE, making the risk for VTE nearly universal among these patients, yet, large prospective studies continue to demonstrate that these preventive methods are significantly under utilized. ,,,,
While individual centers have published results of successful local initiatives for improving the deployment of VTE prophylaxis, no single strategy has yet been proven to be consistently effective, sustainable, and widely applicable to other centers. 
To implement effective protocols to minimize the incidence of hospital-acquired VTE, while at the same time minimizing adverse outcomes, redesign is needed in both care delivery and performance tracking. Quality Improvement projects should always develop from the recognition of a gap between the optimal care and care that is actually being delivered. System redesign is a new concept in healthcare reforms. It entails specific redesign in care delivery both in its structure and in its process to re-align a faulty system and improve outcomes. The whole structure or process of care is redesigned to an "ideal process" based on evidence. 
This study came as a reaction to an observational one-day spot-check survey that we conducted in the acute medical wards at King Abdulaziz medical City, National Guard, Riyadh, Saudi Arabia. , All in-patients were risk-assessed for thrombosis and their recommended prophylactic measure as per their risk score was compared with the treating team prescribed intervention. Of 81 acutely admitted medical patients, 64 patients were eligible for thromboprophylaxis, only 30 patients (46.9%) were receiving the appropriate VTE prophylaxis as per the Agency for Healthcare Research and Quality (AHRQ) guidelines.
The Department of Medicine has embarked on several implementation strategies to improve the use of thromboprophylaxis through its KT committee. These included staff education, institution and deployment of a DVT risk-scoring template and the employment of a full-time, ward-based KT monitor.
| Materials and Methods|| |
The King Abdulaziz Medical City in Riyadh, Kingdom of Saudi Arabia with over 1200 beds is a tertiary-care center serving the National Guard recruits, their dependents, and members of the public requiring highly specialized care. The Department of Medicine is one of the largest in the Kingdom with 12 divisions, namely Dermatology, Endocrinology, Gastroenterology, Hematology/Oncology, Infectious Diseases, Internal Medicine, Nephrology, Neurology, Physiotherapy (rehabilitation), Psychiatry, Pulmonology, and Rheumatology. The number of senior medical staff (consultants, associates, and assistants) exceeds 70, all of whom are highly qualified.
In addition to staff education (that include lectures presentations, booklets and guidelines distributions), a risk-scoring template and employment of a KT monitor were undertaken as mentioned above. The latter two interventions were specifically piloted in 3 medical wards with a total bed number of sixty 60.
The DVT risk assessment, an evidence-based template additionally comprising recommended prophylactic strategies as per risk-score and contraindications to the use of anticoagulants was employed. 
The second step was the recruitment of a full-time KT monitor. Knowledge Translation (KT) is defined as a dynamic and iterative process that includes synthesis, dissemination, and exchange and ethically sound application of knowledge to improve the health of patients, provide more effective health services and products resulting in strengthening the healthcare system. This process takes place within a complex system of interactions between researchers and knowledge users, which may vary in intensity, complexity and level of engagement depending on the nature of the research and the findings as well as the needs of the particular knowledge user. 
The KT monitor was specifically trained to assess the risk of VTE for each medical in-patient in wards. Patients on no, suboptimal or contraindicated interventions were identified by the monitor. The treating team is then immediately contacted to initiate the recommended corrective action. The monitor will subsequently follow these patients to guarantee the commencement of action.
Summary statistics, including frequency percentage, means and standard deviations, will be calculated, as required, to summarize data. The compliance rate before and after the implementation was compared using Chi-square (χ2) test and the P ≤ 0.05 was considered statistically significant.
| Results|| |
The one-day spot-check survey shows that out of 81 acutely admitted medical patients with a mean age of 66 years, four were on therapeutic anticoagulation, three had no indication for heparin thromboprophylaxis, and 10 had a contraindication for anticoagulant therapy. Of the remaining 64 patients, only 30 patients (46.9%) were receiving the appropriate VTE prophylaxis, 30 (46.8%) were on a sub-therapeutic heparin regime and four (6.3%) were not offered the indicated prophylaxis as per the AHRQ guidelines.
During the study period from "February - September 2012", a total of 782 patients were admitted to the 3 acute medical wards under study [Table 1]. All these patients were screened for their DVT risk. According to the criteria for VTE prophylaxis, the majority of these patient were high risk for VTE with only 43 patients (6%) having a low risk and, therefore, not requiring any pharmacological prophylaxis.
|Table 1: Pre- and post-results of DVT/PE thromboprophylaxis KT monitor interventions |
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A total of 739 patients were labeled as high-risk group for developing VTE, 117 patients of them were already on therapeutic anticoagulation (warfarin or IV infusion of heparin) and 20 were having contraindications to prophylactic anticoagulation (e.g. active hemorrhage, severe trauma to head or spinal cord, etc).
After eliminating the above groups, the remaining 602 patients were eligible for prophylactic anticoagulation. Four hundred thirty patients (71%) were receiving appropriate VTE prophylaxis compared to (46.9%) as in the one-day spot-check data prior to the KT intervention measures, which showed a significant improvement (P < 0.005).
One hundred twenty four patients (21%) were receiving suboptimal doses of subcutaneous heparin (5000 units every 12 hours) prophylaxis compared to (46.9%) as in the one-day spot-check data prior to the KT intervention measures, which also improved significantly (P < 0.005). After contacting the treating team, thromboprophylaxis was adjusted to the optimal dose in 82 of these patients and the rest (42 patients) had relative contraindications to receive Q 8 hour heparin as per their treating team.
Forty-eight eligible patients (8%) were not receiving any intervention for prophylaxis. The KT monitor informed the treating team and all these 48 patients were subsequently commenced on the appropriate method and dose of prophylaxis.
| Discussion|| |
Despite significant advances in the prevention and treatment of VTE, pulmonary embolism remains the most common preventable cause of hospital death, being responsible for approximately 150,000 to 200,000 deaths per year in the United States. Thus, it is vital that efforts continue to be made to find means of preventing and managing VTE that are safer and more effective than those currently being used.
Our data from the preliminary one-day spot-check, observational study confirmed the under-use of this essential, guidelines recommended, patient-safety intervention. The selected interventions namely staff education, deployment of a compulsory VTE-risk scoring and interventions recommendation template and the employment of a full-time KT monitor were tested in this study. Multiple or multifaceted interventions are generally believed to be more successful in bringing and consolidating change than single interventions.  Baseline compliance of the use of prophylaxis has significantly improved from 45% to 71%, (P < 0.005). The remainder (27%) was eventually put on their recommended prophylactic intervention. Full realization of improvement was only achievable through the KT monitor daily presence in the ward and its scoring actions and direct contact with the treating-staff. The employment of the KT monitor is a vivid example of System Redesign as portrayed and recommended by the AHRQ. System redesign is considered an indispensible tool for knowledge translation and for bringing up and sustaining achievement. The findings of poor adherence to prophylaxis in wards where the KT monitor is not involved are a powerful proof of this patient-safety and quality improvement intervention.
In previous studies, several interventions were tested to increase the physician's compliance to VTE prophylaxis showing different results. ,, Recommended effective strategies for VTE prophylaxis include committed clinical leadership, improved clinician knowledge of risk assessment and prescribing, and a supportive system that removes some of the individual barriers, which presently result in less-than-optimal practices. Studies have also found that barriers to guideline implementation included a lack of systems for data collection and audit; problems with individual staff responsible for implementation; a lack of acceptance of guidelines; and a perceived lack of need in particular clinical areas. Twelve studies used one out of four active strategies in isolation to improve VTE prophylaxis. The four strategies used were computer-based clinical decision support systems, audit and feedback, documentary aids, and quality-assurance activities.  A "forced-function" computerized decision support interface in the institutes computerized physician order entry system is currently planned. This will likely assist in spreading the above results to other medical wards and reduce but not eliminate the need for a full-time ward KT monitor.
The primary goal of our study was to evaluate the effectiveness of the interventions on improving the compliance rate with VTE prophylaxis, focusing on the process measure and not the outcome measures. Cost-efficacy data will similarly be required to determine the net long-term benefits of employing a fulltime prophylaxis nurse/monitor and would likely be required before mandatory systems are established.
| Conclusion|| |
Our results confirm prior findings that, despite the availability of management guidelines and prophylaxis protocols, VTE prophylaxis is under utilized in our acutely ill, hospitalized medical patients. Implementation of multifaceted interventions with system redesign and employment of a ward-based KT monitor resulted in significant improvement in appropriate prophylaxis. Spreading the improvement to other areas of the hospital (surgical patients in particular) is an important next-step with specific considerations and clear plans and protocols.
| References|| |
|1.||Heit JA, Melton LJ 3 rd , Lohse CM, Petterson TM, Silverstein MD, Mohr DN, et al. Incidence of venous thromboembolism in hospitalized patients vs community residents. Mayo Clin Proc 2001;76:1102-10. |
|2.||Heit JA, O'Fallon WM, Petterson TM, Lohse CM, Silverstein MD, Mohr DN, et al. Relative impact of risk factors for deep vein thrombosis and pulmonary embolism: A population-based study. Arch Intern Med 2002;162:1245-8. |
|3.||Tapson VF, Hyers TM, Waldo AL, Ballard DJ, Becker RC, Caprini JA, et al. NABOR (National Anticoagulation Benchmark and Outcomes Report) Steering Committee. Antithrombotic therapy practices in US hospitals in an era of practice guidelines. Arch Intern Med 2005;165:1458-64. |
|4.||Clagett GP, Anderson FA Jr, Heit JA, Levine MN, Wheeler HB. Prevention of venous thromboembolism. Chest 1995;108:312-34S. |
|5.||Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, et al. American College of Chest Physicians. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8 th Edition). Chest 2008;133:381-453S. |
|6.||Goldhaber SZ, Tapson VF. DVT FREE Steering Committee. A prospective registry of 5,451 patients with ultrasound-confirmed deep vein thrombosis. Am J Cardiol 2004;93:259-62. |
|7.||Monreal M, Kakkar AK, Caprini JA, Barba R, Uresandi F, Valle R, et al. The outcome after treatment of venous thromboembolism is different in surgical and acutely ill medical patients. Findings from the RIETE registry. J Thromb Haemost 2004;2:1892-8. |
|8.||Tapson V, Decousus H, Pini M, Chong BH, Froehlich JB, Monreal M, et al. Venous thromboembolism prophylaxis in acutely ill hospitalized medical patients: Findings from the International Medical Prevention Registry on Venous Thromboembolism. Chest 2007;132:936-45. |
|9.||Kahn SR, Panju A, Geerts W, Pineo GF, Desjardins L, Turpie AG, et al. Multicenter evaluation of the use of venous thromboembolism prophylaxis in acutely ill medical patients in Canada. Thromb Res 2007;119:145-55. |
|10.||Cohen AT, Tapson VF, Bergmann JF, Goldhaber SZ, Kakkar AK, Deslandes B, et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): A multinational cross-sectional study. Lancet 2008;371:387-94. |
|11.||Tooher R, Middleton P, Pham C, Fitridge R, Rowe S, Babidge W, et al. A systematic review of strategies to improve prophylaxis for venous thromboembolism in hospitals. Ann Surg 2005;241:397-415. |
|12.||Hagg HW, Workman-Germann J, Flanagan M, Suskovich D, Schachitti S, Corum C, et al. Implementation of Systems Redesign: Approaches to Spread and Sustain Adoption. In: Henriksen K, Battles JB, Keyes MA, Grady ML, editors. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 2: Culture and Redesign). Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 . Available from: http://www.ncbi.nlm.nih.gov/books/NBK43727/. [Last accessed on 2013 Apr 20]. |
|13.||Bo Saeed MA, Hassan IS. Deep venous thrombosis prophylaxis at the Department of Medicine, King Abdulaziz Medical City, Riyadh. Ann Thorac Med 2012;7:52. |
|14.||Preventing Hospital-Acquired Venous Thromboembolism. A Guide for Effective Quality Improvement, AHRQ Publication No. 08-0075 August 2008. Available from: http://www.ahrq.gov. [Last accessed on 2013 Apr 20]. |
|15.||More About Knowledge Transition at CIHR. May 2013. Available from: http://www.cihr-irsc.gc.ca/e/39033.html. [Last accessed on 2013 Apr 22]. |
|16.||Al-Hameed FM. Venous thromboembolism prophylaxis: Solutions are in our hands. Ann Thorac Med 2011;6:105-6. |
|17.||Duff J, Walker K, Omari A. Translating venous thromboembolism (VTE) prevention evidence into practice: A multidisciplinary evidence implementation project. Worldviews Evid Based Nurs 2011;8:30-9. |