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Oct 2012, Vol 147, No. 10 >

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Original Article | Oct 2012

Improved Prophylaxis and Decreased Rates of Preventable Harm With the Use of a Mandatory Computerized Clinical Decision Support Tool for Prophylaxis for Venous Thromboembolism in Trauma

Elliott R. Haut, MD; Brandyn D. Lau, MPH; Franca S. Kraenzlin, MHS; Deborah B. Hobson, BSN; Peggy S. Kraus, PharmD, CACP; Howard T. Carolan, MPH, MBA; Adil H. Haider, MD, MPH; Christine G. Holzmueller, BLA; David T. Efron, MD; Peter J. Pronovost, MD, PhD; Michael B. Streiff, MD
Arch Surg. 2012;147(10):901-907. doi:10.1001/archsurg.2012.2024.
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Objective  Venous thromboembolism is associated with substantial morbidity and mortality and is largely preventable. Despite this fact, appropriate prophylaxis is vastly underutilized. To improve compliance with best practice prophylaxis for VTE in hospitalized trauma patients, we implemented a mandatory computerized provider order entry–based clinical decision support tool. The system required completion of checklists of VTE risk factors and contraindications to pharmacologic prophylaxis. With this tool, we were able to determine a patient's risk stratification level and recommend appropriate prophylaxis. To evaluate the effect of our mandatory computerized provider order entry–based clinical decision support tool on compliance with prophylaxis guidelines for venous thromboembolism (VTE) and VTE outcomes among admitted adult trauma patients.

Design  Retrospective cohort study (from January 2007 through December 2010).

Setting  University-based, state-designated level 1 adult trauma center.

Patients  A total of 1599 hospitalized adult trauma patients with a hospital length of stay greater than 1 day.

Main Outcome Measures  The primary outcome measure was the proportion of patients who were ordered risk-appropriate guideline-suggested VTE prophylaxis. The secondary outcome measure was the proportion of patients with any preventable VTE (defined as VTE in a patient not ordered guideline-appropriate VTE prophylaxis), pulmonary embolism, and/or deep vein thrombosis.

Results  Compliance with guideline-appropriate prophylaxis increased from 66.2% to 84.4% (P < .001). The rate of preventable harm from VTE decreased from 1.0% to 0.17% (P = .04).

Conclusions  Implementation of a mandatory computerized provider order entry–based clinical decision support tool significantly improved compliance with VTE prophylaxis guidelines in hospitalized adult trauma patients. This improved compliance was associated with a significant decrease in the rate of preventable harm, which was defined as VTE events in patients not ordered appropriate prophylaxis.
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Figure 1. Trends in venous thromboembolism (VTE) prophylaxis and events in hospitalized adult trauma patients. The quarterly compliance rates for prophylaxis orders during the baseline period (2007) and the postimplementation period (2008-2010), in which the mandatory computerized provider order entry–based clinical decision support module was implemented, are compared. Also shown is the downward trend in the annual proportion of patients with VTE events during the same time period. Q indicates quarter.

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Figure 2. Proportion of hospitalized adult trauma patients who received venous thromboembolism (VTE) prophylaxis. The proportion of hospitalized adult trauma patients who received pharmacologic prophylaxis (enoxaparin) are compared with the proportion of hospitalized adult trauma patients who received sequential compression devices (SCDs). The baseline period was 2007, and the postimplementation period was 2008, 2009, and 2010 (when the mandatory computerized provider order entry–based clinical decision support module was implemented).

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Figure 3. Compliance rates among hospitalized adult trauma patients, stratified by those with or without documented contraindications to pharmaceutical prophylaxis for venous thromboembolism. The baseline period was 2007, and the postimplementation period was 2008, 2009, and 2010, in which the mandatory computerized clinical decision support tool was used to increase compliance with prophylaxis ordering.

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