Problem Addressed

Deep vein thrombosis (DVT) is a medical condition in which a blood clot forms, most often in the deep veins of the leg, groin, or arm. The clot can result from a slowing of blood flow, damage to the blood vessel lining, or an acquired and/or genetic disposition to blood that clots easily.⁸ DVT can also lead to a pulmonary embolism (PE), which occurs when a clot travels through the circulatory system to the lungs.⁹ Venous thromboembolism (VTE) includes both DVTs and PEs, both of which can cause serious and lasting health impacts. Approximately one-third of patients with VTE suffer PE, and two-thirds develop with DVT.¹⁰ In general, it is estimated that “silent” (i.e., asymptomatic) PE is present in more than half of patients with VTE, and among these patients, PE is estimated to result in death 40% of the time.¹¹ Additionally, persons with one episode of DVT are at a high risk for a recurrent episode.^12,13

Each year in the United States, approximately 900,000 people experience new or pre-existing VTE and 100,000 people die due to causes related to VTE, making it one of the leading causes of preventable harm in hospitalized patients.^14,15 In addition, VTE events cost the U.S. healthcare system around $7–10 billion each year for 375,000 to 425,000 newly diagnosed, medically treated VTE cases.¹⁶ Hospitalized and recently discharged patients are among those at the highest risk for VTE, as the most common triggers for VTE are surgery, cancer, and immobilization.⁹ For example, around 60% of surgical patients are deemed to be at “high risk” for VTE.¹⁷ The incidence of persistent VTE from year to year is due, in part, to increasing hospitalizations and the use of surgical procedures as well as the increasing prevalence of obesity, cancer, and leg paresis.¹⁸

The use of fixed, low-dose prophylactic medication reduces VTE and death among hospitalized patients by 50–80%.¹⁹ However, these medications are not universally prescribed or subsequently used by appropriate, high-risk patients.⁶ This non-use of prophylactic medication is attributed to patients’ lack of awareness of VTE risk as well as provider resistance to using the medications due to fear of bleeding episodes triggered by the medications.²⁰ It is important to note that these medications should not be used routinely or when the risk of VTE is low. ²⁰

Description of the Innovative Activity

A review of patient charts at Johns Hopkins Hospital in 2005 found that only 33% of patients were prescribed appropriate VTE prophylaxis.⁴ Of the hospitalized patients who were prescribed VTE prophylaxis, 12% were not taking the medication, mostly due to patient refusal.⁴ In response to these findings, the Johns Hopkins team developed the VTE Collaborative, which is a multidisciplinary group of provider stakeholders that includes physicians (representing multiple specialties such as medicine and surgery), safety and quality leaders, public health professionals, nurses, pharmacists, trainees, administrators, researchers, and experts in health information technology.

The VTE Collaborative first developed a clinical decision support tool for VTE prophylaxis, which featured bleeding risk assessments as part of the admission and transfer process and recommendations for risk-appropriate prophylaxis.⁴ Individualized feedback was provided to residents in the departments of surgery, medicine, and gynecology and obstetrics about their VTE prophylaxis prescribing habits. Feedback included individual reports in which residents could see how they ranked in their prescribing habits compared with their peers.

This intervention was later adapted to make it scalable and transferable. It was implemented in both an academic hospital and a community hospital and included targeting of blood clot prevention education using the real-time, electronic health record data of 17,000 patients at risk for developing a blood clot.⁸

In the last five years, the VTE Collaborative’s initiatives have expanded and have primarily targeted nurses and patients.^21,22 These initiatives have included:

• Developing an implementation toolkit (e.g., informational aids for nursing staff and patient education materials).
• Building two web-based educational modules about VTE prevention for nurses. Both education modules were computer-based, and they presented the same general concepts about VTE prevention practices, including best practices for communicating the importance of VTE prophylaxis to patients and how to administer VTE prophylaxis. One module provided sequential education using PowerPoint slides with voiceover to cover the concepts. The other module provided interactive, dynamic, scenario-based education that included feedback and an opportunity to apply knowledge to different scenarios.
• Partnering with the North American Thrombosis Forum, ClotCare, and the National Blood Clot Alliance to develop a patient-centered education bundle to improve patient education and engagement on VTE. The bundle provides a discussion guide for discussions between patients and nurses about VTE prevention, a two-page paper handout (available in 13 languages), and a 10-minute patient education video.
• Testing a program that alerts hospital staff and a health educator when a patient misses a dose of VTE medicine. The educator checked with nursing staff regarding the reason for the missed dose, and if it was determined that a patient had refused the medication, the educator met with the patient.²³

Context of the Innovation

Preventing VTE is a priority for healthcare facilities partly because of financial penalties imposed by state and federal agencies for preventable hospital readmissions and complications.^24,25 VTE prophylaxis rates are also reported publicly in The Joint Commission’s core measures and the Centers for Medicare Medicaid Service’s (CMS’s) Hospital Compare. Primarily, VTE Collaborative members say the group wants protect patients by prevent unnecessary morbidity and mortality from DVT and PE. At the time of the start of the initiative, the VTE Collaborative found that only 33% of patients were prescribed risk-appropriate VTE prophylaxis at John Hopkins Hospital. Members of the VTE Collaborative believed that this was a result of the lack of standardized risk assessment tools and order sets.⁴ Missed doses of prescribed VTE prophylaxis were also found to be a cause of preventable harm. It was estimated that 36% to 46% of patients missed at least one dose.²⁴ The VTE Collaborative identified two barriers to medication administration that required improvement: nursing knowledge and patient refusal.²⁴

In a retrospective one-year review of 92 patients who experienced healthcare-associated VTE events, 86% were prescribed optimal prophylaxis, yet only 47% received defect-free care. Defect-free care included receiving appropriate VTE prophylaxis care such as prescriptions and administration of medication or compression socks. Of the patients who received suboptimal care, 27% were not prescribed risk-appropriate prophylaxis and 73% missed at least one dose of prescribed prophylaxis.²⁶

Results

Clinical Decision Support Tool and Provider Feedback Intervention^31,32

In a retrospective cohort study of 1,599 patients, prescriber compliance with guideline-appropriate prophylaxis increased from 66.2% to 84.4% after the implementation of a computerized clinical decision support tool. The rate of preventable harm from VTE also decreased from 1.0% to 0.17%.²⁷

A prospective study on the implementation of a “scorecard” that showed residents’ performance in relation to their peers on a measure of appropriate VTE prophylaxis prescribing found that the percentage of patients who were prescribed appropriate VTE prophylaxis increased from 89.4% to 95.4% (n=2,420).²⁸

Nurse Education Intervention²⁴

A nurse education intervention involving 933 nurses on 21 medical or surgical floos at Johns Hopkins Hospital was evaulated using a doubleblind, cluster randomized trial from April 1, 2014, to March 31, 2015.²⁴ Nurses were cluster-randomized by hospital floor to one of two education interventions: a “dynamic” education intervention (i.e., interactive learning) or a “static” education intervention (i.e., noninteractive learning). Overall, non-administration of VTE prophylaxis improved significantly following education regardless of intervention arm (12.4% vs. 11.1%; conditional OR: 0.87; 95% CI: 0.80,0.95; p = 0.002). The reduction in non-administration of VTE prophylaxis was greater for nurses who were randomized to the dynamic intervention (10.8% vs. 9.2%; conditional OR: 0.83; 95% CI: 0.72,0.95) versus those who were randomized to the static intervention (14.5% vs. 13.5%; conditional OR: 0.92; 95% CI: 0.81,1.03). However, the difference between the interventions was not statistically significant (p=0.26). Satisfaction scores were significantly higher (p<0.05) for the dynamic intervention.²⁴

Patient Education Intervention²⁵

A pre-post analysis of 1,614 patient visits examining missed doses of VTE prophylaxis in a community hospital found that when a patient-centered education bundle was used, the proportion of any missed dose decreased significantly from 13.8% to 8.2% (odds ratio [OR]: 0.56; 95% confidence interval (CI): 0.48, 0.64) between the pre- and post-intervention periods. Patient refusal was the most frequent reason for missed doses. In the post-intervention period, patient refusal decreased significantly from 8.8% to 5.0% (OR: 0.54; 95% CI: 0.46, 0.64).²⁴

A precursor to the above study found that among 19,652 patient visits at Johns Hopkins Hospital, the patient-centered education bundle was associated with a 58% reduction in any missed dose of VTE due to patient refusal (5.9% to 3.4%) while the patient refusal rate did not change in the control group.²⁴

Planning and Development Process

For the pre-implementation planning phase, facility efforts should focus on:

• Assembling a multidisciplinary team
• Obtaining leadership buy-in
• Setting up data collection methods, tools, and protocols
• Conducting focus groups with patients and nurses to inform training and education needs
• Determining process measures, outcome measures, and means of data collection and reporting
• Reviewing best practices
• Understanding patient and provider culture and areas of confusion that contribute to nonadherence with VTE prophylaxis

Resources Used and Skills Needed

According to members of the VTE Collaborative, to implement a VTE collaborative, a site or system needs the following resources and skills:

• A multidisciplinary team
• Time for members to participate in the collaborative, including time for meetings, research, trainings, and conducting assessments related to the work
• Money for research, development, implementation, and sustaining of the intervention(s)
• Institution-wide buy-in, including commitment from leadership
• Data collection for process and outcome measurement, as well as subsequent analysis of data for quality improvement purposes
• Audit and feedback mechanisms for prescriber feedback
• A shared understanding of best practices and use of standardized protocols for assessing VTE risk and creating treatment plans
• Incentives for improved provider performance
• A bottom-up approach to change that includes an understanding of unit culture, nursing attitudes and beliefs, and patient preferences and how each of these factors affect medication administration.⁶
  • Focus groups and other means to understand staff perspectives and their strengths and challenges for preventing VTE
• Engagement of clinical champions from each specialty
• Education of providers using principles of adult learning
• Patient-centered education in the hospital and in the community

Funding Sources

Funding was provided by Johns Hopkins Medicine and various agencies such as the Agency for Healthcare Research and Quality (AHRQ) (e.g., 1R01HS024547), PCORI (e.g., CE-12-11-4489), and the Centers for Disease Control and Prevention (CDC).

Getting Started with This Innovation

To get started with the innovation, members of the VTE Collaborative suggest the following:

• Gather the collaborative team.
• Understand barriers to VTE prophylaxis at the institution.
• Survey staff on their attitudes and beliefs regarding VTE prophylaxis.
• Define measures and goals.
• Establish protocols.
• Secure resources.
• Implement training, audit, and feedback systems.
• Designate champions in multiple units.
• Train educators.
• Share standard best practices with nurses and physicians.
• Use free patient educational materials. Examples can be found at the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality available at bit.ly/bloodclots or https://www.hopkinsmedicine.org/armstrong_institute/improvement_projects/infections_complications/VTE/patients.html.

Sustaining This Innovation

To make this innovation sustainable, the prospective collaborative team should:

• Ensure that all voices in the collaborative are heard and that their perspectives treated equally.
• Work with multiple departments.
• Work with a quality improvement team.
• Collect data and understand what the data are showing in real time.
• Provide orientation to new staff.
• Use real-time audit and feedback tools such as dashboards.
• Designate anticoagulation champions.
• Involve nurse, physician, and pharmacist champions.
• Reinvigorate units that may be struggling with the administration of medication for VTE prophylaxis.
• Incorporate the work into the standard workflow.
• Provide engaging and intensive learner-centered education.
• Train nursing staff to use the program through online education modules.
• Make sure nurses have appropriate resources.
• Make VTE a topic at team meetings and symposia and have patients share their stories, if possible.
• Award incentives for performance.
• Modify the electronic health record system to provide alerts about VTE risk, VTE prophylaxis risks and recommendations, and missed doses of preventative medication.
• Use a clinical decision support tool.
• Provide technical assistance and ongoing consulting to other implementing sites.
• Use a learning collaborative approach.

References/Related Articles

American Society of Hematology. ASH Clinical Practice Guidelines on Venous Thromboembolism. Accessed March 14, 2022. https://www.hematology.org/education/clinicians/guidelines-and-quality-care/clinical-practice-guidelines/venous-thromboembolism-guidelines

Armstrong Institute for Patient Safety and Quality. Information for Patients about Blood Clot Prevention. Johns Hopkins Medicine. Accessed March 14, 2022. https://www.hopkinsmedicine.org/armstrong_institute/improvement_projects/infections_complications/VTE/patients.html

Elder S, Hobson DB, Rand CS, et al. Hidden barriers to delivery of pharmacological venous thromboembolism prophylaxis: the role of nursing beliefs and practices. J Patient Saf. 2016;12(2):63-8. doi:10.1097/PTS.0000000000000086

Haut ER, Aboagye JK, Shaffer DL, et al. Effect of real-time patient-centered education bundle on administration of venous thromboembolism prevention in hospitalized patients. JAMA Netw Open. 2018;1(7):e184741. doi:10.1001/jamanetworkopen.2018.4741

Haut ER, Lau BD, Kraenzlin FS, et al. Improved prophylaxis and decreased rates of preventable harm with the use of a mandatory computerized clinical decision support tool for prophylaxis for venous thromboembolism in trauma. Arch Surg. 2012;147(10):901-7. doi:10.1001/archsurg.2012.2024

Lau BD, Arnaoutakis GJ, Streiff MB, et al. Individualized performance feedback to surgical residents improves appropriate venous thromboembolism prophylaxis prescription and reduces potentially preventable VTE: a prospective cohort study. Ann Surg. 2016;264(6):1181-7. doi:10.1097/SLA.0000000000001512

Lau BD, Shaffer DL, Hobson DB, et al. Effectiveness of two distinct web-based education tools for bedside nurses on medication administration practice for venous thromboembolism prevention: a randomized clinical trial. PLoS One. 2017;12(8):e0181664. doi:10.1371/journal.pone.0181664

Lau BD, Streiff MB, Kraus PS, et al. Missed doses of venous thromboembolism (VTE) prophylaxis at community hospitals: cause for alarm. J Gen Intern Med. 2018;33(1):19-20. doi:10.1007/s11606-017-4203-y

Owodunni OP, Lau BD, Shaffer DL, et al. Disseminating a patient-centered education bundle to reduce missed doses of pharmacologic venous thromboembolism (VTE) prophylaxis to a community hospital. J Patient Saf Risk Manag. 2021;26(1):22-8. doi:10.1177/2516043520969324

Shermock KM, Lau BD, Haut ER, et al. Patterns of non-administration of ordered doses of venous thromboembolism prophylaxis: implications for novel intervention strategies. PLoS One. 2013;8(6):e66311. doi:10.1371/journal.pone.0066311

Streiff MB, Lau BD, Hobson DB, et al. The Johns Hopkins Venous Thromboembolism Collaborative: multidisciplinary team approach to achieve perfect prophylaxis. J Hosp Med. 2016;11(suppl 2):S8-S14. doi:10.1002/jhm.2657

Footnotes

1. Centers for Disease Control and Prevention. Data and Statistics on Venous Thromboembolism. Accessed March 14, 2022. https://www.cdc.gov/ncbddd/dvt/data.html.
2. Heit JA, Crusan DJ, Ashrani AA, Petterson TM, Bailey KR. Effect of a near-universal hospitalization-based prophylaxis regimen on annual number of venous thromboembolism events in the US. Blood. 2017;130(2):109-14. doi:10.1182/blood-2016-12-758995
3. Streiff MB, Lau BD, Hobson DB, et al. The Johns Hopkins Venous Thromboembolism Collaborative: multidisciplinary team approach to achieve perfect prophylaxis. J Hosp Med. 2016;11 (suppl 2):S8-S14. doi:10.1002/jhm.2657
4. Maynard G. Preventing Hospital-Associated Venous Thromboembolism: A Guide for Effective Quality Improvement. 2nd ed. Agency for Healthcare Research and Quality; October 2015. AHRQ Publication No. 16-0001-EF. Accessed March 14, 2022. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/vtguide/vteguide.pdf
5. Maynard G. Preface. In: Preventing Hospital-Associated Venous Thromboembolism: A Guide for Effective Quality Improvement. 2nd ed. Agency for Healthcare Research and Quality; October 2015. AHRQ Publication No. 16-0001-EF. Accessed March 14, 2022. https://www.ahrq.gov/patient-safety/resources/vtguide/preface.html
6. Streiff MB, Carolan HT, Hobson DB, et al. Lessons from the Johns Hopkins multi-disciplinary venous thromboembolism (VTE) prevention collaborative. BMJ. 2012;344:e3935. doi:10.1136/bmj.e3935
7. Patient-Centered Outcomes Research Institute. Adapting a blood clot program for routine use in U.S. hospitals. Accessed March 14, 2022. https://www.pcori.org/research-results/2016/adapting-blood-clot-prevention-program-routine-use-hospitals
8. McLendon K, Goyal A, Attia M. Deep Venous Thrombosis Risk Factors. StatPearls. Updated April 22, 2021. Accessed March 14, 2022. https://www.ncbi.nlm.nih.gov/books/NBK470215/
9. Centers for Disease Control and Prevention. What is Venous Thromboembolism? Accessed March14, 2022. https://www.cdc.gov/ncbddd/dvt/facts.html
10. Heit JA, Spencer FA, White RH. The epidemiology of venous thromboembolism. J Thromb Thrombolysis 41, 3–14 (2016). https://doi.org/10.1007/s11239-015-1311-6
11. Bĕlohlávek J, Dytrych V, Linhart A. Pulmonary embolism, part I: epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism. Exp Clin Cardiol. 2013;18(2):129-38.
12. Office of the Surgeon General, National Heart, Lung, and Blood Institute. Section I: Deep vein thrombosis and pulmonary embolism as major public health problems. In: The Surgeon General's Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism. Office of the Surgeon General; 2008. Accessed March 14, 2022. https://www.ncbi.nlm.nih.gov/books/NBK44181/
13. Lee JS, Moon T, Kim TH, et al. Deep vein thrombosis in patients with pulmonary embolism: prevalence [sic], clinical significance and outcome. Vasc Specialist Int. 2016;32(4):166-74. doi:10.5758/vsi.2016.32.4.166
14. Beckman MG, Hooper WC, Critchley SE, Ortel TL. Venous thromboembolism: a public health concern. Am J Prev Med. 2010;38(4 suppl):S495-501. doi:10.1016/j.amepre.2009.12.017
15. Streiff MB, Brady JP, Grant AM, Grosse SD, Wong B, Popovic T, Centers for Disease Control and Prevention (CDC). CDC Grand Rounds: preventing hospital-associated venous thromboembolism. Morb Mortal Wkly Rep. 2014;63(9):190-3.
16. Grosse SD, Nelson RE, Nyarko KA, Richardson LC, Raskob GE. The economic burden of incident venous thromboembolism in the United States: a review of estimated attributable healthcare costs. Thromb Res. 2016;137:3-10. doi:10.1016/j.thromres.2015.11.033
17. Edeer AD, Comez S, Damar HT, Savci A. Prevalence and risk factors of venous thromboembolism in postoperative patients: a retrospective study. Pak J Med Sci. 2018;34(6):1539-44. doi:10.12669/pjms.346.16021
18. Heit JA, Ashrani A, Crusan DJ, et al. Reasons for the persistent incidence of venous thromboembolism. Thromb Haemost. 2017;117(2):390-400. doi:10.1160/TH16-07-0509
19. Nicholson M, Chan N, Bhagirath V, Ginsberg J. Prevention of venous thromboembolism in 2020 and beyond. J Clin Med. 2020;9(8):2467. doi:10.3390/jcm9082467
20. Henke PK, Kahn SR, Pannucci CJ, et al. Call to action to prevent venous thromboembolism in hospitalized patients: a policy statement from the American Heart Association. Circulation. 2020;141(24):e914-e931. doi:10.1161/CIR.0000000000000769. Erratum in: Circulation. 2021;143(7):e249.
21. Lau BD, Shaffer DL, Hobson DB, et al. Effectiveness of two distinct web-based education tools for bedside nurses on medication administration practice for venous thromboembolism prevention: a randomized clinical trial. PLoS One. 2017;12(8):e0181664. doi:10.1371/journal.pone.0181664
22. Owodunni OP, Lau BD, Shaffer DL, et al. Disseminating a patient-centered education bundle to reduce missed doses of pharmacologic venous thromboembolism (VTE) prophylaxis to a community hospital. J Patient Saf Risk Manag. 2021;26(1):22-8. doi:10.1177/2516043520969324
23. Haut ER, Aboagye JK, Shaffer DL, et al. Effect of real-time patient-centered education bundle on administration of venous thromboembolism prevention in hospitalized patients. JAMA Netw Open. 2018;1(7):e184741. doi:10.1001/jamanetworkopen.2018.4741
24. Centers for Medicare and Medicaid Services (CMS). CMS Measures Inventory Tool. Venous Thromboembolism Prophylaxis (eCQM). Accessed March 14, 2022. https://cmit.cms.gov/CMIT_public/ViewMeasure?MeasureId=5773
25. Thirukumaran CP, Glance LG, Rosenthal MB, et al. Impact of Medicare's nonpayment program on venous thromboembolism following hip and knee replacements. Health Serv Res. 2018;53(6):4381-402. doi:10.1111/1475-6773.13013
26. Haut ER, Lau BD, Kraus PS, et al. Preventability of hospital-acquired venous thromboembolism. JAMA Surg. 2015;150(9):912-5. doi:10.1001/jamasurg.2015.1340
27. Haut ER, Lau BD, Kraenzlin FS, et al. Improved prophylaxis and decreased rates of preventable harm with the use of a mandatory computerized clinical decision support tool for prophylaxis for venous thromboembolism in trauma. Arch Surg. 2012;147(10):901-7. doi:10.1001/archsurg.2012.2024
28. Lau BD, Arnaoutakis GJ, Streiff MB, et al. Individualized performance feedback to surgical residents improves appropriate venous thromboembolism prophylaxis prescription and reduces potentially preventable VTE: a prospective cohort study. Ann Surg. 2016;264(6):1181-7. doi:10.1097/SLA.0000000000001512