Deep vein thrombosis (DVT) and pulmonary embolism (PE) are collectively known as venous thromboembolism (VTE). Deep vein thrombosis is the term used to describe a blood clot in the deep veins of the legs that can travel through the heart and lungs, causing a PE. Together DVT and PE are major causes of death and disability. An estimated 300,000 new cases of VTE occur in the United States annually.1 This statistic is especially alarming in the setting of having well-documented risk factors, preventive therapies, and treatment regimens that are readily available to clinicians in the form of evidenced-based guidelines, performance measures, and consensus statements.2-9 These resources are intended to reduce morbidity and mortality from VTE as well as improve appropriateness and quality of care for various patient groups. They also provide assessment criteria to estimate a patient's level of risk and identify those who would benefit the most from prophylactic therapies. In addition, guidelines provide recommendations for the application of nonpharmacological and pharmacological treatment strategies to prevent and treat VTE. Unfortunately, these guidelines and consensus statements are used inconsistently by healthcare providers throughout the United States and the world.
A Call to Action
On September 15, 2008, the US Surgeon General issued "Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism."10 This scientifically based document calls for multiple strategies aimed at reducing the incidence of VTE, an often preventable yet disabling and deadly disease. Low public awareness of the risk factors and signs and symptoms of VTE and the underutilization of prevention therapies by healthcare providers are targets of the Surgeon General's Call to Action.
The purpose of this article was to examine the gap between VTE prevention guidelines and clinical practice, discuss common barriers to implementation of guidelines, and provide examples of quality improvement (QI) strategies that, together with the Surgeon General's Call to Action, may help with guideline implementation and adherence.
Guideline Compliance Surrounding VTE
In general, healthcare providers inconsistently follow clinical practice guidelines. In a survey performed between October 1998 and August 2000, the average evidenced-based guideline adherence rate for various clinical condition indicators averaged 55%; however, for prophylactic antithrombotic drugs given on admission for patients with hip fracture, adherence was only 22%.11 Since then, compliance with VTE prevention practice guidelines has been variable.12,13 In studies published between 2005 and 2008 that evaluated partial and/or complete compliance to the American College of Chest Physicians (ACCP) guidelines for prevention of VTE from 2001 and 2004 (Table 1), the rates ranged from 2.8% to 84%.14-22
For example, University of Vermont investigators16 analyzed the records of 37,615 patients who were admitted to a general surgery, vascular, and trauma service to determine whether rates of VTE in surgical patients had improved over the 10-year period since initial publication of the ACCP evidence-based practice guidelines for the prevention of VTE in 1995.6 The ACCP guidelines were updated and published every 3 years (1998, 2001, 2004)3-5 during this period in which there were 172 episodes of VTE. Of these, 109 (63%) had complete compliance with the ACCP guideline and thus were determined to be nonpreventable VTE. Partial compliance with the ACCP guideline was achieved in 37 of VTE patients (21%). A total of 37% of VTEs were therefore determined to be preventable had there been complete application of the ACCP guideline. The 63% compliance level was associated with a significant increase in the rate of VTE over the 10-year study period, from 0.13% to 0.41%. Factors cited for this increase included a greater proportion of high-risk patients, a more aggressive approach to making the diagnosis of VTE, and the variable level of adherence to the guidelines.
Evidenced-based practice guidelines for VTE prophylaxis are used to a greater extent in surgical populations compared with medical populations, where adherence is at the low end of the range.12 The effect of guideline noncompliance on patient outcomes, however, is not well documented. A recent, prospective study evaluated 2,726 patients in 183 US hospitals with confirmed DVT by ultrasound. Of these, only 1,147 (42%) received VTE prevention therapy within 30 days before diagnosis, despite their comorbid and high-risk status. The 5 most frequent comorbidities were hypertension (50%), surgery within 3 months (38%), immobility within 30 days (34%), cancer (32%), and obesity (27%).23
A retrospective study of 123,304 at-risk medical, surgical, and trauma patients identified a 13.3% compliance rate or adherence to the 2001 ACCP guideline,4 whereas 23% received some form of VTE prophylaxis.17 Compliance was highest in the orthopedic group (52%) and lowest in patients with at-risk medical conditions, such as myocardial infarction, ischemic stroke, cancer, heart failure, and lung disease. Noncompliance was defined by these investigators as omission of prophylaxis, inadequate duration of prophylaxis, and wrong type of prophylaxis. Omission of prophylaxis was the major reason for noncompliance across most conditions; however, in orthopedic surgery patients, inadequate duration of prophylaxis was the most common reason for noncompliance. Selection of the wrong type of prophylaxis occurred infrequently.
Barriers to Guideline Implementation
Barriers to guideline implementation fall into 3 categories: provider-related barriers, system-related barriers, and patient-related barriers.
Providers
Healthcare provider knowledge, beliefs, and attitudes play a significant role in the application of evidence-based guidelines. The provider-related barriers that contribute to the gaps in translation of guidelines into clinical practice include the following:
1. Variability in knowledge of risk assessment and appropriate prophylaxis strategies
2. Lack of belief and acceptance that the evidence presented in the guidelines for VTE prophylaxis is appropriate in all clinical situations (with a preference toward individualization of care). The perceived need for individualization is especially true in the care of medical patients.
In a survey of 950 physicians from various practice settings (emergency, family practice, cardiology, and orthopedics), 54% self-reported the use of evidence-based guidelines, 32% stated they followed professional society guidelines, and 22% followed guidelines developed by their institution.24 The other 46% reported making treatment decisions on a case-by-case basis.
Clinicians may underestimate risk for VTE in medical patients because of the lack of a commonly accepted risk assessment tool. In 1 study, researchers evaluated the knowledge of VTE risks by giving physicians case studies describing patients hospitalized on a general medical unit.25 Physicians were asked to estimate the risk of VTE in these patients, as low, moderate, or high risk. Compared with a predefined criterion standard (based on the 2004 ACCP guideline3), the level of risk was underestimated almost 50% of the time, resulting in fewer patients referred for appropriate VTE prophylaxis.
A survey of Italian intensive care unit specialists described a heterogeneous set of beliefs and attitudes regarding the use of VTE prophylaxis in major trauma patients.26 Although trauma is identified by the 2004 ACCP guideline3 as a risk factor for VTE, only 82% of intensive care unit specialists in this study believed that sufficient evidence exists to prescribe antithrombotic prophylaxis in cases of major trauma; of these, 62.4% use antithrombotic therapies for all major trauma patients, whereas 37.6% reported the use of antithrombotic drugs in select patients on the basis of risk factors for VTE or in the absence of hemorrhagic contraindications.
Systems
Common system barriers that have led to poor guideline adherence include (1) lack of audit tools and feedback systems, (2) undefined roles/responsibilities, (3) numerous guidelines with conflicting recommendations, and (4) no clear incentives for guideline adherence.
A Scottish study followed the introduction of consensus guideline for VTE prophylaxis in their country and found that barriers to guideline implementation included a lack of supportive systems, including data collection and audit tools, a lack of individual staff responsibility for implementation, a lack of acceptance of guidelines, and a perceived lack of need for the guidelines in particular clinical areas (Table 2).27 One final barrier to adoption of evidence-based guidelines commonly cited by healthcare professionals is the number of guidelines that exist for a given health problem, often with conflicting recommendations. This is true in the case of guidelines for the prevention of VTE, where conflicting guidelines lead clinicians to conclude that disagreement reflects uncertainty about the benefits of thromboprophylaxis, resulting in lack of guideline adherence.28
Until recently, healthcare providers had little incentive to follow the VTE prevention guidelines. Over the last several years, however, in an effort to help with QI audits and reports, The Joint Commission identified, developed, and tested VTE performance measures in partnership with the National Consensus Standards for the Prevention and Care of Venous Thromboembolism project.7 Together they developed 3 measures that focus on prevention and 3 that address treatment recommendations related to The Joint Commission National Patient Safety Goal regarding the use of anticoagulation therapies. The National Quality Forum endorsed the VTE measures in May 2008. Deep vein thrombosis and PE were added to a list of never events by the Centers for Medicare and Medicaid Services in 2008. Never events are defined by the National Quality Forum as errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients. The Centers for Medicare and Medicaid Services plans to deny reimbursement for identified never events. The National Quality Forum expects health systems to investigate causes or contributing factors for each occurrence of a never event, with the hope that the findings will be acted upon to prevent future occurrences.29 Public reporting of event rates should further raise awareness and stimulate critical review.
Patients
The patient can play an important role in the prevention of VTE; however, a US national survey reported that 74% of adults have little to no knowledge of DVT and its effects on health.30 In a study of hospitalized patients receiving pharmacological therapy (injections of low-molecular-weight heparin) for VTE prevention, knowledge of DVT was low.31 Eighty percent of the patients had heard the term DVT, but less than half knew that a DVT was a blood clot or could identify swelling and pain in the leg as a sign or symptom of DVT; 32% accurately cited common risk factors for DVT including bed rest, traveling, and giving birth. Awareness of PE was even lower than that for DVT. The data suggest the need for increased public and patient education around DVT and PE if we expect our patients to participate in self-assessment and reporting of symptoms, as well as to comply with treatment regimens aimed at VTE prevention.
Process Improvement Initiatives
Driven by recent changes in health policy, efforts are under way in hospitals and healthcare systems to identify and overcome barriers associated with VTE prophylaxis through process improvement initiatives. These process improvement strategies are typically divided into 2 categories: passive and active.
Passive strategies include dissemination of written guidelines to healthcare providers. The expectation is that providers will read the guidelines, understand them, remember them, and apply them to all patients for whom they are intended. Adherence to guidelines and the provision of appropriate VTE prophylaxis were less than 50% with passive dissemination of guidelines alone.12 However, when passive dissemination of guidelines was combined with other more active strategies such as live continuing education programs, adherence improved. Other active strategies for process improvement include computer-based clinical decision-support systems, audit and feedback systems, documentation aides, and adherence monitoring programs. All of these result in significant improvements in adherence to guidelines, with an average adherence of 80%.12 The single best strategy to improve guideline adherence and adequacy of VTE prophylaxis was the computer-based alert (decision-support) system, which approached adherence rates of 100%.12,13 Applying multiple strategies at once seems to have positive impact on guideline adherence.
Multifaceted interventions in 1,373 post-acute-care patients in France significantly reduced the DVT rate from 12.8% to 7.8%.32 Interventions included development and distribution of a clinical practice guideline, educational presentations, distribution of written material, visual reminder aides such as office posters, regular chart audits, and feedback regarding progress and results. The success of this study demonstrated that a combination of process improvement strategies helped change professional practice and improved patient outcomes.
In August 2008, the Agency for Healthcare Research and Quality published a resource for hospitals and healthcare systems entitled Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement.33 This guide is intended to help close the gap between evidence and execution and cites the following elements to reach significant improvement in quality of care:
* Institutional support and prioritization that includes meaningful investment in time, equipment, personnel, and informatics
* A multidisciplinary team focused on reaching VTE prophylaxis targets and reporting to key medical staff committees
* Reliable data collection and performance tracking
* Specific goals that are ambitious, time defined, and measurable
* A proven QI framework to coordinate steps toward meaningful improvements
* Protocols that standardize VTE risk assessment and prophylaxis
* Institutional infrastructure, policies, practices, or educational programs that promote the use of a standard protocol
Nurse Practitioners Play a Key Role
In the past 10 to 15 years, nurse practitioners (NPs) have played an increasingly larger role in the care of perioperative patients. At Brigham and Women's Hospital in Boston, Massachusetts, NPs perform preoperative assessments on patients, screening them for application of evidence-based guidelines.34 When an eligible patient is identified, the NP contacts the appropriate healthcare team to ensure implementation, provides instruction to the patient, and documents the recommended protocol in the medical record. With the use of this model, NPs may improve identification of high-risk patients, increase the application of evidence-based guidelines, and subsequently improve patient outcomes.
Conclusion
Hospitals and healthcare providers are key stakeholders in the advancement of the Surgeon General's Call to Action to improve adherence to the VTE prevention guideline. Nurse practitioners can play an important role in this initiative by providing leadership in the implementation of the following strategies:
* Streamlining established evidence-based guidelines into a single document that decreases confusion and supports consensus
* Consistently using accepted VTE risk assessment tools
* Engaging in process improvement strategies that help clinicians assess patient risk, providing suggestions for both nonpharmacological and pharmacological therapies, and streamlining documentation
* Developing and using monitoring systems including chart audits and result reporting
* Developing and distributing patient education tools and programs around VTE signs, symptoms, and prevention
The first public health Call to Action by the Surgeon General occurred 40 years ago, warning of the health risks of smoking. Today, we have several states with laws that ban smoking in public spaces. Let us hope that the Call to Action to prevent DVT and PE has similar, far-reaching effects. The application of multiple process improvement tools, the continuing education of healthcare providers, the increased use of NPs in patient risk assessment, and the promotion of guidelines adherence among all team members are promising strategies.
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