Venous Thromboembolism (VTE) is responsible for significant hospital related morbidity and mortality, with 5–10% of hospital related mortality directly attributable to VTE. Despite the evidence supporting VTE prophylaxis, rates of prophylaxis vary between institutions and initiatives to improve prophylaxis are required. A baseline one-day audit was held at our institution to determine the rate of compliance with internal VTE prophylaxis clinical practice guidelines. The audit revealed an 85% compliance rate in eligible patients.
The emergency department stood our as having a 76% rate of appropriate VTE prophylaxis during the audit. Targeting prophylaxis rates in the emergency department had the potential to increase the overall rates for the hospital if appropriate VTE prophylaxis could be initiated prior to transfer to in-patient care units, it would likely be continued.
A comprehensive plan was put in place to improve VTE prophylaxis rates, which included targeted education, feedback to prescribers and the novel use of pharmacy student resources to increase the rates of VTE prophylaxis at a community hospital. Patients who were not receiving any anticoagulant medication were identified using the hospital information system. Pharmacy students were trained to assess patients for indications for VTE prophylaxis and they assessed all patients not receiving an anticoagulant admitted to the emergency department from Monday to Friday.
When students identified a patient who was not receiving prophylaxis who met the criteria for prophylaxis, they reviewed their findings with the emergency department clinical pharmacist to ensure their assessment was accurate given their status as students. If the pharmacist agreed, the students were authorized to make a recommendation to the physician to start VTE prophylaxis. Recommendations included both pharmacological and mechanical prophylaxis options, depending on patient bleeding risk.
During the first 60 days of the program, 247 patients were assessed by the students for prophylaxis, taking approximately 20 minutes each or 2.5 hours of student time per day. The pharmacy students made 64 recommendations for prophylaxis and 66% of the recommendations were accepted by the emergency room physicians with another 5% resulting in patients receiving a different mode of prophylaxis than recommended by the student (usually receiving pharmacological prophylaxis due to a change in bleeding risk).
There were 794 patients admitted in the emergency department during the initial assessment of the program. Of the 794, 247 patients were assessed by the pharmacy students, who identified patients where prophylaxis was indicated for a rate of a “miss” for VTE prophylaxis in a patient where it was indicated of 8.06% prior to assessment by the student and 2.77% after assessment and recommendations, a 5.3% absolute increase in the rate of appropriate prophylaxis. While the number of patients admitted in the emergency department during the evaluation phase did not decrease, there was a decrease of the number of patients assessed per day by the students from 11 during the first ten days to 7 during the last ten days of the evaluation period. This 36% decrease in the number of patients identified as not receiving prophylaxis was likely multifactorial, and potentially attributed to targeted education, a physician champion who encouraged increased use of the admission pre-printed orders and an increased awareness of VTE prophylaxis due to pharmacy student recommendations.
A post-implementation one-day audit was held to determine rates of appropriate VTE prophylaxis in the institution after the pharmacy student program and targeted education were implemented. The rate of appropriate VTE prophylaxis had risen in just 5 months to 97% of hospitalized patients who were eligible to receive prophylaxis were receiving prophylaxis, an 11% increase in the absolute rate of appropriate VTE prophylaxis according to the hospital clinical practice guideline criteria.
The program continues beyond the initial pilot phase due to the excellent results. The use of pharmacy students, available year-round from a co-op program is an innovative, sustainable and cost-effective means to improve hospital rates of VTE prophylaxis to achieve goals of improved patient care.
No relevant conflicts of interest to declare.
Asterisk with author names denotes non-ASH members.