Patterns of non-administration of ordered doses of venous thromboembolism prophylaxis: implications for novel intervention strategies

Abstract

Background: Recent studies have documented high rates of non-administration of ordered venous thromboembolism (VTE) prophylaxis doses. Intervention strategies that target all patients have been effective, but prohibitively resource-intensive. We aimed to identify efficient intervention strategies based on patterns of non-administration of ordered VTE prophylaxis.

Methods and findings: In this retrospective review of electronic medication administration records, we included adult hospitalized patients who were ordered pharmacologic VTE prophylaxis with unfractionated heparin or enoxaparin over a seven-month period. The primary measure was the proportion of ordered doses of VTE prophylaxis not administered, assessed at the patient, floor, and floor type levels. Differences in non-administration rates between groups were assessed using generalized estimating equations. A total of 103,160 ordered VTE prophylaxis doses during 10,516 patient visits on twenty-nine patient floors were analyzed. Overall, 11.9% of ordered doses were not administered. Approximately 19% of patients missed at least one quarter and 8% of patients missed over one half of ordered doses. There was marked heterogeneity in non-administration rate at the floor level (range: 5-27%). Patients on medicine floors missed a significantly larger proportion (18%) of ordered doses compared to patients on other floor types (8%, Odds Ratio: 2.4, p<0.0001). However, more than half of patients received at least 86% of their ordered doses, even on the lowest performing floor. The 20% of patients who missed at least two ordered doses accounted for 80% of all missed doses.

Conclusions: A substantial proportion of ordered doses of VTE prophylaxis were not administered. The heterogeneity in non-administration rate between patients, floors, and floor types can be used to target interventions. The small proportion of patients that missed multiple ordered doses accounted for a large majority of non-administered doses. This recognition of the Pareto principle provides opportunity to efficiently target a relatively small group of patients for intervention.

Conflict of interest statement

Competing Interests: Dr. MBS has received research funding from Sanofi-Aventis and Bristol Myers Squibb, honoraria for CME lectures from Sanofi-Aventis and Ortho-McNeil, consulted for Sanofi-Aventis, Eisai, Daiichi-Sankyo, and Janssen HealthCare and has given expert witness testimony in various medical malpractice cases. Dr. ERH is the Primary Investigator of a Mentored Clinician Scientist Development Award K08 1K08HS017952-01 from the Agency for Healthcare Research and Quality entitled “Does Screening Variability Make DVT an Unreliable Quality Measure of Trauma Care?” Dr. ERH receives royalties from Lippincott, Williams, & Wilkins for the book “Avoiding Common ICU Errors” and has given expert witness testimony in various medical malpractice cases. Dr. CUL receives royalties from Springer for the book “Pediatric Informatics” and serves on the board of the American Medical Informatics Association. This does not alter the authors' adherence to all the PLOS ONE policies on sharing data and materials.

Figures

Figure 1. Proportion of ordered VTE prophylaxis doses not administered by floor, with floor type indicated, (M = medicine, S = surgery, N = neurology, I = ICU).

Figure 2. Percentile plot of the percent of ordered doses that were administered for each patient on the patient floor with the highest overall administration rate (black) and the patient floor with the lowest overall administration rate (orange).