Sustained impact of electronic alerts on rate of prophylaxis against venous thromboembolism

Summary

Advanced electronic alerts (eAlerts) and computerised physician order entry (CPOE) increase adequate thromboprophylaxis orders among hospitalised medical patients. It remains unclear whether eAlerts maintain their efficacy over time, after withdrawal of continuing medical education (CME) on eAlerts and on thromboprophylaxis indications from the study staff. We analysed 5,317 hospital cases from the University Hospital Zurich during 2006–2009: 1,854 cases from a medical ward with eAlerts (intervention group) and 3,463 cases from a surgical ward without eAlerts (control group). In the intervention group, an eAlert with hospital-specific venous thromboembolism (VTE) prevention guidelines was issued in the electronic patient chart 6 hours after admission if no pharmacological or mechanical thromboprophylaxis had been ordered. Data were analysed for three phases: pre-implementation (phase 1), eAlert implementation with CME (phase 2), and post-implementation without CME (phase 3). The rates of thromboprophylaxis in the intervention group were 43.4% in phase 1 and 66.7% in phase 2 (p<0.001), and increased further to 73.6% in phase 3 (p=0.011). Early thromboprophylaxis orders within 12 hours after admission were more often placed in phase 2 and 3 as compared to phase 1 (67.1% vs. 52.1%, p<0.001). In the surgical control group, the thromboprophylaxis rates in the three phases were 88.6%, 90.7%, 90.6% (p=0.16). Advanced eAlerts may provide sustained efficacy over time, with stable rates of thromboprophylaxis orders among hospitalised medical patients.

Keywords

Clinical decision support systems - computerised medical records systems - venous thromboembolism/prevention & control - software - reminder systems

• References

• 1 Hellmann I, Ellis MH. Prevention of venous thromboembolism in medical patients: recent advances and future directions. Isr Med Assoc J 2009; 11: 753-757.
• 2 Spencer FA, Emery C, Lessard D. et al. The Worcester Venous Thromboembolism study: a population-based study of the clinical epidemiology of venous thromboembolism. J Gen Intern Med 2006; 21: 722-727.
• 3 Cohen AT, Agnelli G, Anderson FA. et al. Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost 2007; 98: 756-764.
• 4 Francis CW. Clinical practice. Prophylaxis for thromboembolism in hospitalized medical patients. N Engl J Med 2007; 356: 1438-1444.
• 5 Cushman M, Tsai AW, White RH. et al. Deep vein thrombosis and pulmonary embolism in two cohorts: the longitudinal investigation of thromboembolism etiology. Am J Med 2004; 117: 19-25.
• 6 Stein PD, Kayali F, Olson RE. Estimated case fatality rate of pulmonary embolism, 1979 to 1998. Am J Cardiol 2004; 93: 1197-1199.
• 7 Shojania KG, Duncan BW, McDonald KM. et al. Making health care safer: a critical analysis of patient safety practices. Evid Rep Technol Assess (Summ) 2001; 43: i-x 1-668.
• 8 Cohn SL. Prophylaxis of venous thromboembolism in the US: improving hospital performance. J Thromb Haemost 2009; 7: 1437-1445.
• 9 Dentali F, Douketis JD, Gianni M. et al. Meta-analysis: anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalized medical patients. Ann Intern Med 2007; 146: 278-288.
• 10 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 (Suppl. 06) 381S-453S.
• 11 Cohen AT, Tapson VF, Bergmann JF. et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet 2008; 371: 387-394.
• 12 Tapson VF, Decousus H, Pini M. et al. Venous thromboembolism prophylaxis in acutely ill hospitalized medical patients: findings from the International Medical Prevention Registry on Venous Thromboembolism. Chest 2007; 132: 936-945.
• 13 Goldhaber SZ, Tapson VF. A prospective registry of 5,451 patients with ultrasound-confirmed deep vein thrombosis. Am J Cardiol 2004; 93: 259-262.
• 14 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.
• 15 Baroletti S, Munz K, Sonis J. et al. Electronic alerts for hospitalized high-VTE risk patients not receiving prophylaxis: a cohort study. J Thromb Thrombolysis 2008; 25: 146-150.
• 16 Kucher N, Puck M, Blaser J. et al. Physician compliance with advanced electronic alerts for preventing venous thromboembolism among hospitalized medical patients. J Thromb Haemost 2009; 7: 1291-1296.
• 17 van der Sijs H, Aarts J, Vulto A. et al. Overriding of drug safety alerts in computerized physician order entry. J Am Med Inform Assoc 2006; 13: 138-147.
• 18 Chopard P, Dorffler-Melly J, Hess U. et al. Venous thromboembolism prophylaxis in acutely ill medical patients: definite need for improvement. J Intern Med 2005; 257: 352-357.
• 19 Spirk D, Husmann M, Willenberg T. et al. Inconsistencies in the planning of the duration of anticoagulation among outpatients with acute deep-vein thrombosis. Results from the OTIS-DVT Registry. Thromb Haemost 2011; 105: 239-244.
• 20 Dexter PR, Perkins S, Overhage JM. et al. A computerized reminder system to increase the use of preventive care for hospitalized patients. N Engl J Med 2001; 345: 965-970.
• 21 Shiffman RN, Liaw Y, Brandt CA. et al. Computer-based guideline implementation systems: a systematic review of functionality and effectiveness. J Am Med Inform Assoc 1999; 6: 104-114.
• 22 Damiani G, Pinnarelli L, Colosimo SC. et al. The effectiveness of computerized clinical guidelines in the process of care: a systematic review. BMC Health Serv Res 2010; 10: 2.
• 23 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.
• 24 Franke RH, Kaul JD. Hawthorne Experiments - 1st Statistical Interpretation. Am Sociol Rev 1978; 43: 623-643.
• 25 McCarney R, Warner J, Iliffe S. et al. The Hawthorne Effect: a randomised, controlled trial. Bmc Med Res Methodol 2007; 7: 30.
• 26 Chopard P, Spirk D, Beer HJ. et al. Swiss results from a global observational study of venous thromboembolism risk and prophylaxis use in the acute care hospital setting: analysis from the ENDORSE study. Swiss Med Wkly 2009; 139: 630-635.
• 27 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.
• 28 Nendaz MR, Chopard P, Lovis C. et al. Adequacy of venous thromboprophylaxis in acutely ill medical patients (IMPART): multisite comparison of different clinical decision support systems. J Thromb Haemost 2010; 8: 1230-1234.
• 29 Gibson NS, Douma RA, Squizzato A. et al. Application of a decision rule and a D-dimer assay in the diagnosis of pulmonary embolism. Thromb Haemost 2010; 103: 849-854.
• 30 Fiumara K, Piovella C, Hurwitz S. et al. Multi-screen electronic alerts to augment venous thromboembolism prophylaxis. Thromb Haemost 2010; 103: 312-317.
• 31 van der Sijs H, Mulder A, van Gelder T. et al. Drug safety alert generation and overriding in a large Dutch university medical centre. Pharmacoepidem Dr S 2009; 18: 941-947.