ELECTRONIC REPORTING TO ASSESS AND IMPROVE VENOUS THROMBOEMBOLISM PROPHYLAXIS

Purpose: Venous thromboembolism (VTE) causes substantial morbidity and mortality among hospitalized patients.   Fortunately, VTE risk is reduced with prophylaxis.   Prior work demonstrates increased ordering of VTE prophylaxis by using computerized physician order entry (CPOE) to facilitate electronic alerts and order sets.  However, 2012 data indicates only 30.0% of US hospitals have CPOE.  Furthermore, CPOE affects ordering, but not order execution. We leveraged electronic reporting in a pre and post-CPOE setting to monitor both VTE prophylaxis ordering and order execution.

Methods: The pre-intervention VTE prophylaxis surveillance process at our large hospital was for patients' nurses to review each chart and electronic medication administration record, and to address deficiencies.  The necessary information to review usually resides in pharmacy information systems, electronic clinical nursing documentation, and electronic order transmittal systems.  These resources are often present even in the 70.0% of hospitals lacking CPOE.  We used these resources to automate an electronic report for daily delivery to nurses.  The report includes all patients eligible for VTE prophylaxis, as defined by TJC's VTE-1 and VTE-2 quality indicators, and patients' associated VTE prophylaxis order, order execution, and contraindication records.  We compared rates of appropriate VTE prophylaxis order execution for patients admitted 20 days before and after report implementation and subsequent CPOE implementation.  To classify VTE prophylaxis deficiencies as ordering deficiencies versus order execution deficiencies, we accessed a random sample of 258 eligible patient charts from these time periods that had been previously manually reviewed for quality reporting.  The report could not perform this classification due to manual exclusions for low-risk patients.

Results: Compared with eligible patients admitted during the 20 days before report implementation, patients admitted during the 20 days afterwards had 1.6 times (95% CI 1.3 – 1.9) higher odds of VTE prophylaxis order execution.  Subsequent implementation of CPOE with voluntary use of order sets that guided physicians to order VTE prophylaxis was associated with 1.8 times (95% CI 1.5 – 2.3) higher odds of VTE prophylaxis order execution.  The random sample lacked sufficient statistical power, but suggested that the report might have improved order execution.

Conclusions: An electronic report increased odds of appropriate VTE prophylaxis order execution about as much as subsequent CPOE with order sets.  Achieving very high quality requires assessing not just ordering, but also order execution.