Implementation Science Extends Multidisciplinary Education on VTE Prophylaxis at World-Class Children’s Hospital

Let’s continue yesterday's thread with venous thromboembolism (VTE) education in a new patient population: children. In this quality improvement article, Raffini et al point out that while risks of VTE are far lower in children than in adults, children still need clinicians to maintain an appropriate level of suspicion and take action on VTE risk with prophylaxis.

What a nice way to phrase a practice gap and the need to narrow that gap: “VTE prophylaxis for patients at risk is often overlooked in pediatric health care institutions, which provides an opportunity to improve patient care.” Even at the world-class Children’s Hospital of Philadelphia (CHOP) at the University of Pennsylvania, children and adolescents were not receiving an appropriate level of risk assessment and prophylaxis, leading researchers to undertake this four-year quality improvement study.

CME/CEhp initiatives often do not extend into local facilities, but this study used reinforcing methods of implementation science to communicate and support the desired behaviors and tasks. These extended “multidisciplinary educational forums” into patient-care settings. Here’s a summary of the intervention’s rollout of CHOP’s locally established guidelines to “encourage timely initiation of thromboprophylaxis." These interventions included 1) VTE risk assessment in the nursing admission intake forms; 2) a VTE-prophylaxis order set implemented into the computerized ordering system; 3) ICU nurses assessing VTE risk and preventive practice daily during team rounds; 4) trials of various pneumatic compression devices with appropriate sizing for children; 5) acquisition of more compression devices with storage near high-risk areas; and 6) development of a protocol for perioperative nurses to initiate pneumatic compression before surgery for certain patients, later expanded to all inpatient settings.

So was extension of multidisciplinary education into care settings, using methods of implementation science, effective? YES. The study’s primary outcome measure was “compliance with thromboprophylaxis guidelines in patients at risk for VTE.” Clinically meaningful improvements were seen: “Over the 4-year study period, the observed rate of VTE prophylaxis in patients at risk increased from a baseline of 22% to an average rate of 82%, and there were intermittent improvements up to 100%.” Implementation science methods, when added to multidisciplinary clinical education, quadrupled or even quintupled guidelines-based care in an underserved population.    

There’s also a nice feature to point out to those watching IRB “requirements” that peer-reviewed journals increasingly expect of performance-change initiatives: “This project was a quality-improvement activity and exempt from review from the institutional review board at the Children's Hospital of Philadelphia.” The QI initiative was not seen as human subjects research (HSR).

Reference cited: Raffini L, Trimarchi T, Beliveau J, Davis D. Thromboprophylaxis in a pediatric hospital: a patient-safety and quality-improvement initiative. Pediatrics. 2011;127(5):e1326-32. PMID: 21464186.
See also the ACCP and ICSI guidelines linked from the September 7, 2015 post (http://fullcirclece.blogspot.com/2015/09/pharmacy-education-for-hospital.html)
PubMed: http://www.ncbi.nlm.nih.gov/pubmed/21464186
Free full text (Pediatrics final version): http://pediatrics.aappublications.org/content/127/5/e1326.full.pdf+html
MeSH *Major* terms: Anticoagulants/administration & dosage*; Guideline Adherence*; Patient Selection*; Primary Prevention/organization & administration*; Venous Thromboembolism/prevention & control*
(And for those of you who love MeSH and UMLS, many quality-improvement and program change-related MeSH terms were assigned by NLM but not starred as “major” terms.)