S. O’Malley1, M. S. Stumpf1, G. Prellwitz2, J. Sutyak1, S. Ganai1, M. Smith1, E. Mackinney1 1Southern Illinois University School Of Medicine,Surgery,Springfield, IL, USA 2Memorial Medical Center,Springfield, IL, USA
Introduction: Venous thromboembolism (VTE) prophylaxis in trauma patients is an important yet often lower tier process measure due to competing priorities during trauma. Order sets are commonly employed in electronic medical records (EMR) to streamline health care performance. A pop-up order set to address VTE prophylaxis was implemented prompting the user to address VTE prophylaxis at admission. We hypothesized that a prompted VTE order set would decrease the average time to prophylaxis and ensure appropriate use of mechanical and chemical prophylaxis in a trauma population.
Methods: A retrospective chart review was conducted on a random number-generated sample of trauma patients pre- (Spring 2016) and post-intervention (Spring 2017) to evaluate an order set implemented in June 2016 to improve VTE prophylaxis utilization at a Level-I trauma center. Exclusion criteria included trauma patients with evidence of intracranial bleeding. The quality improvement framework used Lean Six-Sigma methodology. Upper control limits (UCL) are defined at 3 standard deviations above the mean. Data were analyzed using non-parametrical statistical techniques and process control charts were created.
Results: After exclusions, a total of 54 patients in 2016 and 34 patients in 2017 were studied. Median time to mechanical prophylaxis order decreased from 120.9 (interquartile range (IQR), 63.5 to 200.1) minutes to 91.8 (IQR, 70.2 to 112.2) minutes (p=0.12). The UCL for admission time to mechanical prophylaxis order decreased from 28.5 to 4.2 hours. Median time from admission to receipt of chemical prophylaxis increased from 16.6 (IQR, 14.1 to 26.6) hours to 32.4 (IQR, 15.1 to 64.9) hours (p=0.08). The UCL for admission time to chemical prophylaxis increased from 73.6 to 99.0 hours.
Conclusion: Our data did not support the hypothesis that an order set prompt at admission would improve timing of VTE prophylaxis. While there were no statistically-significant differences between time of admission and VTE prophylaxis, variability was observed in ordering practices. Despite a trend towards decreased timing to mechanical prophylaxis order, an indicator of actual use of the order set, there was a concurrent increase in time and variability of chemical prophylaxis administration, suggesting bypass of decision to place an order for chemical prophylaxis. Future areas of study include qualitative analysis of other potential sources of delay such as click fatigue, as well as correlative studies examining the relationship of process with outcome.