title: Implementation of clinical practice guidelines for prevention of thromboembolism in spinal cord injury.
abstract: OBJECTIVE
  The purpose of this study was to determine whether publication of the "Prevention of Thromboembolism in Spinal Cord Injury" clinical practice guideline (CPG) changed patient management and whether adherence to CPG recommendations improved after a targeted implementation strategy.
  
  
  METHODS
  Data were abstracted from medical records of 134 and 520 patients with acute and chronic spinal cord injury (SCI), respectively, from 6 Veterans Affairs medical centers over 3 time periods: prepublication (T1), preimplementation (T2), and postimplementation (T3) of the CPG. Targeted interventions were developed to address provider-perceived barriers to guideline adherence, based on findings from focus groups conducted at each site. The interventions incorporated two implementation strategies: standardized documentation templates/standing orders and social marketing/outreach visits.
  
  
  RESULTS
  Use of the specified duration for pharmacologic prophylaxis increased from 60% to 65% to 75% of patients with acute SCI in T1, T2, and T3, respectively (P = 0.060 and 0.041 for T1 vs T2 and T2 vs T3, respectively). Rates of use for individual pharmacologic prophylaxis agents changed significantly over the course of the study, with use of low-molecular-weight heparin increasing from 7% in T1 to 42% in T3. Physical assessments for thrombosis on hospitalization days 1 and 30 improved between T2 and T3. Use of prophylaxis in chronically injured patients with new risk factors for thromboembolism increased from 16% to 31% to 34% during T1, T2, and T3 (P = 0.001 and 0.87, respectively).
  
  
  CONCLUSIONS
  The CPG publication had only a modest effect on practice. Use of structured implementation further increased the adherence to some CPG recommendations for thromboembolism prophylaxis. Similar implementation strategies should be considered for CPG recommendations with low adherence and high potential for morbidity and mortality.
authors.affiliation: Spinal Cord Injury Service (128), VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle WA 98108, USA. spburns@u.washington.edu
authors.forename: Stephen P
authors.initials: SP
authors.lastname: Burns
authors.forename: Audrey L
authors.initials: AL
authors.lastname: Nelson
authors.forename: Helen T
authors.initials: HT
authors.lastname: Bosshart
authors.forename: Lance L
authors.initials: LL
authors.lastname: Goetz
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Harrow
authors.forename: Kevin D
authors.initials: KD
authors.lastname: Gerhart
authors.forename: Harriet
authors.initials: H
authors.lastname: Bowers
authors.forename: Barbara
authors.initials: B
authors.lastname: Krasnicka
authors.forename: Marylou
authors.initials: M
authors.lastname: Guihan
mesh_terms: D000328:Adult; D005260:Female; D019983:Guideline Adherence; D006787:Hospitals, Veterans; D006801:Humans; D033181:Information Dissemination; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D012189:Retrospective Studies; D013119:Spinal Cord Injuries / Q000150:complications*; D013923:Thromboembolism / Q000209:etiology* / Q000517:prevention & control*