M. Shyu1,2, L. Kreutzer2, K. Y. Bilimoria2,3, A. D. Yang2,3, J. K. Johnson2,3 1Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA 2Feinberg School Of Medicine – Northwestern University,Surgical Outcomes And Quality Improvement Center (SOQIC), Department Of Surgery,Chicago, IL, USA 3Feinberg School Of Medicine – Northwestern 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 ambulation, mechanical prophylaxis, and chemoprophylaxis; however, patients often refuse chemoprophylaxis which raises their VTE risk. Institutional data highlighted that surgical residents have high rates of unanswered electronic VTE prophylaxis alerts. Our objective was to better understand resident barriers to providing appropriate VTE prophylaxis and responding to alerts.
Methods: Semi-structured interviews were conducted with 18 preliminary and categorical general surgery residents at one hospital who had received at least 10 alerts over 9 months. The interview shared resident-specific alert response and asked about their understanding of VTE prophylaxis components, barriers to patient communication, and reasons for alert nonresponse. Interviews were recorded and transcribed verbatim. Common themes were identified using a constant-comparative approach. The Theoretical Domains Framework (TDF) was used to study behavioral factors creating barriers to VTE prophylaxis.
Results: Five themes describe resident barriers to VTE chemoprophylaxis provision and alert response: knowledge, setting patient expectations, administration verification, communication of prophylaxis failures, and alert fatigue. These themes map to three TDF domains: knowledge, social/professional role and identity, and environmental context and resources (Table). Residents have misconceptions about the necessity of, and contraindications to, chemoprophylaxis (knowledge). Residents expected nurses to execute orders and notify them of patient refusals (social/professional role and identity). Residents said they educate patients on chemoprophylaxis only if the patient asks questions or refuses the shot and rarely set patient expectations preoperatively. Reasons for nonresponse to alerts included alert de-prioritization and fatigue (environmental context and resources). Residents mostly overestimate personal performance with regard to alert response rate and individual patient refusal rate.
Conclusion: Knowledge, social/professional role and identity, and environmental context and resources affect resident provision of appropriate VTE prophylaxis and alert response. Specific interventions to improve VTE prophylaxis rates and reduce patient refusals will need to address factors identified in our resident-focused study. Future initiatives will use similar methods to explore the perspectives of attending surgeons in VTE prophylaxis provision.
