Multidisciplinary initiative to improve inpatient anticoagulation and management of venous thromboembolism.
OBJECTIVE
The implementation of best practices to optimize inpatient anticoagulation and venous thromboembolism (VTE) management are described.


CONCLUSIONS
A multidisciplinary team of pharmacists, hospitalists, computer prescriber-order-entry system (CPOE) experts, and data specialists was assembled. A VTE management best-practices bundle was designed and implemented using education, CPOE upgrades, clinical decision support, triggered consultation, and checklists. Process performance data were collected from CPOE and chart review. A total of 189 patients with 211 identified VTE events were included in the analysis. Compliance with warfarin adjustment by protocol improved significantly, from 70% before the launch of the order set to 96% afterward. Heparin-warfarin overlap nearly tripled, from 26% to 74%, but still over a quarter of postimplementation cases did not meet this quality measure. While low-molecular-weight heparin (LMWH) was used appropriately in all six postintervention cases of cancer-related VTE, the result was not a significant improvement over the 68% compliance in the period preceding the order set. The prescription rate of compression stockings after leg DVT was low in both periods. Point estimates for mean length of hospital stay improved but did not reach statistical significance. Measures of mortality and readmission rates were limited by sample size and were not significantly changed.


CONCLUSIONS
Implementation by a multidisciplinary team of a VTE management bundle incorporated CPOE upgrades and other interventions. Laboratory testing before warfarin treatment, warfarin education, warfarin adjustment by protocol, and warfarin-heparin overlap improved after the interventions, but LMWH education, compression stocking use, laboratory testing before heparin treatment, and clinical outcomes did not change significantly.
Greg Maynard, M.D., M.S., is Clinical Professor of Medicine; Doug Humber, Pharm.D., is Associate Clinical Professor of Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences; and Ian Jenkins, M.D., is Associate Clinical Professor of Medicine, University of California San Diego Medical Center, San Diego.
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Maynard
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Humber
Ian
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Jenkins
D000925:Anticoagulants / Q000008:administration & dosage / Q000627:therapeutic use*; D002985:Clinical Protocols; D019983:Guideline Adherence; D006495:Heparin, Low-Molecular-Weight / Q000008:administration & dosage / Q000627:therapeutic use; D006801:Humans; D007297:Inpatients; D007902:Length of Stay; D050316:Medical Order Entry Systems / Q000592:standards; D010348:Patient Care Team / Q000458:organization & administration*; D019984:Quality Indicators, Health Care; D054556:Venous Thromboembolism / Q000188:drug therapy*; D014859:Warfarin / Q000008:administration & dosage / Q000627:therapeutic use
D000925:Anticoagulants; D006495:Heparin, Low-Molecular-Weight; D014859:Warfarin