Correlation of venous thromboembolism prophylaxis and electronic medical record alerts with incidence among surgical patients.

BACKGROUND: Venous thromboembolism events are potentially preventable adverse events. We investigated the effect of interruptions and delays in pharmacologic prophylaxis on venous thromboembolism incidence. Additionally, we evaluated the utility of electronic medical record alerts for venous thromboembolism prophylaxis. METHODS: Venous thromboembolisms were identified in surgical patients retrospectively through Core Measure Venous ThromboEmbolism-6-6 and Patient Safety Indicator 12 between November 2013 and March 2015. Venous thromboembolism pharmacologic prophylaxis and prescriber response to electronic medical record alerts were recorded prospectively. Prophylaxis was categorized as continuous, delayed, interrupted, other, and none. RESULTS: Among 10,318 surgical admissions, there were 131 venous thromboembolisms; 23.7% of the venous thromboembolisms occurred with optimal continuous prophylaxis. Prophylaxis, length of stay, age, and transfer from another hospital were associated with increased venous thromboembolism incidence. Compared with continuous prophylaxis, interruptions were associated with 3 times greater odds of venous thromboembolism. Delays were associated with 2 times greater odds of venous thromboembolism. Electronic medical record alerts occurred in 45.7% of the encounters and were associated with a 2-fold increased venous thromboembolism incidence. Focus groups revealed procedures as the main contributor to interruptions, and workflow disruption as the main limitation of the electronic medical record alerts. CONCLUSION: Multidisciplinary strategies to decrease delays and interruptions in venous thromboembolism prophylaxis and optimization of electronic medical record tools for prophylaxis may help decrease rates of preventable venous thromboembolism.

Association between Interruptions in Chemical Prophylaxis and VTE Formation.

Venous thromboembolisms (VTE) are considered preventable events with appropriate mechanical or chemical prophylaxis. However, chemical prophylaxis is frequently delayed or interrupted during hospitalization. We investigated the impact of delayed initiation and interruption of chemical prophylaxis on VTE rates. The incidence of VTE at an urban academic medical center was measured in patients hospitalized for >2 days between November 2013 and May 2014. Patients receiving prophylaxis were grouped as complete (started within 24 hours of admission and no interruptions), delayed (started >24 hours and no interruptions), and interrupted (interruption for >24 hours with or without delay). There were 9961 hospital admissions and 33 VTE (3.3 per 1000 admissions). 25.2 per cent had complete, 16.4 per cent had delayed, and 11.8 per cent had interrupted prophylaxis. 36.8 per cent received no prophylaxis. Interrupted prophylaxis was associated with more VTE than complete (10.2 vs 2.0 per 1000, P < 0.01) and 5.2 greater odds. Admission to a surgical service and prolonged hospital stay were independently associated with increased likelihood of VTE. There was a lower likelihood of getting complete prophylaxis among patients admitted to orthopedic, transplant, cardiac, plastic, and vascular surgery. Surgical patients are at higher risk for VTE and interruptions in VTE prophylaxis significantly increase the risk of VTE.

A statewide collaborative initiative to improve the quality of care for patients with acute myocardial infarction and heart failure.

BACKGROUND: To enhance quality improvement, we created a unique statewide collaboration among 3 organizations: the Virginia Health Quality Center (Virginia's Medicare Quality Improvement Organization), the American College of Cardiology, and the American Heart Association. The goal was to improve discharge measures for acute myocardial infarction and heart failure. METHODS AND RESULTS: In 2004, 29 hospitals participated in the collaborative initiative. Using Medicare data submitted from 2004 through the second quarter of 2006, we analyzed adherence to individual discharge measures and all-or-none appropriate care measures for acute myocardial infarction, heart failure, and both. To control for differences in hospital characteristics, we were able to match 21 of the participating hospitals with 21 similar nonparticipating hospitals. In this paired analysis, the total appropriate care measure increased from 61% to 77% in participating hospitals compared with an increase from 51% to 60% in nonparticipating hospitals (P<0.0001). A generalized linear mixed model examining the full data set at the patient level failed to show a clear advantage among participating hospitals. Participating hospitals had higher baseline rates for most quality measures, suggesting a possible effect of a prior collaborative. Further analysis of only hospitals that participated in a prior collaborative showed that participants in the current collaborative initiative had higher rates of improvement for 7 of 10 quality measures and appropriate care measures for heart failure, acute myocardial infarction, or both (all P<0.05). CONCLUSIONS: We report a unique collaboration of a Medicare Quality Improvement Organization and 2 national organizations to address quality of care for acute myocardial infarction and heart failure. A composite measure of quality (the total appropriate care measure) improved more in the participating hospitals during the timeframe of the intervention, although the greater improvement in this and other measures in the participating hospitals appeared to be dependent on participation in a prior collaborative initiative.

Improving the timeliness of written patient notification of mammography results by mammography centers.

Timely reporting of mammogram results helps to reduce anxiety for women with negative results and speeds up diagnosis or treatment in the case of abnormal results. The goal of this project was to improve the rate at which Virginia mammography centers provide a written report to women in lay terms within 30 days of a mammogram. The project included six intervention and five control mammography centers. The baseline period was prior to when new regulations in the Mammography Quality Standards Act (MQSA) took effect in April 1999. The re-measurement period was after April 1999. Data were obtained from abstraction of mammography reports and patient notification letters from a sample of patients with negative and abnormal mammography results at each mammography center. Each intervention mammography center received a notebook that included numerous tools on systems for patient notification and tracking, baseline notification rates and other abstracted information, biopsy recommendations, sample results letters, and a copy of the MQSA. For negative mammograms, the intervention group in aggregate increased from 24% at baseline to 79% at re-measurement in their rate of notification within 30 days. The control group increased from 25% to 46%. For abnormal mammograms, increases were from 35% to 85% and from 25% to 58%, respectively. The intervention group's increases were considerably higher, suggesting an effect due to the interventions that involved technical assistance, education, and system change. All increases were statistically significant (p < 0.01). At baseline, three intervention centers and two controls had policies for written notification. All 11 had policies at re-measurement. However, only two of the five control centers could provide clear supporting documentation for dates of notification at re-measurement. Mammography centers can benefit from guidance in the form of intervention materials specifically designed to address the MQSA sections that apply to patient notification, tracking, and positive predictive value of biopsy recommendations.