M. S. Stumpf1, S. O’Malley1, G. Prellwitz2, J. Sutyak1, S. Ganai1, E. Mackinney1, M. Smith1 1Southern Illinois University School Of Medicine,Surgery,Springfield, IL, USA 2Memorial Medical Center,Springfield, IL, USA
Introduction: Inappropriate venous thromboembolism (VTE) prophylaxis may pose harm to those at high-risk of VTE including trauma patients. To improve timing and utilization of VTE prophylaxis, an admission VTE order set was implemented in a Level-I Trauma center, but rather than mandating calculation of Caprini score, it prompted the user to determine risk level and prophylaxis type based on an explanation of the score in the order set. We hypothesized that use of a parsimonious order set process would improve appropriate use of mechanical and/or chemical prophylaxis according to risk categorization.
Methods: A retrospective cohort study was conducted to evaluate the effects of the order set implementation in June 2016 on VTE prophylaxis at a Level-I trauma center using a number-generated random sample of trauma patients pre- (Spring 2016) and post-intervention (Spring 2017). Caprini scores were calculated for each patient to determine guideline-appropriate recommendations for mechanical and/or chemical prophylaxis based on risk level. ”Appropriate use” was defined as strict adherence to guidelines, while “extra use” was defined as going beyond guideline recommendations by risk level. Comparisons by proportion were made using Fisher’s exact test.
Results: After exclusions, a total of 54 patients in 2016 and 34 patients in 2017 were analyzed. No significant difference in injury severity scores (pre 9.1±7.5; post 8.9±7.0; p=0.15) or admission Caprini score risk levels (p=0.27) were seen between cohorts. Appropriate use of DVT prophylaxis across all risk levels was 24.1% pre-intervention and 41.1% post-intervention (p=0.10). At the high-risk level, appropriate use increased significantly from 17.9% to 60.0% (p=0.005). No significant difference was seen in appropriate use across the low to moderate risk levels, which trended down from 30.7% to 16.7% (p=0.45). Extra use of VTE prophylaxis options increased from 72.2% to 92.9% across the low to moderate risk levels (p=0.21).
Conclusions: The data support the hypothesis that a simple order set process can improve appropriate VTE prophylaxis use according to risk categorization, but these findings were significant only in the high-risk subgroup and not across all groups. It appears that risk stratification without prompt for calculation is imprecise and users leaned towards ordering more than recommended in low to moderate risk groups. Further examination of harms and benefits of this approach will require a greater sample size to assess association with outcomes including VTE and bleeding incidence.