Hospital-associated venous thromboembolism (HA-VTE) is a common source of morbidity and mortality. While VTE sometimes occurs despite the best available prophylaxis, there are many lost opportunities to optimize prophylaxis and reduce VTE risk factors in virtually every hospital. This guide targets these failure modes in the process of preventing VTE in the inpatient setting and provides improvement teams with field-tested strategies and tools to enhance their chances of success.
Several essential elements are needed to achieve meaningful improvement in VTE prevention. These include an empowered, interdisciplinary team, supported by the institution, to standardize processes, monitor and measure VTE processes and outcomes, implement institutional policies, and educate providers and patients.
Guidelines for VTE prevention are numerous and do not always agree, and the complexity of the inpatient setting and the variability of patients make implementation of evidence-based guidelines challenging. This implementation guide reviews several guidelines, with a particular focus on the implications for implementation; it then breaks down the steps to translate these guidelines into practice in the form of a VTE prevention protocol.
A VTE prevention protocol includes a VTE risk assessment, a bleeding risk assessment, and clinical decision support (CDS) on prophylactic choices based on the combination of VTE and bleeding risk factors. The VTE protocol CDS must be available at crucial junctures of care, such as at admission to the hospital, at transfer to different levels of care, and postoperatively. This VTE protocol guidance is most often embedded in order sets that are commonly used (or mandated for use) in these settings, essentially hard wiring the VTE risk assessment into the process.
Risk assessment is essential, as there are harms, costs, and discomfort associated with prophylactic methods; for some inpatients, the risk of anticoagulant prophylaxis may outweigh the risk of HA-VTE. There is no perfect VTE risk assessment tool. This guide outlines strengths and limitations of the different models and discusses the inherent tension between the desire to provide comprehensive, detailed guidance and the need to keep the process simple to understand and measure.
This guide also discusses principles for effective implementation of reliable interventions, including simple to advanced models. Order sets with CDS are of no use if they are not used correctly and reliably, so monitoring this process is crucial. No matter which VTE risk assessment model is used, it is usually more effectively implemented if every effort is made to enhance ease of use for the ordering provider. This may include "carving out" special populations for modified VTE risk assessment and order sets, which allows streamlining and simplification of the VTE prevention order sets for the general medical and surgical population.
Successful integration of a VTE prevention protocol into heavily used admission and transfer order sets serves as a foundational beginning point for VTE prevention efforts. Throughout this guide, multiple failure modes are described, as are strategies to address potential lapses in care.
Publicly reported measures and CMS Core Measures set a relatively low bar for performance and are inadequate to drive breakthrough levels of improvement. Teams may wish to assess the adequacy of VTE prophylaxis not only on admission or transfer to the ICU, but also across the hospital stay. Month-to-month reporting is important to follow overall progress. But the team can also identify at least some measures that can drive concurrent intervention to address deficits in prophylaxis in real time. This method of active surveillance (aka measure-vention) is described in this guide along with other suggested methods for measuring HA-VTE outcomes, VTE prophylaxis rates, and other parameters (e.g., adherence to prescribed prophylaxis).
This guide outlines a comprehensive, interdisciplinary approach to optimizing inpatient VTE prevention, and the techniques described are designed to be portable to a wide variety of inpatient settings. We emphasize optimizing the EHR for standardization of order sets and integration of measurement systems in documentation and orders, which is a key strategy for dissemination within hospital systems.