Impact of a venous thromboembolism prophylaxis "smart order set": Improved compliance, fewer events.

Venous thromboembolism (VTE) affects over 700,000 Americans annually. Prophylaxis reduces the risk of VTE by 60% but many patients still do not receive risk-appropriate VTE prophylaxis. To improve our institution's VTE prophylaxis performance, we developed mandatory computerized clinical decision support-enabled "smart order sets" that required providers to assess VTE risk factors and contraindications to pharmacologic prophylaxis. Using provider responses, the order set recommends evidence-based risk-appropriate VTE prophylaxis. To study the impact of our "smart order set" on prescription of risk-appropriate VTE prophylaxis and clinical outcomes, we conducted a retrospective chart review of consecutive patients admitted to the Medicine service during one month immediately prior to (November 2007) and a single month subsequent to (April 2010) order set launch. Data collection included patient demographics, VTE risk factors, and the use and type of VTE prophylaxis. The pre- and post-implementation cohorts contained 1,000 and 942 patients, respectively. After implementation of the "smart order set", the prescription of risk-appropriate VTE prophylaxis increased from 65.6% to 90.1% (P < 0.0001). Orders for any form of VTE prophylaxis increased from 76.4% to 95.6% (P < 0.0001). Radiographically documented symptomatic VTE within 90 days of hospital discharge declined from 2.5% to 0.7% (P = 0.002). Preventable harm was completely eliminated (1.1% to 0%, P = 0.001) with no difference in major bleeding or all-cause mortality. A VTE prophylaxis computerized clinical decision support-enabled "smart order set" improved prescription of risk-appropriate VTE prophylaxis, reduced symptomatic VTE and eliminated preventable harm from VTE without increasing major bleeding.

Prioritizing Health Care Solutions for Pressure Ulcers Using the Quality Function Deployment Process.

Reducing the incidence and morbidity of pressure ulcers remains a leading national priority in patient safety. However, the optimal strategy for a hospital or health system to address this safety goal is not straightforward given the number and complexity of available solutions. Leveraging techniques from systems engineering, such as the quality function deployment process, may provide a transparent and objective way to address this challenge. A detailed and practical application of quality function deployment is presented that demonstrates the value of applying engineering practices for prioritizing solutions for pressures ulcers specifically and can easily be adapted to other conditions.

Intensive care unit providers more quickly and accurately assess risk of multiple harms using an engineered safety display.

Project Emerge took a systems engineering approach to reduce avoidable harm in the intensive care unit. We developed a socio-technology solution to aggregate and display information relevant to preventable patient harm. We compared providers' efficiency and ability to assess and assimilate data associated with patient-safety practice compliance using the existing electronic health record to Emerge, and evaluated for speed, accuracy, and the number of mouse clicks required. When compared to the standard electronic health record, clinicians were faster (529 ± 210 s vs 1132 ± 344 s), required fewer mouse clicks (42.3 ± 15.3 vs 101.3 ± 33.9), and were more accurate (24.8 ± 2.7 of 28 correct vs 21.2 ± 2.9 of 28 correct) when using Emerge. All results were statistically significant at a p-value < 0.05 using Wilcoxon signed-rank test (n = 18). Emerge has the potential to make clinicians more productive and patients safer by reducing the time and errors when obtaining information to reduce preventable harm.

Use of provider-level dashboards and pay-for-performance in venous thromboembolism prophylaxis.

BACKGROUND: Despite safe and cost-effective venous thromboembolism (VTE) prevention measures, VTE prophylaxis rates are often suboptimal. Healthcare reform efforts emphasize transparency through programs to report performance and payment incentives through pay-for-performance programs. OBJECTIVE: To sequentially examine an individualized physician dashboard and pay-for-performance program to improve VTE prophylaxis rates among hospitalists. DESIGN: Retrospective analysis of 3144 inpatient admissions. After a baseline observation period, VTE prophylaxis compliance was compared during both interventions. SETTING: A 1060-bed tertiary care medical center. PARTICIPANTS: Thirty-eight part-time and full-time academic hospitalists. INTERVENTIONS: A Web-based hospitalist dashboard provided VTE prophylaxis feedback. After 6 months of feedback only, a pay-for-performance program was incorporated, with graduated payouts for compliance rates of 80% to 100%. MEASUREMENTS: Prescription of American College of Chest Physicians' guideline-compliant VTE prophylaxis and subsequent pay-for-performance payments. RESULTS: Monthly VTE prophylaxis compliance rates were 86% (95% confidence interval [CI]: 85-88), 90% (95% CI: 88-93), and 94% (95% CI: 93-96) during the baseline, dashboard, and combined dashboard/pay-for-performance periods, respectively. Compliance significantly improved with the use of the dashboard (P = 0.01) and addition of the pay-for-performance program (P = 0.01). The highest rate of improvement occurred with the dashboard (1.58%/month; P = 0.01). Annual individual physician performance payments ranged from $53 to $1244 (mean $633; standard deviation ±$350). CONCLUSIONS: Direct feedback using dashboards was associated with significantly improved compliance, with further improvement after incorporating an individual physician pay-for-performance program. Real-time dashboards and physician-level incentives may assist hospitals in achieving higher safety and quality benchmarks.

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

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.

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.

OBJECTIVE: Venous thromboembolism is associated with substantial morbidity and mortality and is largely preventable. Despite this fact, appropriate prophylaxis is vastly underutilized. To improve compliance with best practice prophylaxis for VTE in hospitalized trauma patients, we implemented a mandatory computerized provider order entry-based clinical decision support tool. The system required completion of checklists of VTE risk factors and contraindications to pharmacologic prophylaxis. With this tool, we were able to determine a patient's risk stratification level and recommend appropriate prophylaxis. To evaluate the effect of our mandatory computerized provider order entry-based clinical decision support tool on compliance with prophylaxis guidelines for venous thromboembolism (VTE) and VTE outcomes among admitted adult trauma patients. DESIGN: Retrospective cohort study (from January 2007 through December 2010). SETTING: University-based, state-designated level 1 adult trauma center. PATIENTS: A total of 1599 hospitalized adult trauma patients with a hospital length of stay greater than 1 day. MAIN OUTCOME MEASURES: The primary outcome measure was the proportion of patients who were ordered risk-appropriate guideline-suggested VTE prophylaxis. The secondary outcome measure was the proportion of patients with any preventable VTE (defined as VTE in a patient not ordered guideline-appropriate VTE prophylaxis), pulmonary embolism, and/or deep vein thrombosis. RESULTS: Compliance with guideline-appropriate prophylaxis increased from 66.2% to 84.4% (P < .001). The rate of preventable harm from VTE decreased from 1.0% to 0.17% (P = .04). CONCLUSIONS: Implementation of a mandatory computerized provider order entry-based clinical decision support tool significantly improved compliance with VTE prophylaxis guidelines in hospitalized adult trauma patients. This improved compliance was associated with a significant decrease in the rate of preventable harm, which was defined as VTE events in patients not ordered appropriate prophylaxis.