L. J. Kreutzer1, C. J. Minami1,2, L. Saadat1, K. Y. Bilimoria1,2, A. D. Yang1,2, J. K. Johnson1,2 1Northwestern University,Surgical Outcomes And Quality Improvement Center,Chicago, IL, USA 2Northwestern University,Center For Healthcare Studies In The Institute For Public Health And Medicine,Chicago, IL, USA
Introduction: Venous Thromboembolism (VTE) is a serious medical condition that results in preventable morbidity and mortality. Optimal VTE prophylaxis in hospitalized patients includes three components: ambulation, sequential compression devices, and chemoprophylaxis; however, patients can refuse one or more of these components, which can increase their VTE risk. Previous studies have shown that nurses can influence patient compliance with VTE prophylaxis. Our objectives were to identify nursing-related drivers of patient refusal of VTE prophylaxis and to develop customized interventions to reduce refusal rates.
Methods: We conducted focus group interviews (n=14) with day and night shift nurses from 5 units (2 medical, 3 surgical) at 1 hospital to assess nurse understanding of VTE prophylaxis and perception of why patients refuse each prophylaxis component. Four units were selected for participation by their high patient refusal rate along with the unit that had the lowest rate. Focus groups were recorded and transcribed verbatim. Nurse perception of drivers of patient refusals of VTE prophylaxis were analyzed using the Theoretical Domain Framework (TDF), which is an integrative framework that applies theoretical approaches to interventions aimed at behavior change.
Results: The process for ordering and administering VTE prophylaxis allows identification of potential points of patient refusal (Figure 1). Focus group findings highlight that patient refusals are influenced by three main TDF domains: environmental context and resources, knowledge, and beliefs about consequences. One key environmental context and resource barrier identified was the lack of patient education materials on VTE prophylaxis. Nurses did not have the resources required to supplement their explanation to patients about the significance of prophylaxis. Furthermore, the knowledge barrier was highlighted by the many nurses having the misconception that all three components of prophylaxis are not necessary. This overlapped with the barrier on beliefs about consequences because many nurses felt that chemoprophylaxis was not necessary in ambulating patients.
Conclusion: Nursing-related drivers of patient refusal of VTE prophylaxis include lack of knowledge and misperceptions of the consequences of missed elements of VTE prophylaxis. These factors appear to be modifiable targets for quality improvement, particularly by focusing on equipping nurses to address potential patient refusals and by engaging patients in their care. Interventions can be tailored to specifically address these vulnerabilities. Future initiatives will use similar methods to identify how physicians can influence patient refusals of VTE prophylaxis.
