Yates M, Reddy M, Machumpurath B, Phelps G, Hampson S-A
Ballarat Health Services, Ballarat, Victoria, Australia; School of Medicine, Deakin University, Geelong, Victoria, Australia.
Intern Med J. 2014 Feb;44(2):190-4. doi: 10.1111/imj.12346.
Venous thromboembolism (VTE) is a significant contributor to morbidity and mortality in Australia. While there is well-established evidence for the use of VTE prophylaxis in hospital inpatients, adherence to such guidelines is poor.
The aim of the present study is to assess the impact of education and system change on improving rates of VTE prophylaxis in hospital inpatients.
We performed four consecutive audits of inpatient medical records of a regional hospital service over 2 years. The audits aimed to test the impact of serial interventions at increasing the appropriate use of VTE prophylaxis (based on risk assessment). The interventions were (i) staff education and (ii) a process change that mandated a prophylaxis decision by modifying the National Inpatient Medication Chart with 'VTE avoidance' preprinted in the first medication box.
Our results from the baseline study showed that of the 236 medical inpatients reviewed, 80% were at high risk of VTE. Of this high-risk cohort, 34.9% (confidence interval (CI) 28-42%) had appropriate prophylaxis decisions. Post the education intervention, 43.2% (CI 37-49%) of the high-risk cohort received appropriate VTE prophylaxis, an improvement of 8.3% (CI -1% to 18%) from baseline. With the subsequent introduction of a process change, 82.1% (CI 66-92%) of the high-risk cohort received appropriate prophylaxis, an improvement of 47.2% and 38.8% (CI 24-54%) when compared with baseline and education respectively. Retention rates at 11 months postsystem change were 73% (CI 55-86%).
This study therefore concluded that while education has an impact on rates of appropriate VTE prophylaxis, it is system change that has the most marked and sustained effect.
静脉血栓栓塞症（VTE）是澳大利亚发病和死亡的一个重要因素。虽然有充分证据支持在医院住院患者中使用VTE预防措施，但对这些指南的依从性较差。
本研究的目的是评估教育和系统变革对提高医院住院患者VTE预防率的影响。
我们在2年时间内对一家地区医院服务机构的住院患者病历进行了连续4次审核。这些审核旨在测试一系列干预措施对增加VTE预防措施适当使用（基于风险评估）的影响。干预措施包括：（i）员工教育；（ii）流程变革，通过在首个药盒中印上“避免VTE”来修改国家住院用药图表，从而强制做出预防决定。
我们基线研究的结果显示，在审查的236名内科住院患者中，80%有VTE高风险。在这个高风险队列中，34.9%（置信区间（CI）28 - 42%）做出了适当的预防决定。教育干预后，高风险队列中有43.2%（CI 37 - 49%）接受了适当的VTE预防，与基线相比提高了8.3%（CI -1%至18%）。随着后续流程变革的引入，高风险队列中有82.1%（CI 66 - 92%）接受了适当的预防，与基线和教育阶段相比分别提高了47.2%和38.8%（CI 24 - 54%）。系统变革后11个月的留存率为73%（CI 55 - 86%）。
因此，本研究得出结论，虽然教育对适当的VTE预防率有影响，但系统变革具有最显著和持续的效果。
