From the 2018 HVPAA National Conference
Lauren Harter (UPMC), Jennifer Rodriguez (UPMC), Sinthana Umakanthan (UPMC), Terence Harrington (UPMC), Allison Dekosky (UPMC), Gregory Bump (UPMC)
Prior to this project, there were no established guidelines for VTE prophylaxis at UPMC Presbyterian/Montefiore for hospitalized medical patients, and prescribing practices between UFH and LMWH varied. Review of cost associated with these led to an institutional preference for LMWH. This study was therefore initiated to change housestaff prescribing practices.
- To modernize institution-approved guidelines on preferred VTE prophylaxis
- To change prescribing practices among internal medicine housestaff for better compliance
The intervention was conducted at a university hospital amongst housestaff general medicine teams. We first created a flowchart to guide clinicians on VTE selection. Flowchart posters were placed in all housestaff medicine team rooms. Additional universal interventions included a lecture focused on this new recommendation, education to hospitalists at routine meetings, as well as several mentions in resident morning report.
We then implemented a peer-to-peer education and feedback process on half of our medicine teams, with a non-randomized, convenience sample. The intervention teams were educated in-person at the beginning of each rotation regarding the new recommendations. They subsequently received in-person feedback based on patient audits, initially once a month, then expanded to twice a month.
After several months we introduced a financial incentive to residents and other frontline providers to meet goals for appropriate VTE prophylaxis prescription. As part of this incentive, peer-to-peer education was extended to include all medicine teams. This was completed in e-mail form, which also provided education on preferred prophylaxis and feedback on how each team was doing on a biweekly basis compared to the institution’s goal.
Every other week, beginning August 2017 in a continuous process, data was collected regarding current VTE prescription on all patients admitted to the housestaff medicine teams and analyzed via run charts. Data collection will continue through June 2018.
Prior to initiation of study, UFH was prescribed 55% of the time in patients for whom enoxaparin was LMWH was preferred. This rate has improved significantly to 13% on the most recent monthly average. Interim data has shown an improvement in appropriate VTE prophylaxis. At study initiation 83% of patients received guidelines consistent DVT prophylaxis, with improvement to greater than 90% on biweekly average.
This study found peer-to-peer education to be an effective model for changing VTE prophylaxis prescription to reflect institutional guidelines. Applying different techniques over an extended period of time allowed this education to reach enough residents to sustain change.
Implications for the Patient
While this particular study focused on VTE prophylaxis, its value lies in its demonstration of effective change in our housestaff’s prescribing practices. We effectively used peer-to-peer education and feedback, along with other tools, to implement a new guideline. This is broadly applicable for other interventions aimed at changing housestaff practice.