For a patient confined to a hospital bed, the biggest danger is not always the condition that brought them there in the first place. The very bed rest that is part of their treatment can lead to serious complications if not prevented.

Deep vein thrombosis (DVT)—the formation of a blood clot in a deep vein, usually in the legs or pelvis—is a major concern for hospitals. According to AHRQ, one in 10 of the 2 million Americans who develop DVT every year goes on to die from a pulmonary embolism (PE), one of the most preventable causes of death in a hospital. Those 200,000 patient deaths represent more deaths in this country than from AIDS, breast cancer, and traffic accidents combined. And patients with history of any kind of venous thromboembolism (VTE) suffer a 30% risk of reoccurrence.

The cost for hospitals is high, both in patient well-being and in money. The estimated cost for the average hospital-acquired case of DVT is $10,000 and $20,000 for a PE. This makes DVT a high-priority target for hospitals looking to improve patient care, which is why staff at the Washington DC VA Medical Center created a system to leverage the electronic medical record to ensure that patients at risk for DVT were given therapy to prevent it.

Standardizing Prevention Therapy

“It’s a severe problem in all hospitals,” explained Dr Ross Fletcher, DCVAMC chief of staff, in an interview with U.S. Medicine. “And I think we have been giving good care. But we have not had a way of assessing whether that care was uniform, adequate, and with the least amount of risk. That is, until we produced this order set.”

That order set is a series of prompts given through the electronic medical record that allows physicians to note whether a patient is at risk for DVT and to prescribe the appropriate prevention therapy. “Patients with congestive heart failure, who are unable to move about, will have a lot of swelling in their feet and about their legs. It can lead to clot formation,” Fletcher explained. “We just made sure that evidence-based therapy was being implemented in a standard way across the hospital.”

In 2007, a DCVAMC pharmacy employee sought to improve prevention of DVT practices in at- risk bed-ridden patients. Soon after, DCVAMC applied and was selected for a one-on-one mentorship from the Society of Hospital Medicine to develop a DVT prevention strategy.

Staff members from the hospital’s informatics, pharmacy, and hematology departments worked with clinical staff to create an order set that leads healthcare providers through an evidence-based risk-factor assessment. When patients are admitted or transferred, the order set prompts physicians to assess and analyze the patient’s condition by guiding the physician through specific steps.

“We had a need for a standardized way to get DVT prevention therapy to our patients. And whenever we see a problem like that come up, we often move to the electronic health record to try to achieve a method of improving care,” Fletcher said.

“And at this point in time there are numerous reasons to be on DVT prophylaxis, and there are various levels of risk and, depending on that level of risk, various medications. One has to be really concerned that that dosing continues and is carried out throughout the problem, throughout the time of risk for the patient, and that it is done on all patients [that need it].

“Our staff developed a way so that when the patient is admitted and was carrying some risk, with a simple template for delivering care, we could put in the level of risk, the medication that’s being delivered, and the dosing that was appropriate.”

Prompting Physicians

When a patient is admitted or transferred, a physician at the DCVAMC will be faced with a prompt, guiding them to analyze and assess the patient’s condition. The program will list varying risk factors for DVT by severity. Patients most at risk include those who have had major orthopedic surgery, major arthroplasty, multiple major trauma, and recent spinal cord injuries, among others. Those at moderate risk include patients with heart disease, lung disease, and patients with a history of VTE.

Risk factors can also stack. Patients with several low risk factors could be counted as at moderate risk. And those with more than one moderate risk factor could be bumped up to high risk level.

Once all of the patient’s risk factors have been checked off, the physician is prompted to inform the patient about the possible benefits of DVT prophylaxis. The order set then shows the physician a list of approved therapies in varying dosages and combinations, and which are recommended for the given risk level. These therapies include the pharmaceutical—enoxaparin, warfarin, and heparin, for example—and the non-pharmacologic, such as sequential compression devices and compression stockings.

The program also gives the physician contraindications for VTE prophylaxis, ensuring that the prevention does not do more harm than good. “There’s a very heavy decision-support element to this process,” Fletcher explained.

Once the therapy is selected, ordered, and distributed, all of the information is automatically gathered into a note on the patient’s medical record. “And a report goes up every day or every week listing all the patients who are on DVT prophylaxis,” Fletcher declared. “And we achieve a very high rate of using that therapy and preventing DVT from occurring in the hospital.”

And how would DVT prevention be administered in hospitals without the kind of electronic medical record VA has come to depend on? “The patient’s risk would be known. The therapies that could be given could be looked up by the doctor, and he would probably write an order,” Fletcher said. “But in any [hospital without an electronic medical record to track patients], you’d have no way to see if those orders are written except to look at the chart. Here we have a way of seeing all patients that were admitted, what percentage of patients are receiving some form of care, and whether that care is ongoing.”

Hospital staff tracks those numbers on a weekly basis to make sure that those patients needing DVT prophylaxis continue to receive it.

Another benefit of VA’s electronic medical record is that an order set that works at one hospital has the potential to be transferred relatively seamlessly to another VA hospital.

This is how innovations frequently spread throughout the VA system—finding success at one hospital and then spreading to the rest of the hospitals in the network, and then nationwide. Fletcher expects that it will not be too much longer until Baltimore and Martinsburg—the other two hospitals in DCVAMC’s network—adopt the practice. Recent positive publicity will only speed up matters.

In February, the hospital was honored with the DVTeamCare Hospital Award, presented by Eisai, Inc and the North American Thrombosis Forum, recognizing the hospital’s work in DVT prevention. The award was presented at the annual Thrombosis Prevention Conference at Harvard Medical School in April.

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