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Hospitalized patients not receiving all VTE prophylaxis doses
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Nearly 12% of venous thromboembolism prophylaxis doses ordered for hospitalized patients to reduce the risk of blood clots were not administered, according to a retrospective review of electronic medication administration records.
The rate of missed doses — which researchers described as “unacceptably high” — may be due at least in part to unnecessary concern on the part of patients and their caregivers, according to Kenneth M. Shermock, PharmD, PhD, director of the Center for Medication Quality and Outcomes at Johns Hopkins Hospital.
“There appeared to be a lack of understanding about the risks and benefits of blood thinners among patients and medical staff, even though the research is clear that blood thinners are very effective at preventing blood clots,” Shermock said in a press release. “Blood clots and their resulting effects are the most common cause of avoidable death for hospitalized patients, and we’ve got a medication that can prevent most of these events, but too many patients are not benefitting.”
As part of their study, researchers aimed to identify efficient interventions that are grounded in patterns of non-administration of prophylactic VTE therapies.
The analysis included adult patients who had hospital stays during a 7-month period at Johns Hopkins Hospital. The review accounted for 103,160 prophylaxis doses assigned during 10,516 patient visits. Eligible participants had been assigned pharmacologic VTE prophylaxis with unfractionated heparin or enoxaparin.
The proportion of ordered doses not administered served as the primary outcome measure. This was assessed at the patient, floor and floor type levels. The analysis included patients from 29 floors — 11 medicine floors, nine surgery floors, four neurology floors and five intensive care units.
Overall, the non-administration rate was 11.9%. Patient or family member refusal was the most commonly documented reason (59%). In other cases, patients were in surgery or undergoing tests on a different floor at the time the doses were scheduled to be administered.
About 60% of patients received all ordered doses. Approximately 19% of the cohort missed at least one-quarter of scheduled doses, and 8% missed more than half of their ordered doses. About 20% of patients accounted for 80% of missed doses, according to the researchers.
Heterogeneity in non-administration was reported at the floor level (range, 5%-27%).
Patients on medicine floors missed 18% of assigned doses vs. the 8% missed dose rate observed on other floor types (OR=2.4; P<.0001).
“The heterogeneity in non-administration rate between patients, floors and floor types can be used to target interventions,” the researchers concluded.
Electronic medical records show in real time which patients refused their medication, and that information can be used to stage immediate interventions, the researchers added.
“We want to be able to get to these patients before there is an adverse event,” Shermock said.
Michael B. Streiff
Some patients are at low risk of developing blood clots, raising questions about whether all patients on medical floors need prophylactic blood thinners, according to researcher Michael B. Streiff, MD, associate professor of medicine and pathology in the division of hematology at Johns Hopkins. However, no well-validated tool exists to identify which patients require prophylaxis.
“The nurses may be exactly right that some of the patients don’t need blood thinners, but more research is needed,” Streiff said in a press release.
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