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‘Active learning’ module improves VTE prophylaxis administration
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A dynamic learner-centered education module appeared more effective than a linear static education module for engaging nurses and improving the administration of necessary doses of venous thromboembolism prophylaxis, according to study results.
“We teach in hopes of improving patient care, but there is actually very little evidence that online professional education can have a measurable impact. Our results show that it does,” Elliott R. Haut, MD, PhD, FACS, vice chair of quality, safety and serve in the department of surgery at The Johns Hopkins University School of Medicine, said in a press release.
Many successful interventions have improved venous thromboembolism (VTE) prophylaxis for hospitalized patients. Yet, a significant proportion of doses of prescribed preventive medications are not administered to these patients.
Haut and colleagues evaluated the effectiveness of nurse education on medication administration practice for more than 900 nurses at The Johns Hopkins Hospital. Researchers randomly assigned nurses to either a dynamic approach module — which included a scenario-based experience in which nurses selected responses within given clinical scenarios — or a static approach module, which included a PowerPoint slide show in combination with traditional voiceover explaining the information.
Nonadministration of prescribed VTE prophylaxis medication served as the primary outcome measure, and nurse-reported satisfaction with education modules served as a secondary outcome.
Nonadministration improved significantly after education (12.4% vs. 11.1%, conditional OR = 0.87; 95% CI, 0.8-0.95). The reduction in nonadministration appeared greater in the group randomly assigned to the dynamic approach (10.8% vs. 9.2%; conditional OR = 0.83; 95% CI, 0.72-0.95) than the static arm (14.5% vs. 13.5%; conditional OR = 0.92; 95% CI, 0.81-1.03), but the difference did not reach statistical significance.
In addition, satisfaction scores were significantly higher for all survey items for nurses assigned the dynamic approach (P < .05).
HemOnc Today spoke with Haut and Brandyn Lau, MPH, assistant professor of radiology and health sciences informatics at The Johns Hopkins University School of Medicine, about the study, the ease of use of this online education tool, and what still must be confirmed in future research.
Question: What prompted this study?
Haut: We have been working on improving prophylaxis for VTE as a group for at least 10 years now at Johns Hopkins, and we have spent many years getting the physicians to write the right orders for VTE prophylaxis. This was the first step. We thought once we did this, we could fix the problem. As it turns out, getting this part done did not necessarily equate to better administration of prophylaxis, because we realized that patients were missing doses for a variety of reasons, some of which were documented as patient refusal. As we delved into this more deeply, some of these refusals were actually the nurse making the decision that the patient did not need the medication. Once we realized the bedside nurse was a critical piece in this equation, we decided to focus on targeting this specific nurse-patient interaction.
Lau: This research was prompted through a multiyear initiative. Our research group, The VTE Collaborative, has been in existence since 2005 when a lot of emphasis was placed on improving risk assessment and prescribing appropriate prophylaxis for VTE. This was met with great success through the implementation of clinical decision support and giving feedback to prescribers. When we looked at differences in administration, we actually noticed that a substantial number of doses of prescribed medication to prevent VTE were not being administered to patients. We recognized there was a huge gap in opportunity to improve communication between nurses and patients. We wanted to ensure that everyone had at least a baseline idea about the basic harms and benefits of VTE prophylaxis.
Q: How did you conduct the study?
Haut: We received funding for a project originally focused on patient-nurse communication as a piece of targeting these missed doses of VTE prophylaxis for hospitalized patients. As we were working on patient education in parallel, we noticed nurses needed education, too. Some nurses were deciding to hold, skip or not give these medications due to commonly held misconceptions. We recruited 933 permanently employed nurses between April 1, 2014, and March 31, 2015. We created a dynamic education module experience that featured Q&As instead of the ‘death by PowerPoint’-type learning. If the nurse gets the question correct, it takes them in one direction; if they get the question wrong, it takes them in another direction and teaches them more. Our main hypothesis was that education could work to improve nurses’ knowledge and more doses of these medications being administered. A secondary hypothesis was that one education tool was going to be better than another tool. We followed the outcomes of the patients that nurses were treating to see if the practices of those nurses changed.
Q: What did you find?
Haut: Education works. It seems obvious because people have been educating in health care for forever, but I think the finding was important that this education works to improve clinical care, not just tests of knowledge. There have been many things to show that education improves knowledge. This already exists. It is harder to find research that shows education works to change clinicians’ practice. The measurement was not if they received a higher score on the test; the primary outcome measure was seeing if the patients received more doses after the nurse received the education. This is one example of education that I know for certain has been proven to change practice. Moreover, we think that the new education worked better. The clinical outcome difference was small and not statistically significant. However, when combining this small difference along with the dramatically higher satisfaction rates among the nurses, they were much happier with this newer education model. This is now the type of education that we will be using at our hospital.
Lau: The more engaging approach of having nurses participate throughout the entire course was more beneficial. Overall, we were delightfully surprised to see that they actually found this education module engaging and applicable to their practice. In general, they were much more satisfied after taking the dynamic module test.
Q: What are the clinical implications of the findings?
Haut: We know that missed doses of VTE prophylaxis are associated with VTE events. In general, patients who miss doses are more likely to get VTE. Knowing this, whatever we can do to prevent the missed doses will hopefully impact the negative clinical outcomes of these patients. If we can educate more nurses and more nurses are successfully administering these doses, this is one way we can prevent VTE events from occurring.
Lau: The direct clinical implications are somewhat nebulous at this point. We know patients are missing doses, and we know that missing doses is potentially associated with developing VTE. The challenge is, we do not know how many doses it takes to place a patient from moderate risk for VTE to high risk for VTE. When looking at the evidence, all trials have closely monitored that the medication is being administered to patients. The overall clinical implications of this is that we can ensure that every patient is receiving every dose as prescribed, and we are getting closer and closer to real-world effectiveness of VTE prophylaxis that we see in the clinical trials.
Q: How easy is it for other institutions to replicate this?
Haut: It will be a lot easier very soon. We have the active-learning education module built into our learning system within Johns Hopkins Medicine. Nurses at Johns Hopkins Medicine can log in to the course and take it for free. We are collaborating to move this from only being available at our institution to an external learning system so we can get this out to as many nurses as possible outside of Johns Hopkins. Our goal is to be able to send the link so any nurse across the United States can participate in this education module online and receive the same education to improve VTE prophylaxis for hospitalized patients.
Q: What else needs to be confirmed or examined in future research?
Haut: Missed doses of VTE prophylaxis is an ongoing problem at our hospital and health system, as well as other institutions nationwide. The first thing to confirm is to see if this is, in fact, as large of a problem at other institutions. Also, can this education improve prophylaxis at other institutions? Basically, we want to know if we can reproduce this and whether it is applicable at other places.
Lau: We have an NIH grant to explore how many doses a patient can miss before they are certain to clot. We really need to figure out who is at high risk for clotting and missing VTE prophylaxis. We need to ensure that we are effectively communicating the harms of VTE prophylaxis. Beyond this — and perhaps more applicable to this current study — is that we need to find out what those continued barriers are. We have shown a continued improvement in administration, but I would argue that the proportion of doses missed is still unacceptably high. We need to figure out what is not working and what needs to be done to ensure that we are doing all we can to effectively communicate the harms to try and improve administration practices. We are not trying to force patients to take the medications. We respect patients’ autonomy to refuse medication or any treatment that they wish. We only want to make sure that they are making an informed refusal and that we have done everything in our power to explain the risks and benefits.
Q: How can this effort specifically benefit patients with cancer?
Lau: Patients with cancer are at extremely high risk for developing VTE. We see a number of patients in our oncology population who develop VTE. There has been some work looking into patients with cancer who undergo surgery where they are receiving prophylaxis after discharge because they are at significantly high risk even after they leave the hospital. When these patients actively leave the hospital, we are not able to monitor every dose that is administered all the time. These patients need to know the harms and benefits of VTE prophylaxis, and we need to effectively communicate this while they are still in the hospital.
Q: Is there anything else that you would like to mention?
Lau: People do not oftentimes look at how we educate people. Education is a formulaic approach to what needs to be covered. One of the exciting things about this is that we rigorously tested two different methods of education, and it really goes to show that it is not what you are teaching, but how you teach it that will help to make a difference in the way that people practice in health care. – by Jennifer Southall
Reference:
Lau BD, et al. PLoS One. 2017;doi:10.1371/journal.pone.0181664.
For more information:
Elliott R. Haut, MD, PhD, FACS, can be reached at The Johns Hopkins University School of Medicine, Zayed 6107C, 1800 Orleans St., Baltimore, MD 21287; email: ehaut1@jhmi.edu.
Brandyn Lau, MPH, can be reached at Johns Hopkins Medicine, 600 N. Wolfe St., Baltimore, MD 21287; email: blau2@jhmi.edu.
Disclosure: Haut and Lau report support from the Patient-Centered Outcomes Research Institute, the Agency for Healthcare Research and Quality, and the NIH/NHLBI.