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. 2012 Jun 19:344:e3935.
doi: 10.1136/bmj.e3935.

Lessons from the Johns Hopkins Multi-Disciplinary Venous Thromboembolism (VTE) Prevention Collaborative

Michael B Streiff  1 , Howard T Carolan, Deborah B Hobson, Peggy S Kraus, Christine G Holzmueller, Renee Demski, Brandyn D Lau, Paula Biscup-Horn, Peter J Pronovost, Elliott R Haut
Affiliations

Lessons from the Johns Hopkins Multi-Disciplinary Venous Thromboembolism (VTE) Prevention Collaborative

Michael B Streiff et al. BMJ. .

Abstract

Problem: Venous thromboembolism (VTE) is a common cause of potentially preventable mortality, morbidity, and increased medical costs. Risk-appropriate prophylaxis can prevent most VTE events, but only a small fraction of patients at risk receive this treatment.

Design: Prospective quality improvement programme.

Setting: Johns Hopkins Hospital, Baltimore, Maryland, USA.

Strategies for change: A multidisciplinary team established a VTE Prevention Collaborative in 2005. The collaborative applied the four step TRIP (translating research into practice) model to develop and implement a mandatory clinical decision support tool for VTE risk stratification and risk-appropriate VTE prophylaxis for all hospitalised adult patients. Initially, paper based VTE order sets were implemented, which were then converted into 16 specialty-specific, mandatory, computerised, clinical decision support modules.

Key measures for improvement: VTE risk stratification within 24 hours of hospital admission and provision of risk-appropriate, evidence based VTE prophylaxis.

Effects of change: The VTE team was able to increase VTE risk assessment and ordering of risk-appropriate prophylaxis with paper based order sets to a limited extent, but achieved higher compliance with a computerised clinical decision support tool and the data feedback which it enabled. Risk-appropriate VTE prophylaxis increased from 26% to 80% for surgical patients and from 25% to 92% for medical patients in 2011.

Lessons learnt: A computerised clinical decision support tool can increase VTE risk stratification and risk-appropriate VTE prophylaxis among hospitalised adult patients admitted to a large urban academic medical centre. It is important to ensure the tool is part of the clinician's normal workflow, is mandatory (computerised forcing function), and offers the requisite modules needed for every clinical specialty.

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Conflict of interest statement

All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: apart from the disclosures listed below, no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Disclosures: MBS has received research funding from Sanofi-Aventis and BristolMyersSquibb; honoraria for CME lectures from Sanofi-Aventis and Ortho-McNeil; consulted for Sanofi-Aventis, Eisai, Daiichi-Sankyo, and Janssen HealthCare; and has given expert witness testimony in various medical malpractice cases. DBH has given expert witness testimony in various medical malpractice cases. ERH is the primary investigator of a Mentored Clinical Scientist Development Award from the Agency for Healthcare Research and Quality entitled “Does screening variability make DVT an unreliable quality measure of trauma care?”; receives royalties from Lippincott Williams & Wilkins for the book Avoiding Common ICU Errors; and has given expert witness testimony in various medical malpractice cases. PJP receives consultancy fees from the Association for Professionals in Infection Control and Epidemiology; grant or contract support from the Agency for Healthcare Research and Quality, National Institutes of Health, Robert Wood Johnson Foundation, and the Commonwealth Fund; honoraria from various hospitals and the Leigh Bureau (Somerville NJ); and royalties from his book Safe Patients Smart Hospitals. CGH has received a honorarium from MCIC Vermont to speak about organising and writing a manuscript reporting patient safety or quality improvement research.

Figures

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Fig 1 Changes in venous thromboembolism (VTE) risk assessment for medical and surgical inpatients at key points in the implementation of a clinical decision support tool for VTE risk stratification
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Fig 2 Changes in venous thromboembolism (VTE) risk assessment for medical and surgical inpatients since implementation of a computerised clinical decision support tool for VTE risk stratification
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