Computerised checklist offers best preventive strategy for venous thromboembolism

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A computerised checklist system designed to help physicians identify and use the best methods of preventing potentially venous thromboembolism (VTE) in hospitalised trauma patients dramatically reduced the number of these dangerous VTEs, according to researchers from the Johns Hopkins University School of Medicine, Baltimore, USA.

When a doctor enters medical orders for such patients, the automated checklist recommends evidence-based best treatments for each patient’s needs, usually the regular administration of low-dose blood thinners or the use of compression devices. The researchers say this new system worked far better than previous methods, which included handing out laminated cards outlining best practices or lectures presented on the topic of preventing VTE.

The research team found a nearly two-fold improvement in prophylaxis orders among patients who had no contraindications to receiving the low-dose blood thinners.

While the rate of pulmonary emboli (PE) events, stayed steady throughout study period, the researchers found the rate of deep vein thrombosis (DVT) in legs dropped nearly 90%, from 2.26% of trauma patients to 0.25% of trauma patients in the final year of the study. Though the size of the study was small, Haut and his team say the research shows that getting doctors to order the correct treatment is a key to reducing this major type of preventable harm to patients.

“VTE hits all segments of the population,” said Elliott R Haut, an associate professor of surgery at the Johns Hopkins University School of Medicine, and leader of the study described in the October issue of Archives of Surgery. “All hospitalised patients are at risk for this complication, and a huge number of these deadly clots are preventable if we give patients the right prophylaxis. We tried education alone for years and still only 40 to 60% of patients were getting optimal treatment. With this computerised system, we have made great strides toward making sure every patient gets exactly what he or she needs.”

As part of the study, Johns Hopkins computer programmers added a checklist for appropriate VTE prophylaxis to the hospital’s computerised health records system. After information is input about the patient’s case, the computer suggests appropriate treatment for prevention. Doctors can still override the system if they choose.

Before the checklist was put in place in January 2008, records show that physicians at the Johns Hopkins Hospital offered the best prophylaxis to two-thirds of trauma patients, the researchers said. During the four-year implementation of the programme, they found, 85% of the 1,599 trauma patients in the study received appropriate prophylaxis.

“It is a huge jump in doing right for patients,” Haut said, but the goal is 100%.

Trauma patients are at a particularly high risk of developing DVT or PE, as risk factors for VTE include major surgery and extreme injury, especially to the spinal cord.

Haut said that many hospitals―including Johns Hopkins―have in recent years been giving nearly all of their patients some sort of prophylaxis for VTE. But the problem, he said, is that patients do not always get as much treatment as they need and, in many cases, evidence-based best practices are not being followed.

Many hospitals say they give nearly all of their patients some type of VTE prophylaxis and that is true Haut said, but they often fail to give all that is necessary to prevent blood clots.

“The computerised tool makes ordering the right thing really easy,” said Haut, a trauma surgeon on the core faculty of the Johns Hopkins Armstrong Institute for Patient Safety.

Haut said he understands that not every hospital has electronic health records up and running, but said the expense of adding the VTE checklist to existing electronic systems is minimal now that Hopkins has designed the program.

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