Skip to main content

Advertisement

SpringerLink
Log in

Bridging the Gap Between Evidence and Practice in Venous Thromboembolism Prophylaxis: The Quality Improvement Process

  • Clinical Review
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

Venous thromboembolism (VTE) is considered to be the most common preventable cause of hospital-related death. Hospitalized patients undergoing major Surgery and hospitalized patients with acute medical illness have an increased risk of VTE. Although there is overwhelming evidence for the need and efficacy of VTE prophylaxis in patients at risk, only about a third of those who are at risk of VTE receive appropriate prophylaxis. To address the shortfall in VTE prophylaxis, the US Joint Commission and the National Quality Forum (NQF) endorse standardized VTE prophylaxis practices, and are identifying and testing measures to monitor these standards. Hospitals in the USA accredited by Centers for Medicare and Medicaid Services to receive medicare patients will need VTE prophylaxis programs in place to conform to these national consensus standards. This review aims to give background information on initiatives to improve the prevention of VTE and to identify key features of a successful quality improvement strategy for prevention of VTE in the hospital. A literature review shows that the key features of effective quality improvement strategies includes an active strategy, a multifaceted approach, and a continuous iterative process of audit and feedback. Risk assessment models may be helpful for deciding which patients should receive prophylaxis and for matching VTE risk with the appropriate intensity of prophylaxis. This approach should assist in implementing the NQF/Joint Commission-endorsed standards, as well as increase the use of appropriate VTE prophylaxis.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Figure 1
Figure 2
Figure 3

Similar content being viewed by others

References

  1. Heit JA, Cohen AT, Anderson Jr FA, et al. On behalf of the VTE impact assessment group. Estimated annual number of incident and recurrent, non-fatal and fatal venous thromboembolism (VTE) events in the US. Blood. (ASH Annual Meeting Abstracts) 2005;106:Abstract 910.

  2. MacDougall DA, Feliu AL, Boccuzzi SJ, Lin J. Economic burden of deep-vein thrombosis, pulmonary embolism, and post-thrombotic syndrome. Am J Health Syst Pharm. 2006;63(20 Suppl 6):S5–S15.

    Article  PubMed  Google Scholar 

  3. Alikhan R, Cohen AT, Combe S, et al. Risk factors for venous thromboembolism in hospitalized patients with acute medical illness: analysis of the MEDENOX Study. Arch Intern Med. 2004;164:963–968.

    Article  PubMed  Google Scholar 

  4. Samama MM. An epidemiologic study of risk factors for deep vein thrombosis in medical outpatients: the Sirius study. Arch Intern Med. 2000;160:3415–20.

    Article  PubMed  CAS  Google Scholar 

  5. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(3 Suppl):338S–400S.

    Article  PubMed  CAS  Google Scholar 

  6. Joint Commission. Performance measurement initiatives - national consensus standards for prevention and care of venous thromboembolism (VTE) - Last updated 3/5/07. Available at: http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/VTE.htm Accessed July 11, 2007.

  7. Anderson Jr FA, Zayaruzny M, Heit JA, Cohen AT. On behalf of the VTE impact assessment group. Estimated annual number of US acute-care hospital inpatients meeting ACCP criteria for venous thromboembolism (VTE) prophylaxis. Blood. (ASH Annual Meeting Abstracts) 2005;106:Abstract 903.

  8. Tooher R, Middleton P, Pham C, et al. A systematic review of strategies to improve prophylaxis for venous thromboembolism in hospitals. Ann Surg. 2005;241:397–415.

    Article  PubMed  Google Scholar 

  9. Burleigh E, Wang C, Foster D, et al. Thromboprophylaxis in medically ill patients at risk for venous thromboembolism. Am J Health Syst Pharm. 2006;63(20 Suppl 6):S23–S29.

    Article  PubMed  Google Scholar 

  10. University of California at San Francisco (UCSF)-Stanford University evidence-based practice center. Evidence report/technology assessment no. 43. Making health care safer: A critical analysis of patient safety practices. July 20, 2001. Available at: http://www.ahrq.gov/clinic/ptsafety/pdf/ptsafety.pdf. Accessed March 27, 2007.

  11. Shojania KG, Grimshaw JM. Evidence-based quality improvement: the state of the science. Health Aff (Millwood). 2005;24:138–50.

    Article  Google Scholar 

  12. Grimshaw JM, Thomas RE, MacLennan G, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004;8:1–72.

    Google Scholar 

  13. Grupper A, Grupper A, Rudin D, et al. Prevention of perioperative venous thromboembolism and coronary events: differential responsiveness to an intervention program to improve guidelines adherence. Int J Qual Health Care. 2006;18:123–126.

    Article  PubMed  CAS  Google Scholar 

  14. Colorado Foundation for Medical Care. Surgical Care Improvement Project (SCIP). Available at: http://www.cfmc.org/hospital/hospital_scip.htm. Accessed March 27, 2007.

  15. Agency for Healthcare Research and Quality. 30 Safe practices for better health care. March 2005. Available at: http://www.ahrq.gov/qual/30safe.pdf. Accessed March 27, 2007.

  16. The National Quality Forum. National quality forum endorses consensus standards for prevention and care of venous thromboembolism. May 18, 2006. Available at: http://216.122.138.39/pdf/news/DVT5-18-06.pdf. Accessed March 27, 2007.

  17. Bratzler DW, Raskob GE, Murray CK, Bumpus LJ, Piatt DS. Underuse of venous thromboembolism prophylaxis for general surgery patients: physician practices in the community hospital setting. Arch Intern Med. 1998;158:1909–12.

    Article  PubMed  CAS  Google Scholar 

  18. Ahmad HA, Geissler A, MacLellan DG. Deep venous thrombosis prophylaxis: are guidelines being followed? ANZ J Surg. 2002;72:331–334.

    Article  PubMed  Google Scholar 

  19. Rashid ST, Thursz MR, Razvi NA, et al. Venous thromboprophylaxis in UK medical inpatients. J R Soc Med. 2005;98:507–12.

    Article  PubMed  CAS  Google Scholar 

  20. Peterson GM, Drake CI, Jupe DM, Vial JH, Wilkinson S. Educational campaign to improve the prevention of postoperative venous thromboembolism. J Clin Pharm Ther. 1999;24:279–87.

    Article  PubMed  CAS  Google Scholar 

  21. McEleny P, Bowie P, Robins JB, Brown RC. Getting a validated guideline into local practice: implementation and audit of the SIGN guideline on the prevention of deep vein thrombosis in a district general hospital. Scott Med J. 1998;43:23–5.

    PubMed  CAS  Google Scholar 

  22. Schumock GT, Blackburn JC, Nutescu EA, Walton SM, Finley JM, Lewis RK. Impact of prescribing guidelines for inpatient anticoagulation. Ann Pharmacother. 2004;38:1570–5.

    Article  PubMed  Google Scholar 

  23. Kucher N, Koo S, Quiroz R, et al. Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med. 2005;352:969–77.

    Article  PubMed  CAS  Google Scholar 

  24. Mosen D, Elliott CG, Egger MJ, et al. The effect of a computerized reminder system on the prevention of postoperative venous thromboembolism. Chest. 2004;125:1635–41.

    Article  PubMed  Google Scholar 

  25. Khan R, Byrne P. Audit of thromboprophylaxis in women undergoing caesarean section. Ir Med J. 2004;97:72–4.

    PubMed  CAS  Google Scholar 

  26. Stinnett JM, Pendleton R, Skordos L, Wheeler M, Rodgers GM. Venous thromboembolism prophylaxis in medically ill patients and the development of strategies to improve prophylaxis rates. Am J Hematol. 2005;78:167–72.

    Article  PubMed  Google Scholar 

  27. Cohn SL, Adekile A, Mahabir V. Improved use of thromboprophylaxis for deep vein thrombosis following an educational intervention. J Hosp Med. 2006;1:331–8.

    Article  PubMed  Google Scholar 

  28. Dobesh PP, Stacy ZA. Effect of a clinical pharmacy education program on improvement in the quantity and quality of venous thromboembolism prophylaxis for medically ill patients. J Manag Care Pharm. 2005;11:755–62.

    PubMed  Google Scholar 

  29. Ruttimann S, Danner M, Glaser MG. Explicit versus implicit risk assessment for the indication of antithrombotic prophylaxis in acutely ill medical in-patients. Swiss Med Wkly. 2005;135:228–34.

    PubMed  Google Scholar 

  30. Labarere J, Bosson JL, Brion JP, et al. Validation of a clinical guideline on prevention of venous thromboembolism in medical inpatients: a before-and-after study with systematic ultrasound examination. J Intern Med. 2004;256:338–48.

    Article  PubMed  CAS  Google Scholar 

  31. Byrne GJ, McCarthy MJ, Silverman SH. Improving uptake of prophylaxis for venous thromboembolism in general surgical patients using prospective audit. BMJ. 1996;313:917.

    PubMed  CAS  Google Scholar 

  32. McCarthy MJ, Byrne G, Silverman SH. The setting up and implementation of a venous thromboembolism prophylaxis policy in clinical hospital practice. J Eval Clin Pract. 1998;4:113–7.

    PubMed  CAS  Google Scholar 

  33. Durieux P, Nizard R, Ravaud P, Mounier N, Lepage E. A clinical decision support system for prevention of venous thromboembolism: effect on physician behavior. JAMA. 2000;283:2816–21.

    Article  PubMed  CAS  Google Scholar 

  34. Caprini JA, Arcelus JI, Reyna JJ. Effective risk stratification of surgical and nonsurgical patients for venous thromboembolic disease. Semin Hematol. 2001;38(2 Suppl 5):12–9.

    Article  PubMed  CAS  Google Scholar 

  35. Cohen AT, Alikhan R, Arcelus JI, et al. Assessment of venous thromboembolism risk and the benefit of thromboprophylaxis in medical patients. Thromb Haemost. 2005;94:750–9.

    PubMed  Google Scholar 

  36. Cardiovascular Disease Educational and Research Trust; Cyprus Cardiovascular Disease Educational and Research Trust; European Venous Forum; International Surgical Thrombosis Forum; International Union of Angiology; Union Internationale de Phlebologie. Prevention and treatment of venous thromboembolism. International consensus statement (guidelines according to scientific evidence). Int Angiol. 2006;25:101–61.

    Google Scholar 

  37. Goldhaber SZ, Tapson VF. DVT FREE steering committee. A prospective registry of 5,451 patients with ultrasound-confirmed deep vein thrombosis. Am J Cardiol. 2004;93:259–62.

    Article  PubMed  Google Scholar 

  38. Chopard P, Dorffler-Melly J, Hess U, et al. Venous thromboembolism prophylaxis in acutely ill medical patients: definite need for improvement. J Intern Med. 2005;257:352–7.

    Article  PubMed  CAS  Google Scholar 

  39. Ageno W, Squizzato A, Ambrosini F, et al. Thrombosis prophylaxis in medical patients: a retrospective review of clinical practice patterns. Haematologica. 2002;87:746–50.

    PubMed  Google Scholar 

  40. Duggirala AV, Chen FM, Gergen PJ. Postoperative adverse events in teaching and nonteaching hospitals. Fam Med. 2004;36:508–13.

    PubMed  Google Scholar 

Download references

Acknowledgments

The author received writing/editorial support in the preparation of this manuscript, funded by Sanofi-Aventis, NJ, USA. Hester van Lier, PhD provided writing/editorial support.

Potential conflicts of interest

Dr Michota has acted as a consultant for Sanofi-Aventis, Takeda Pharmaceuticals, GlaxoSmithKline, Bacchus Vascular, Inc., and AstraZeneca.

Author information

Authors and Affiliations

  1. Section of Hospital Medicine, Department of General Internal Medicine, Cleveland Clinic, S70/9500 Euclid, Avenue, Cleveland, OH, 44195, USA

    Franklin A. Michota MD

Authors
  1. Franklin A. Michota MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Franklin A. Michota MD.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Michota, F.A. Bridging the Gap Between Evidence and Practice in Venous Thromboembolism Prophylaxis: The Quality Improvement Process. J GEN INTERN MED 22, 1762–1770 (2007). https://doi.org/10.1007/s11606-007-0369-z

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11606-007-0369-z

KEY WORDS

Search

Navigation