Alert-Triggered Patient Education Versus Nurse Feedback for Nonadministered Venous Thromboembolism Prophylaxis Doses: A Cluster-Randomized Controlled Trial

Abstract

Background Many hospitalized patients are not administered prescribed doses of pharmacologic venous thromboembolism prophylaxis. Methods and Results In this cluster-randomized controlled trial, all adult non-intensive care units (10 medical, 6 surgical) in 1 academic hospital were randomized to either a real-time, electronic alert-triggered, patient-centered education bundle intervention or nurse feedback intervention to evaluate their effectiveness for reducing nonadministration of venous thromboembolism prophylaxis. Primary outcome was the proportion of nonadministered doses of prescribed pharmacologic prophylaxis. Secondary outcomes were proportions of nonadministered doses stratified by nonadministration reasons (patient refusal, other). To test our primary hypothesis that both interventions would reduce nonadministration, we compared outcomes pre- versus postintervention within each cohort. Secondary hypotheses were tested comparing the effectiveness between cohorts. Of 11 098 patient visits, overall dose nonadministration declined significantly after the interventions (13.4% versus 9.2%; odds ratio [OR], 0.64 [95% CI, 0.57-0.71]). Nonadministration decreased significantly (P<0.001) in both arms: patient-centered education bundle, 12.2% versus 7.4% (OR, 0.56 [95% CI, 0.48-0.66]), and nurse feedback, 14.7% versus 11.2% (OR, 0.72 [95% CI, 0.62-0.84]). Patient refusal decreased significantly in both arms: patient-centered education bundle, 7.3% versus 3.7% (OR, 0.46 [95% CI, 0.37-0.58]), and nurse feedback, 9.5% versus 7.1% (OR, 0.71 [95% CI, 0.59-0.86]). No differential effect occurred on medical versus surgical units. The patient-centered education bundle was significantly more effective in reducing all nonadministered (P=0.03) and refused doses (P=0.003) compared with nurse feedback (OR, 1.28 [95% CI, 1.0-1.61]; P=0.03 for interaction). Conclusions Information technology strategies like the alert-triggered, targeted patient-centered education bundle, and nurse-focused audit and feedback can improve venous thromboembolism prophylaxis administration. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03367364.

Keywords: deep vein thrombosis; patient‐centered care; prophylaxis; pulmonary embolism; randomized trial; venous thromboembolism.

Figures

Figure 1. Consolidated Standards of Reporting Trials (CONSORT) flow diagram of hospital units receiving the patient‐centered education bundle vs nurse feedback interventions.

Patient visits reflect patients with prescribed pharmacologic venous thromboembolism (VTE) prophylaxis doses during 1 hospital encounter. In the patient‐centered education bundle arm, a nonadministered prophylaxis dose triggers an alert leading to the delivery of the patient‐centered education bundle intervention. The patient‐centered education bundle is only delivered once to patients. Nurse leaders in the nurse feedback arm received monthly scorecards detailing VTE prophylaxis administration practices by individual nurse.

Figure 2. Time series analysis for all units (A) of the patient‐centered education bundle and nurse feedback arms stratified by surgery (B) and medicine (C) hospital units.

This trend analysis reflects the monthly data for nonadministered doses of venous thromboembolism (VTE) prophylaxis in the preintervention (July 1, 2017 to December 31, 2017) and postintervention (February 1, 2018 to April 30, 2018) periods, comparing both intervention arms. Data for January 2018 were excluded (washout period). Our findings show that no changes are evident before the postimplementation period.