Multi-screen electronic alerts to augment venous thromboembolism prophylaxis

Karen Fiumara; Chiara Piovella; Shelley Hurwitz; Gregory Piazza; Clyde M. Niles; John Fanikos; Marilyn Paterno; Matthew Labreche; Leslie-Ann Stevens; Steven Baroletti; Samuel Z. Goldhaber

doi:10.1160/TH09-09-0634

Thrombosis and Haemostasis, Table of Contents

Thromb Haemost 2010; 103(02): 312-317
DOI: 10.1160/TH09-09-0634

Blood Coagulation, Fibrinolysis and Cellular Haemostasis

Schattauer GmbH

Multi-screen electronic alerts to augment venous thromboembolism prophylaxis

Authors

Karen Fiumara

¹Department of Pharmacy, Brigham and Women’s Hospital, Harvard Medical School Boston, Massachusetts, USA
Chiara Piovella

²Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School Boston, Massachusetts, USA
Shelley Hurwitz

³Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School Boston, Massachusetts, USA
Gregory Piazza

²Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School Boston, Massachusetts, USA

³Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School Boston, Massachusetts, USA
Clyde M. Niles

²Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School Boston, Massachusetts, USA
John Fanikos

¹Department of Pharmacy, Brigham and Women’s Hospital, Harvard Medical School Boston, Massachusetts, USA
Marilyn Paterno

⁴Information Systems, Brigham and Women’s Hospital, Harvard Medical School Boston, Massachusetts, USA
Matthew Labreche

¹Department of Pharmacy, Brigham and Women’s Hospital, Harvard Medical School Boston, Massachusetts, USA
Leslie-Ann Stevens

²Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School Boston, Massachusetts, USA
Steven Baroletti

¹Department of Pharmacy, Brigham and Women’s Hospital, Harvard Medical School Boston, Massachusetts, USA
Samuel Z. Goldhaber

¹Department of Pharmacy, Brigham and Women’s Hospital, Harvard Medical School Boston, Massachusetts, USA

³Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School Boston, Massachusetts, USA

Abstract

Summary

Venous thromboembolism (VTE) prophylaxis in high-risk patients is frequently underutilised. We previously devised a one-screen computer alert program that identified hospitalised patients at high risk for VTE who were not receiving prophylaxis and advised their physicians to prescribe prophylaxis. While this strategy reduced the 90-day incidence of symptomatic VTE by 41%, the majority of electronic alerts were ignored. We have now developed a serial three-screen alert computer program designed to educate physicians who initially declined to order prophylaxis after a single screen alert. Of a total cohort of 880, the responsible physicians for 425 patients received a single electronic alert, whereas 455 who declined prophylaxis after the first screen received the second and third screens of the novel three-screen alert. Our enhanced serial three-screen alert program generated VTE prophylaxis orders for 58.4% of the 455 patients whose physicians initially declined to order prophylaxis following the one-screen alert. There was no significant difference in symptomatic 90-day VTE rates between the two cohorts (2.8% for the one-screen vs. 2.2% for the three-screen, p=0.55). We conclude that our three-screen computer alert program can markedly increase prophylaxis among physicians who decline an initial single screen alert.

Keywords

Computerised decision support - deep venous thrombosis - prophylaxis - pulmonary embolism - venous thromboembolism

Full Text

References

References
1 Piazza G, Fanikos J, Zayaruzny M. et al. Venous thromboembolic events in hospitalised medical patients. Thromb Haemost 2009; 102: 505-510.
2 Fanikos J, Piazza G, Zayaruzny M. et al. Long-term complications of medical patients with hospital acquired venous thromboembolism. Thromb Haemost 2009; 102: 688-693.
3 Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999; 353: 1386-1389.
4 Piazza G, Goldhaber SZ. Acute pulmonary embolism: part II: treatment and prophylaxis. Circulation 2006; 114: e42-e47.
5 Geerts WH, Bergqvist D, Pineo GF. et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133: 381S-453S.
6 Prevention and treatment of venous thromboembolism.. International Consensus Statement (guidelines according to scientific evidence). Int Angiol 2006; 25: 101-161.
7 Amin A, Stemkowski S, Lin J. et al. Thromboprophylaxis rates in US medical centers: success or failure?. J Thromb Haemost 2007; 5: 1610-1616.
8 Kahn SR, Panju A, Geerts W. et al. Multicenter evaluation of the use of venous thromboembolism prophylaxis in acutely ill medical patients in Canada. Thromb Res 2007; 119: 145-155.
9 Yu HT, Dylan ML, Lin J. et al. Hospitals’ compliance with prophylaxis guidelines for venous thromboembolism. Am J Health Syst Pharm 2007; 64: 69-76.
10 Kucher N, Koo S, Quiroz R. et al. Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med 2005; 352: 969-977.
11 Urbankova J, Quiroz R, Kucher N. et al. Intermittent pneumatic compression and deep vein thrombosis prevention. A meta-analysis in postoperative patients. Thromb Haemost 2005; 94: 1181-1185.
12 Gerhard-Herman M, Gardin JM, Jaff M. et al. Guidelines for noninvasive vascular laboratory testing: a report from the American Society of Echocardiography and the Society of Vascular Medicine and Biology. J Am Soc Echocardiogr 2006; 19: 955-972.
13 Stein PD, Fowler SE, Goodman LR. et al. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med 2006; 354: 2317-2327.
14 Value of the ventilation/perfusion scan in acute pulmonary embolism.. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). The PIOPED Investigators. J Am Med Assoc 1990; 263: 2753-2759.
15 An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction.. The GUSTO investigators. N Engl J Med 1993; 329: 673-682.
16 Dennis M, Sandercock PA, Reid J. et al. Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial. Lancet 2009; 373: 1958-1965.
17 Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med 2003; 348: 2526-2534.
18 Durieux P, Nizard R, Ravaud P. et al. A clinical decision support system for prevention of venous thromboembolism: effect on physician behavior. J Am Med Assoc 2000; 283: 2816-2821.
19 Durieux P. Electronic medical alerts--so simple, so complex. N Engl J Med 2005; 352: 1034-1036.
20 Lecumberri R, Marques M, Diaz-Navarlaz MT. et al. Maintained effectiveness of an electronic alert system to prevent venous thromboembolism among hospitalized patients. Thromb Haemost 2008; 100: 699-704.
21 Amarasingham R, Plantinga L, Diener-West M. et al. Clinical information technologies and inpatient outcomes: a multiple hospital study. Arch Intern Med 2009; 169: 108-14.
22 Tooher R, Middleton P, Pham C. et al. A systematic review of strategies to improve prophylaxis for venous thromboembolism in hospitals. Ann Surg 2005; 241: 397-415.