N. A. Lee1, R. Ramanathan1, Z. Gu2, E. M. Rensing2, R. Sampson2, M. B. Burrows2, S. M. Hartigan3, N. Nguyen2, T. G. Potter2, T. Trimmer2, A. C. Grover1 1Virginia Commonwealth University,Department Of Surgery,Richmond, VA, USA 2Virginia Commonwealth University Health System,Richmond, VA, USA 3Virginia Commonwealth University,Department Of Internal Medicine,Richmond, VA, USA
Introduction:
Venous thromboembolisms (VTE) are potentially preventable adverse events associated with significant morbidity and mortality. VTE rates are also a publicly tracked patient safety measure affecting institutional quality metrics and reimbursement. Electronic medical record (EMR) alerts have been widely adopted to improve VTE prophylaxis administration. This study examines the association of VTE prophylaxis and EMR alerts with VTE rates.
Methods:
At our urban academic medical center, 10318 adult surgical admissions between November 2013 and March 2015 were queried for VTE defined by Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator 12 and Joint Commission Core Measure VTE-6. Daily pharmacologic prophylaxis patterns were prospectively collected for patients and categorized as continuous (initiated within 24h without interruptions), delayed (initiated >24h without interruptions), interrupted (interrupted for >24h with or without delay), none, or other (nonstandard drugs or dosing). Patients were also categorized by whether an EMR alert fired during their admission. Associations between VTE incidence, prophylaxis, length of stay (LOS), and demographics were explored.
Results:
There were 131 VTEs (12.7 VTE per 1000 patients) among the surgical admissions. Patients who developed a VTE were older (56.4 vs. 52.2 years, p<0.01) and had longer LOS (16.3 vs. 6.5 days, p<0.01). 45.7% of patients had an EMR alert to prescribe VTE prophylaxis. The VTE rate for patients who received an alert was significantly higher than patients without an alert (17.5 vs 9.0 per 1000 patients; p<0.01). 33.6% of patients received continuous prophylaxis, 18.3% experienced delays, 13.2% experienced interruptions, 25.7% received no prophylaxis and 9.3% had nonstandard prophylaxis regimens. Patients with interruptions had a significantly higher incidence of VTE than patients with continuous prophylaxis (8.8 vs 30.7 per 1000 patients, p<0.01) and all other prophylaxis groups. Increased LOS was associated with increased likelihood of interruptions and VTE. In multivariate logistic regression analysis, prophylaxis group and age were associated with VTE incidence independent of gender, race, and LOS. The highest incidences of VTE were among patients admitted to cardiac surgery, followed by trauma and otolaryngology. Interruptions were most common among patients admitted to trauma surgery, otolaryngology, and bariatric surgery.
Conclusion:
Despite continuous prophylaxis 8.8 per 1000 patients still developed a VTE, and interruptions conferred more risk of VTE than delays. This suggests patient safety measures should be reevaluated to emphasize minimizing interruptions in addition to delays and overall VTE rates. Increased efforts to investigate causes and develop multidisciplinary strategies to minimize interruptions should be undertaken. Optimization of EMR alerts may be a useful adjunct to identify patients at high risk for VTE.