Decreasing Missed Doses of Chemoprophylaxis to Improve Venous Thromboembolic Rates in Neurologic Patients

From the 2019 HVPAA National Conference

Dr. Alexis Steinberg (University of Pittsburgh), Dr. Lauren Brandes (University of Pittsburgh), Ms. Sarah Cook (University of Pittsburgh), Ms. Therese Dawson (University of Pittsburgh), Dr. Shashvat Desai (University of Pittsburgh), Ms. Amy Lukanski (University of Pittsburgh), Dr. Lori Shutter (University of Pittsburgh), Dr. Joshua Levenson (University of Pittsburgh)


Neurologic patients are at high risk for developing pulmonary embolism and deep venous thrombosis. Previously at UPMC, a venous thromboembolism (VTE) prophylaxis protocol for Neurologic Patients did not exist. Decreasing missed doses of VTE prophylaxis has been identified as a modifiable factor to reduce VTE.


To create a quality improvement (QI) project focusing on improving rates of venous thromboembolism (VTE) in Neurology patients by decreasing the number of missed doses of chemoprophylaxis.


In September 2017, a nurse and physician stakeholder workgroup was formed to design a new VTE prophylaxis protocol for Neurology patients with acute ischemic stroke, non-traumatic intracerebral hemorrhage and general neurologic problems. In January 2018, our new protocol switched chemoprophylaxis from two- or three- times daily unfractionated heparin (UH) to once daily low molecular weight heparin (LMWH). Additionally, Neurology nursing education was initiated November 2017 with more focused education starting in January 2018. Education included SCD utilization, mobility, no missed doses of anticoagulation, and patient education.


A total of 4700 Neurology patients were analyzed, 2300 (49%) patients from before protocol implementation and 2400 (51%) after protocol was initiated. Rates of LMWH increased significantly after starting our protocol (2% before vs 85% after), demonstrating a switch from UH to LMWH. In one year, our VTE prophylaxis protocol reduced missed doses by a relative reduction of 41%. Before intervention, the rate of missed doses was 8.57% and afterwards it decreased to 5.1% (p value = < 0.0001). After QI intervention implementation, the missed doses rates decreased for both the Neurology floors and Neurovascular ICU patients. The rate of missed doses in Neurovascular ICU decreased from 5.0% to 3.17%, which is lower than the average missed doses rate in 2018 for all Neurology patients. In contrast, the missed doses rate on the Neurology floors decreased from 9.50% to 5.6%, indicating an area for future improvement. Over the one year period, the amount of injections that nursing had to administer was reduced by 6000 subcutaneous injections.


Development of a new VTE prophylaxis protocol using daily LMWH and dedicated nursing education significantly decreased rates of missed VTE chemoprophylaxis doses. After protocol initiation, missed doses were lowest in the Neurovascular ICU, indicating an area for future improvement which would target to Neurology floors. The QI intervention also led to decreased nursing workload. The impact of lower missed VTE chemoprophylaxis doses on rates of VTE in Neurology patients is a focus of future analysis.


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