Contributor

Wynne Parry
Essential Insights contributor, healthcare writer
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:
1. Summarize the evidence
2. Pilot test to identify barriers
3. Measure performance
4. Ensure patients receive the intervention
Other best practices
1. Keep it simple
- 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.
2. Solicit feedback and continue to monitor
- 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.
3. Design reliability into the process
- 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.
Effective implementation pays off
- 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.