How Johns Hopkins made venous thromboembolism protocols more effective

One hospital's success offers insights on the ways an institution can set itself up for success.

Evidence-based practices result in better outcomes, but putting them into practice is the tricky part. The Agency for Healthcare Research and Quality (AHRQ) stresses the importance of effective implementation of protocols for venous thromboembolism (VTE), noting that it can increase adequate prophylaxis rates to 80% or more.

However, without comprehensive execution, even an excellent protocol will fail.

In 2005, an audit at The Johns Hopkins Hospital found that only 33% of 322 surgical patients received appropriate VTE prophylaxis. To improve performance, the hospital formed a VTE Collaborative, which at first included two physicians, a nurse, and a pharmacist before growing into a much larger group, notes an account in the Journal of Hospital Medicine.

Ultimately, the collaborative developed mandatory clinical decision support (CDS) tools to stratify risk and prescribe appropriate prophylaxis for 16 specialties. It developed and implemented these tools using the Translating Research into Practice model, an effort described in the British Medical Journal. Here is how the model's four steps played out:

The collaborative first reviewed professional VTE prevention guidelines and identified the most relevant practices. To start off, they developed one-page, paper order sets for six clinical services. Collaborative members met with clinicians to explain the goals and establish consensus.

Paper order sets turned out to be cumbersome, so the collaborative turned to an electronic system. The group requested that a CDS tool be built into the hospital's computerized physician order entry (CPOE) system. The collaborative then developed 16 evidence-based, specialty-specific order sets using flowchart-style decision-making algorithms that capture risk factors, contraindications, and recommended prophylaxis. The first of these order sets was pilot tested on orthopedic spine surgery in 2007, with other specialties following.

A web-based database made it possible to assess performance at the level of the institutional, department, division, service, and individual provider.

Departmental meetings, annual hospital-wide symposia, monthly audits, and collaboration with local service champions helped keep staff educated and engaged. Incentives have included individual bonuses and a pizza party.

• Nest the VTE protocol within larger order sets. At Johns Hopkins, it is embedded within specialty-specific admission and transfer order sets.
• Minimize data entry by auto-populating information drawn from a patient's medical records.
• Automatically generate recommendations for risk-appropriate prophylaxis. At Johns Hopkins, clinicians can order the recommended intervention or a different option.
• Integrate the protocol into the existing workflow. Clinicians will reject an intervention that interrupts workflow, the AHRQ cautions.

• Seek input from those using the protocol during its pilot phase.
• Plan to continue to improve. The AHRQ recommends monitoring order set use and designing an ongoing process to identify the cases that may fall through the cracks and address the issues responsible.

• Make it mandatory to follow the protocol by using a forcing function in the electronic order set. Requiring clinicians to assign risk factors and contraindications ensures every patient undergoes a risk assessment. The Johns Hopkins team found this measure ensured consistency.

After implementing this new approach to prevention, Johns Hopkins saw impressive results. Studies of trauma and medicine patients, for example, revealed improvements in two metrics: prescription of prophylaxis and harm caused by VTE. Meanwhile, no increase in major bleed events occurred, according to the Journal of Hospital Medicine.

• For trauma patients, appropriate prescriptions increased from 66.2% to 84.4% 
• Preventable harm dropped from 1% to 0.17% 
• For medical patients, appropriate prescriptions increased from 65.6% to 90.1% 
• Preventable harm dropped from 1.1% to 0%

The collaborative has continued to push for improvement by, for example, developing patient education materials.

To learn more about lessons from Johns Hopkins and other institutions, download our free eBook, Implementing a venous thromboembolism (VTE) protocol.