Venous thromboembolism prophylaxis: a path toward more appropriate use.

To cite: Grant PJ, Flanders SA. BMJ Qual Saf Published Online First: [please include Day Month Year] doi:10.1136/bmjqs-2015004612 Hospital-acquired venous thromboembolism (VTE) is a leading cause of preventable death in hospitalised patients and its prevention with pharmacological prophylaxis has been rated a top patient safety practice. Furthermore, the rate at which VTE prophylaxis is administered to ‘at-risk’ patients along with the rate of ‘potentially preventable’ VTE events are national performance measures for US hospitals. As a result, many hospitals have spent considerable time and effort implementing processes designed to increase rates of VTE prophylaxis. Missed doses due to patient refusal of VTE prophylaxis is a commonly encountered barrier. Strategies to minimise anticoagulant refusal in patients who would otherwise benefit from prophylaxis are needed. Baillie et al describe a multifaceted approach designed to increase adherence to pharmacological VTE prophylaxis in hospitalised patients. By standardising the nursing response to patient refusal of heparin injections (which included a strong focus on patient education), assessing successful administration of VTE prophylaxis on a daily basis via a multidisciplinary rounding checklist, and receiving regular feedback on patient refusal rates, the authors were able to demonstrate a reduction in missed doses in over 20 000 patient admissions to medical and oncology units. Much of the improvement was due to reductions in patient refusal. The fact that the reduction in missed doses was not seen in several units serving as the control group further supports the effectiveness of the intervention. As the authors highlight, which aspects of the multifaceted intervention primarily influenced the improvement remains unknown. For example, the intervention’s nursing response to patient refusal included offering low molecular weight heparin (LMWH) as an alternative to unfractionated heparin (LMWH requires fewer injections but is not the default due to higher costs). The post-intervention cohort saw a fivefold increase in the use of LMWH, which likely contributed to the significant drop in the percentage of patients missing any dose. However, there was also an increase in administered prophylaxis doses (as a percentage of the total hospital stay) to patients who initially refused, suggesting the benefit did not solely come from increased LMWH use. The patient education efforts probably also contributed to the improvement. Although the authors successfully improved adherence to orders for VTE prophylaxis, the study had insufficient power to detect a difference in hospital-acquired VTE event rates. We are thus left without a clear understanding of the intervention’s impact on patient outcomes. But are improved clinical outcomes necessary to demonstrate that this intervention benefited patients? One might argue that decreasing rates of refusal and increasing prophylaxis rates for all hospitalised patients is good enough. We are not so sure. Many thought leaders argue that the vast majority of hospitalised patients have significant risk factors for VTE. Since large randomised controlled trials have shown a profound reduction in deep vein thrombosis (DVT) and pulmonary embolism (PE) events (albeit including asymptomatic events in highly selected patient populations), experts increasingly advocated for the implementation of widespread prophylaxis strategies for almost all hospitalised patients. In recent years, however, we have learned that the observed rate of symptomatic VTE in hospitalised medical patients is actually much lower than previously suggested, varying between 0.4% and 1.0% in several series. 8 Our own work with the EDITORIAL