Hospitalists know the importance of medications for VTE prophylaxis, but 12.7% of prescribed doses were not administered in a study of 75 patients at Johns Hopkins Hospital, published in March 2018 by the American Journal of Health-System Pharmacy. Because the most commonly cited reason for nonadministration was patient refusal, the Johns Hopkins VTE Collaborative decided to tackle the problem with patient education.
“Our first step was to ask patients what they wanted to learn,” said Elliott R. Haut, MD, PhD, vice chair of quality, safety, and service in the department of surgery at Johns Hopkins Medicine. After collecting patient input, the research group developed a patient education bundle composed of a two-page form about blood-clot prevention, a 10-minute video of patients' stories (shown on a hospital tablet, the TV, or a patient's personal device), and in-person support from a nurse educator.
How it works
The intervention was tied into the hospital's electronic health record, which provided real-time notifications to the study team when patients missed doses. After an alert, a nurse educator from the study team spoke to the patient and bedside nurse for a median of 10 and two minutes, respectively, and offered patients all three parts of the education bundle, said Dr. Haut. “They could pick and choose which things they wanted. . . . Some patients only want the paper, some patients really like a video, some patients don't want either and they want to talk to a nurse or doctor,” he said.
The group rolled out the bundle for patients on four intervention units and compared the percentage of missed doses of VTE prophylaxis medications to that among patients on 12 control units. The control units saw no significant change in missed doses (13.6% to 13.3%), but the percentage of missed doses dropped from 9.1% to 5.6% on the intervention units, according to results published online in November 2018 by JAMA Network Open.
“That is a statistically significant, huge drop. It's basically over a 40% relative reduction in missed doses of VTE prophylaxis,” said Dr. Haut, lead author of the study and also an associate professor of surgery, anesthesiology/critical care medicine, and emergency medicine at the Johns Hopkins University School of Medicine.
Based on that success, the program is being expanded to most of the hospital.
The biggest challenge has been expanding the grant-funded project without any additional full-time employees, Dr. Haut said. The solution involved convincing nurses that the intervention improves patient care and is not necessarily extra work. “Nurses are already supposed to educate patients—that's their job,” he said. “I think that's probably the biggest barrier we've overcome.”
In addition, as the intervention improved communication between patients and nurses and led to administration of more prophylaxis doses without extra notifications, the whole process became easier, said Brandyn D. Lau, MPH, CPH, an assistant professor of radiology and radiological science and health sciences informatics at Johns Hopkins and senior author of the study. “It is changing practice in a way that subsequently reduces the burden of the intervention,” he said.
One question that remains is what the role of the physician should be after a patient declines the medication, Dr. Haut said. “That is a piece we're actively working on. . . . It very much depends on how this medication is offered,” he said, adding that alternative agents such as newer oral anticoagulants may be an appropriate option in some cases.
In addition to the expansion across the hospital, the effort has moved to Howard County General Hospital, a community hospital within the health system, and Dr. Haut hopes to also expand to other institutions. “We would love to partner with larger groups to try to implement this on a larger scale,” he said, adding that patient education materials are available for free download online.
Words of wisdom
Rather than assuming that patients always receive their prescribed VTE prophylaxis doses, physicians should communicate with nurses to verify administration and should also tell patients why the medication is important when they prescribe it, said Dr. Haut. “Mentioning that up front makes it a lot easier when the nurse goes in and is explaining what each drug is for and why they're getting it,” he said. “It's easier if they've heard about it from the doctor.”