- Michael B Streiff, associate professor of medicine12,
- Howard T Carolan, quality and innovations project administrator3,
- Deborah B Hobson, patient safety clinical specialist, surgical intensive care nurse and coordinator34,
- Peggy S Kraus, clinical specialist for anticoagulation5,
- Christine G Holzmueller, senior research coordinator II, medical writer and editor36,
- Renee Demski, senior director, quality and safety3,
- Brandyn D Lau, medical informatician7,
- Paula Biscup-Horn, clinical pharmacy specialist, anticoagulation management8,
- Peter J Pronovost, professor, director, senior vice president for patient safety and quality 63910,
- Elliott R Haut, associate professor of surgery346911
- 1Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore MD, USA
- 2Department of Pathology, Johns Hopkins University School of Medicine
- 3Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore MD
- 4Department of Surgery, Johns Hopkins University School of Medicine
- 5Department of Pharmacy, Johns Hopkins Hospital, Baltimore MD
- 6Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine
- 7Department of Medicine, Johns Hopkins Hospital
- 8Department of Pharmacy, Allegheny General Hospital, Pittsburgh PA, USA
- 9Graduate Training Program in Clinical Investigation, Johns Hopkins University Bloomberg School of Public Health, Baltimore MD
- 10Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health
- 11Department of Emergency Medicine, Johns Hopkins University School of Medicine
- Correspondence to: E R Haut, Johns Hopkins University School of Medicine, Sheikh Zayed 6107C, 1800 Orleans St, Baltimore, MD 21287
- Accepted 22 March 2012
Problem Venous thromboembolism (VTE) is a common cause of potentially preventable mortality, morbidity, and increased medical costs. Risk-appropriate prophylaxis can prevent most VTE events, but only a small fraction of patients at risk receive this treatment.
Design Prospective quality improvement programme.
Setting Johns Hopkins Hospital, Baltimore, Maryland, USA.
Strategies for change A multidisciplinary team established a VTE Prevention Collaborative in 2005. The collaborative applied the four step TRIP (translating research into practice) model to develop and implement a mandatory clinical decision support tool for VTE risk stratification and risk-appropriate VTE prophylaxis for all hospitalised adult patients. Initially, paper based VTE order sets were implemented, which were then converted into 16 specialty-specific, mandatory, computerised, clinical decision support modules.
Key measures for improvement VTE risk stratification within 24 hours of hospital admission and provision of risk-appropriate, evidence based VTE prophylaxis.
Effects of change The VTE team was able to increase VTE risk assessment and ordering of risk-appropriate prophylaxis with paper based order sets to a limited extent, but achieved higher compliance with a computerised clinical decision support tool and the data feedback which it enabled. Risk-appropriate VTE prophylaxis increased from 26% to 80% for surgical patients and from 25% to 92% for medical patients in 2011.
Lessons learnt A computerised clinical decision support tool can increase VTE risk stratification and risk-appropriate VTE prophylaxis among hospitalised adult patients admitted to a large urban academic medical centre. It is important to ensure the tool is part of the clinician’s normal workflow, is mandatory (computerised forcing function), and offers the requisite modules needed for every clinical specialty.
Contributors: MBS conducted the baseline evaluation, designed the paper order sets, developed the computerised order sets, conceived the research question, and interpreted the results. He is the guarantor for the article. DBH conducted the baseline evaluation, designed the paper order sets, developed the computerised order sets, conceived the research question, collected the data, and interpreted the results. PSK developed the computerised order sets, conceived the research question, and interpreted the results. ERH developed the computerised order sets, conceived the research question, collected the data, designed the data analysis, and interpreted the results. RD conceived the research question, provided administrative support, and interpreted the results. PJP conceived the research question and interpreted the results. HTC conceived the research question, collected the data, and interpreted the results. CGH helped draft and revise the manuscript and interpreted the results. PBH conducted the baseline evaluation and designed the paper order sets. BDL collected the data, designed the data analysis, and interpreted the results.
All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: apart from the disclosures listed below, no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Disclosures: MBS has received research funding from Sanofi-Aventis and BristolMyersSquibb; honoraria for CME lectures from Sanofi-Aventis and Ortho-McNeil; consulted for Sanofi-Aventis, Eisai, Daiichi-Sankyo, and Janssen HealthCare; and has given expert witness testimony in various medical malpractice cases. DBH has given expert witness testimony in various medical malpractice cases. ERH is the primary investigator of a Mentored Clinical Scientist Development Award from the Agency for Healthcare Research and Quality entitled “Does screening variability make DVT an unreliable quality measure of trauma care?”; receives royalties from Lippincott Williams & Wilkins for the book Avoiding Common ICU Errors; and has given expert witness testimony in various medical malpractice cases. PJP receives consultancy fees from the Association for Professionals in Infection Control and Epidemiology; grant or contract support from the Agency for Healthcare Research and Quality, National Institutes of Health, Robert Wood Johnson Foundation, and the Commonwealth Fund; honoraria from various hospitals and the Leigh Bureau (Somerville NJ); and royalties from his book Safe Patients Smart Hospitals. CGH has received a honorarium from MCIC Vermont to speak about organising and writing a manuscript reporting patient safety or quality improvement research.