Evaluation of Venous Thromboembolism Prevention Practices in US Hospitals

Background

Hospital-associated venous thromboembolism (HA-VTE) is a significant, deadly, costly, and growing public health problem. While as many as 70% of cases of HA-VTE in patients could be prevented, proven VTE prevention strategies are not applied systematically across U.S. hospitals systems. There is a need to assess and better understand the landscape around VTE prevention practices in U.S. hospitals.

Methods

The Joint Commission and the Centers for Disease Control and Prevention (CDC) collaborated in the development of a probability-based hospital survey collected in accordance with the American Association for Public Opinion Research guidelines. The population comprised all U.S. and territorial general medical, general surgical, and critical-access hospitals in the 2019 American Hospital Association database. Hospitals were stratified by bed size (small ≤100 beds; medium 100-399 beds; and large ≥400 beds), then randomly sampled an equal number of hospitals in each group. The intended respondent was the chief medical officer, director of quality or safety, or person of a similar title. The questionnaire comprised 44 items, including topics on hospital policies and protocols, barriers to implementation of VTE prevention practice, quality monitoring and improvement efforts, and risk assessment activities. The χ2 test was used to examine differences in response rates by hospital characteristics. This project was deemed non-research in accordance with federal regulation for the protection of human subjects in research.

Results

There were 4605 eligible hospitals, of which 1290 were randomly selected for the sample, and 1212 had available contact information and were presumed reached. Of these, 311 submitted sufficient data for inclusion, a response rate of 25.7%. Response rates did not differ significantly by location (urban vs rural) or bed size, however major teaching hospitals were more likely to respond than minor or non-teaching hospitals (p<.001). (Table 1)

More than half of hospitals reported having a VTE prevention policy (58.0%) (Table 2). Most had a hospital-wide VTE prevention protocol (81.5%) and/or unit-specific protocols (59.9%). Less than half had a VTE prevention team, committee, or workgroup and only 21.8% had a designated VTE prevention team and 19.2% reported VTE prevention activities were addressed by another committee. Large hospitals were more likely to have a designated team (p<.001). When a team or committee exists, there is representation from at least 2 departments (96.7%).

Almost 80% reported they have clinical decision support (CDS) tools to help guide the selection of appropriate VTE prophylaxis for medical and surgical patients. The availability of CDS was greater in large and medium hospitals for both medical and surgical units (p<.002). Approximately 60% reported that their admission order sets addressed VTE prophylaxis and completion is mandatory. Reminders or alerts are provided for patients by about 60% of hospitals. Missed anticoagulant doses are routinely documented at 80.1% of hospitals. Around 50% of hospitals reported they conduct audits and provide feedback related to VTE prophylaxis for patients.

Over 70% of hospitals educate patients about VTE prevention, including the importance of VTE prophylaxis, during the hospitalization; a little more than a third of hospitals provide annual VTE prevention education to clinicians. About half reported they have an ambulation protocol for patients. There were no variations by hospital bed size for education or ambulation protocols.

Data on the number of newly diagnosed HA-VTE is collected in 75.6% of hospitals. This was lower in small hospitals (p=.004). Whereas just 44.7% track the number of patients with bleeding events and/or complications related to anticoagulant prophylaxis. Only 43.7% collect data on the patients receiving appropriate VTE prophylaxis and even fewer collect data on of patients receiving risk assessment (29.3%).

Conclusion

This survey of hospital VTE prevention practices identified numerous areas for improvement in the establishment and implementation of HA-VTE prevention policies and procedures. Overall, there were limited differences in prevention practices based on hospital bed size. Improving the awareness and application of evidence-based guidelines and interventions may reduce the incidence of HA-VTE.