International Journal for Quality in Health Care Advance Access originally published online on October 18, 2005
International Journal for Quality in Health Care 2006 18(2):123-126; doi:10.1093/intqhc/mzi083
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Quality in Practice
Prevention of perioperative venous thromboembolism and coronary events: differential responsiveness to an intervention program to improve guidelines adherence
1 Faculty of Medicine, Hebrew University of Jerusalem, Israel, 2 Department of Anesthesiology, Hadassah Hebrew-University Hospital, Ein Kerem Campus, Jerusalem, Israel, 3 Department of Hematology, Hadassah Hebrew-University Hospital, Ein Kerem Campus, Jerusalem, Israel, 4 Adult Echocardiography Laboratory, The Heart Institute, Hadassah Hebrew-University Hospital, Ein Kerem Campus, Jerusalem, Israel, 5 Department of Obstetrics and Gynecology, Hadassah Hebrew-University Hospital, Ein Kerem Campus, Jerusalem, Israel, 6 Department of Surgery, Hadassah Hebrew-University Hospital, Ein Kerem Campus, Jerusalem, Israel and 7 Quality & Safety Committee, Hadassah Hebrew-University Hospital, Ein Kerem Campus, Jerusalem, Israel
Introduction. Prevention of venous thromboembolism and coronary events (with ß-blockers) during and after surgery is at the top of a list of safety practices for hospitalized patients, recommended by the Agency for Health Care Research and Quality (AHRQ). We wished to determine and improve adherence to clinical guidelines for these topics in our institution.
Patients, material, and methods. A prospective survey was conducted over several weeks on operated patients in a 1200-beds medical center (a teaching, community and referral hospital in Jerusalem, Israel). Eligibility for and actual administration of prophylactic treatment with anticoagulant and ß-blockers were determined. Following an intervention program, which included staff meetings, development of local protocols, and academic detailing by a nurse, the survey was repeated.
Results. In general, adherence to recommended anticoagulation prophylaxis was low, found in only 29% [95% confidence interval (CI) = 23–36] of eligible patients. After the intervention, adequate anticoagulation increased to 50% (95% CI = 40–59) of eligible patients (P < 0.001). Initiation of ß-blockers in preventing perioperative cardiac events was very low (0%, 95% CI = 0–5%) and did not increase after intervention.
Conclusions. Adherence to guidelines for prevention of surgical complications was found to be low in our institution. A multifaceted intervention significantly increased use of prophylaxis for venous thromboembolism but not for coronary events. This differential response suggests that the success of a quality improvement project strongly depends on topic content and its phase of acceptance.
Keywords: academic detailing, barriers to quality improvement, beta blockers, diffusion of innovations, guidelines adherance, thromboembolism prophylaxis
Address reprint requests to M. Brezis, Center for Clinical Quality & Safety, Hadassah Hebrew-University Hospital, Ein-Kerem, PO Box 12000, Jerusalem 91120, Israel. E-mail: brezis{at}vms.huji.ac.il
Accepted for publication September 18, 2005.
The Agency for Health Care Research and Quality (AHRQ) recently listed priority practices to improve the safety of hospitalized patients [1], and at the top of this list is the prophylaxis to prevent venous thromboembolism in at-risk patients and the use of perioperative ß-blockers. These practices were prioritized because of the strength of evidence regarding their effectiveness and safety, because of their potential impact, and because of their relative ease of implementation [1]. Our institutional Committee for Quality and Safety decided to examine adherence to these recommendations by the AHRQ in our hospitals. This article presents the results of a 2-year survey and of an intervention program.
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Methods |
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Study setting
The study took place at Hadassah Medical Center, the leading academic institution for the Faculty of Medicine of the Hebrew University of Jerusalem, which operates two sites: a larger (900 beds) hospital (Ein Kerem campus) and smaller (300 beds) hospital (Mount Scopus campus). The study was exempted from the local institutional review board.
Study timeline
During a period of 7 weeks in 2002, data were collected from the operating theater daily logbook on all surgical patients (including general surgery, gynecology, orthopedic surgery, and surgical subspecialties). After several months of intervention, another survey was conducted over another few weeks in the latter half of year 2003, using the same methodology.
Data collection
Presence of eligibility criteria for prophylaxis was recorded, based on recent literature for venous thromboembolism [2] as discussed in chapter 31 of reference [1] and for ischemic heart disease [3] as discussed in chapter 25 of reference [1], including the absence of contra-indications to prophylaxis as summarized in Table 1. The rate of each prophylaxis usage was calculated from the total number of eligible patients, without contra-indications, who actually received it.
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Intervention
As prophylaxis utilization was found to be low, an intervention was designed and included (i) presentation and discussion of the data with a review of the literature at staff meetings of surgery, gynecology, and anesthesiology; (ii) development of local protocols, adapted from recommendations by professional agencies [1] in agreement with senior cardiologist (DG), hematologist (DV), anesthesiologists, and surgeons, and approved by department heads; (iii) academic detailing: for several months during the first half of 2003, a nurse was available to the ward staff in Ein Kerem to identify untreated patients at risk and, using face-to-face encounters with physicians, to discuss the recommendations and encourage their implementation. The Surgery Department at Mount Scopus was not exposed to any intervention and was used as a control group. The Gynecology Department at Mount Scopus shares all educational and administrative activities with the Gynecology Department at Ein Kerem and therefore received a partial intervention based on [i] and [ii] but without academic detailing.
As this work was designed to measure processes rather than outcomes [4], no attempt was made to examine incidence of venous thromboembolism or coronary events—for which a meaningful evaluation would have required a much larger sample. Likewise, no systematic attempt was made to examine side effects from treatment. Because observations in our hospitals revealed that early ambulation after surgery was the rule while use of intermittent pneumatic compression was the exception, no quantitative evaluation of these preventive measures was carried out.
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Results |
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Venous thromboembolism prophylaxis
Before the intervention, out of 704 operated patients, 241 were found eligible for venous thromboembolism prophylaxis and less than half of these patients received prophylaxis (generally with low molecular weight heparin, enoxaparin). As summarized in Table 2, except for orthopedics, where prophylaxis usage was close to 100%, in all other departments, prophylaxis usage was lower than 50% and even lower than 20% in gynecology. When used, prophylaxis was mostly given to high or very high-risk patients as defined in [2].
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Departments with a rate of venous thromboembolism prophylaxis usage lower than 50% were targeted by the intervention. As summarized in Table 2, the rate of prophylaxis increased in most departments exposed to the intervention from an average of 29 [95% confidence interval (CI) = 23–36] to 50% (95% CI = 40–59) (P < 0.001). At the same time, the rate of prophylaxis in surgery Mount Scopus (MS), not exposed to any intervention, remained low.
Beta-blockers prophylaxis
A preintervention survey, among 602 patients that were operated in our medical center, found 75 patients eligible for perioperative prophylactic treatment with ß-blockers: 18 had known coronary artery disease and 57 had at least two risk factors for it. None of these patients began receiving such treatment. On the other hand, in all 43 patients routinely taking ß-blockers before surgery, this treatment was not discontinued.
After the intervention, no significant difference was noted: a repeated survey of 475 patients undergoing non-cardiac operations found 72 patients eligible for perioperative prophylactic treatment with ß-blockers (18 had known coronary artery disease and 54 had at least two risk factors for it). Again, none of these patients began receiving such treatment.
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Discussion |
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We found low compliance with two priority patient safety practices advised by the AHRQ [1]. After a multifaceted intervention, the rate of venous thromboembolism prophylaxis usage significantly rose from 29 to 50% of eligible patients. Suboptimal venous thromboembolism prophylaxis is common [4–8] and, as shown by others, can be improved by active enforcement [4,8]. By contrast, the perioperative use of ß-blockers was essentially non-existent and did not increase after the intervention.
We were surprised by the resilience to change with regard to the use of perioperative ß-blockers: although the medical staff knew and generally accepted the recommendations, they did not implement them (except that ß-blockers were not discontinued). One department head even said: ‘it is easy: when you stop aspirin before an elective operation, start atenolol’. Medical students reported that surgeons began asking them at exams about perioperative use of ß-blockers. The Head of Surgery in the Ein Kerem Campus notified one of us (MB) about new literature reports on the value of perioperative ß-blockers. Recognition of the issue was not sufficient to lead to implementation of a guideline.
Discussion with physicians confirmed what others have reported about underutilization of perioperative ß-blockers, ascribing it to doubts about efficacy, concern of adverse drug effects, and reluctance to change [9]. An additional reason may be the equivocal responsibility for implementation: the surgeon thinks this is a problem for cardiologists or internists (who do not see most of the patients) or for anesthesiologists (who see the patients too late). Another reason, also true for venous thromboembolism prophylaxis, is the need for the clinician to recognize multiple risks and contra-indications of the treatment (Table 1) for which a computer-based reminder might be useful [10].
Lack of physician concordance with guidelines has been recognized and analyzed [11]. Types of intervention programs and their success rates to improve guidelines adherence vary considerably [12–15]. Our study shows differential uptake of guidelines by identical teams, under comparable conditions and following a similar intervention. Our results suggest that implementation of a guideline largely depends on its content and phase of acceptance. Venous thromboembolism prophylaxis, largely known and already in use to a variable extent, was boosted by our intervention by mode of reinforcement. Perioperative usage of ß-blockers, a relatively new idea [3] largely unknown to our teams before the start of our project, was unchanged by our intervention, probably at least in part because physicians were at earlier phases of guideline learning, including lack of awareness, familiarity, or agreement [11]. Our observations gave us an opportunity to look at two different stages in the diffusion of innovations [16].
Within the venous thromboembolism prophylaxis, we also observed a differential response to our intervention, as summarized in Table 2. Improvement was obvious in Surgery A (where baseline usage was low), but not in Surgery B (where baseline usage was high), perhaps because physicians in Surgery B felt more complacent or because of a ‘ceiling’ effect (whereby administration of enoxaparin to low-risk patients raises more concerns about adverse effects versus benefits). Of note, as summarized in Table 2, within the same Division of Gynecology, comparable degrees of improvement were noted in the Ein Kerem campus, with academic detailing, as in Mount Scopus campus, without academic detailing. It is possible that the development and promulgation of a local division protocol was the main cause for the improvement noted in this setting, regardless of the help from the visiting nurse. This study emphasizes the need for more research to better understand and utilize successful modalities for implementation of clinical guidelines.
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Acknowledgement |
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Ms Ilana Gross, B.Sc., R.N., provided excellent help in academic detailing and data collection. A. Grupper, A. Grupper and D. Rudin were medical students at the time of the study, which was performed as part of their MD thesis.
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References |
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