Lovely Jenna K, Hickman Joel A, Johnson Matthew G, Naessens James M, Morgenthaler Timothy I
Department of Pharmacy, Mayo Clinic, Rochester, MN.
Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
Mayo Clin Proc Innov Qual Outcomes. 2020 Feb 17;4(2):159-169. doi: 10.1016/j.mayocpiqo.2019.10.006. eCollection 2020 Apr.
To study the impact of multiphase quality improvement efforts to enhance appropriate use of chemical and mechanical venous thromboembolism (VTE) prophylaxis (VTEP) on the rate of hospital-acquired VTE and determine whether efforts have been associated with increased bleeding complications.
All adult inpatients discharged between January 1, 2005, and December 31, 2015, were included in the study. Retrospective interrupted time series analysis compared VTEP performance, VTE outcomes, and unintended consequences (derived from linked administrative and clinical data) across 5 improvement phases: baseline (January 1, 2005-December 31, 2006), paper order set phase (January 1, 2007-February 9, 2009), electronic order set phase (February 10, 2009-December 16, 2009), active reminder phase (December 17, 2009-May 31, 2012), and maintenance phase (June 1, 2012-September 30, 2015).
Guideline VTEP plan adherence at the end of the study period (including documenting contraindications) reached 88.8% (654,138 of 736,384 patient days). Delivery of pharmacological VTEP increased from 43.9% (49,155 of 111,906 patients) to 60.8% (75,784 of 124,676 patients); delivery of mechanical or pharmacological VTEP increased less (65.0% [431,791 of 664,087 patient days] to 67.4% [496,625 of 736,384 patient days]). Mean VTE rates decreased from 4.6 per 1000 hospitalizations (21.7 VTEs per month) at baseline to 4.3 per 1000 hospitalizations (18.0 VTEs per month) during the maintenance phase (<.001). More than 97% of patients who had development of VTE (534 of 548) received VTEP, but 65.7% (360 of 548) experienced gaps of 1 or more days in VTEP delivery. Measured in-hospital bleeding rates were fairly consistent over the study (4.6% [5,198 of 111,906 patients] at baseline to 5.3% [6,662 of 124,676 patients] during the reminder phase). There was little change in rates of 7-day readmission with bleeding or VTE.
Our VTEP project improved guideline compliance, increased the proportion of patients receiving VTEP, and was associated with a decrease in VTE. Gaps in VTEP delivery occurred despite protocoled order sets and electronic feedback. Further improvements in VTE may require new approaches.
研究多阶段质量改进措施对提高化学和机械性静脉血栓栓塞症（VTE）预防措施（VTEP）合理使用情况的影响，以及这些措施是否会增加出血并发症的发生率，并确定其与医院获得性VTE发生率之间的关系。
本研究纳入了2005年1月1日至2015年12月31日期间出院的所有成年住院患者。采用回顾性中断时间序列分析，比较了5个改进阶段的VTEP执行情况、VTE结局及意外后果（源自关联的行政和临床数据），这5个阶段分别为：基线期（2005年1月1日至2006年12月31日）、纸质医嘱集阶段（2007年1月1日至2009年2月9日）、电子医嘱集阶段（2009年2月10日至2009年12月16日）、主动提醒阶段（2009年12月17日至2012年5月31日）和维持阶段（2012年6月1日至2015年9月30日）。
在研究期末，指南VTEP计划的依从性（包括记录禁忌证）达到88.8%（736,384个患者日中的654,138个）。药物性VTEP的实施率从43.9%（111,906例患者中的49,155例）提高到60.8%（124,676例患者中的75,784例）；机械性或药物性VTEP的实施率提高幅度较小（从65.0%[664,087个患者日中的431,791个]提高到67.4%[736,384个患者日中的496,625个]）。VTE的平均发生率从基线时的每1000次住院4.6例（每月21.7例VTE）降至维持阶段的每1000次住院4.3例（每月18.0例VTE）（P<0.001）。发生VTE的患者中，超过97%（548例中的534例）接受了VTEP，但65.7%（548例中的360例）在VTEP实施过程中出现了1天或更长时间的间断。在整个研究过程中，测量的院内出血率相当一致（基线时为4.6%[111,906例患者中的5,198例]，提醒阶段为5.3%[124,676例患者中的6,662例]）。因出血或VTE再次入院7天的发生率变化不大。
我们的VTEP项目提高了指南依从性，增加了接受VTEP的患者比例，并与VTE发生率的降低相关。尽管有规范的医嘱集和电子反馈，但VTEP实施过程中仍存在间断。VTE的进一步改善可能需要新的方法。
