Pharmacy News

Managing Missed Doses Could Improve VTE prevention

[April 15, 2014, AJHP News]

Kate Traynor

BETHESDA, MD 31 Mar 2014—Preventing venous thromboembolism (VTE) in hospitalized patients requires both ordering anticoagulant prophylaxis and ensuring that the drugs are administered to patients—and the latter step doesn't always occur, according to a recent report.

A research team at Oregon Health & Science University found that nearly 60% of 202 patients admitted to the health system's trauma center for trauma or general surgery missed at least one dose of enoxaparin that had been ordered for VTE prevention. These patients were found to be at increased risk for deep vein thrombosis (DVT), a major type of VTE.

According to the report, just two variables—interrupted enoxaparin therapy and patient age of 50 years or older—were associated with the increased DVT risk. The report, published online February 26 in JAMA Surgery, described the missed doses as the only identified risk factor that can be ameliorated by clinicians.

The Centers for Disease Control and Prevention (CDC) estimates that more than 500,000 cases of VTE are diagnosed in hospitalized adults each year. Hospitalization is a major risk factor for VTE, and many cases are preventable, according to CDC.

The Centers for Medicare and Medicaid Services (CMS) does not reimburse hospitals for costs associated with certain VTEs, and the Joint Commission factors compliance with VTE-prevention measures into accreditation decisions.

Pharmacists, according to a 2012 ASHP Therapeutic Position Statement, should take a leadership role in hospitals' VTE prevention programs.

"Our pharmacists are pretty involved in VTE prevention," said Anne Rose, pharmacy coordinator for the University of Wisconsin (UW) Hospitals and Clinics.

Rose said a UW pharmacist performs a VTE risk assessment for all adult patients during the first 24 hours of the inpatient stay. The assessment is repeated as necessary when the patient's condition or situation changes, such as after a transfer from a medical ward to a surgical ward.

Once an assessment is done, pharmacists and other team members determine which VTE prophylaxis is appropriate for that patient.

"Most patients really do have risks" for VTE, Rose noted.

Rose said that UW uses electronic order sets instead of having pharmacists independently start patients on VTE prophylaxis. She said this helps increase general awareness among the medical staff about the importance of VTE prevention.

She said pharmacists can check the electronic medical record (EMR) system to see if any anticoagulant doses were missed, but dose tracking normally falls to the nursing staff.

"The physicians place the orders, the pharmacists do the double check, and we also have the nurses involved as well. So the nurse is really who we rely on to catch those missed doses so that the patients receive them," Rose said.

Rose said the nurses may report, for example, that heparin administration three times daily doesn't integrate well with a particular patient's schedule of activities. After consultation, a different therapy, one that better fits the patient's situation, may be ordered.

Rose said UW's anticoagulation stewardship program relies heavily on the EMR system, which pharmacists use to document each risk assessment and record risk scores.

Doug Humber, clinical pharmacist specialist in cardiology at the University of California San Diego Health System's Sulpizio Cardiovascular Center, said having an EMR in place could potentially help improve adherence to VTE prophylaxis recommendations.

Doug Humber

"We do have the capability, within our electronic record system, to run reports for missing doses. And we have recently done that" for certain medications, he said. But he was unsure if reports had been run for enoxaparin or other anticoagulants.

And he emphasized that the data are retrospective, meaning that the patients who missed doses may have already left the hospital.

"One of the things that we're trying to really decide is how to best utilize the data that we're generating. And I think it was . . . a fact-finding mission for us to figure out if we had a culture in our hospital where we're missing too many doses," Humber said.

He said the data may help determine whether missed doses are associated with certain patient populations or service areas within the hospital or whether doses are being unnecessarily withheld in patients undergoing minor procedures.

Humber said patients may be refusing medication doses—particularly doses of injectable drugs, like anticoagulants, or drugs that are used for preventive purposes.

In the case of VTE, he said, it's possible that patients "are not comfortable with the concept of preventative therapy if they've never been diagnosed with a clot."

Humber said patient education could be developed to better communicate the benefits of VTE prevention. And if a patient initially refuses prophylaxis, it could perhaps be offered again periodically during the inpatient stay.

"It's exciting that there's data to be looked at, and it's something that we can improve upon," Humber said. "We're trying to decide where to go and what to do with that data."

Humber said his hospital uses a "stepwise approach to VTE prophylaxis" that includes a risk assessment and a variety of therapeutic options, all of which is embedded in the EMR system.

He said physicians are responsible for performing VTE risk assessments, and pharmacy staff ensures that the therapy is safe on the basis of each patient's characteristics.

Humber said VTE awareness improved among health care providers after CMS started taking into account VTE prevention in reimbursement decisions.

"This is one of the biggest [preventable problems], in terms of morbidity and mortality," Humber said.

Rose likewise said that although some VTEs are not preventable, VTE remains one of the most common preventable adverse events that may occur during a hospital stay.

"It's important for hospitals to have a solid foundation to make sure patients are getting what they should be" for VTE prevention, she said.


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