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Original Research: PULMONARY VASCULAR DISEASE |

Medication Chart Intervention Improves Inpatient Thromboembolism ProphylaxisChart Intervention Improves Thromboprophylaxis FREE TO VIEW

David S. H. Liu, MBBS (Hons), BMedSc; Margaret M. W. Lee, MBBS, BMedSc; Tim Spelman, MBBS; Christopher MacIsaac, MBBS (Hons), PhD; John Cade, MD, PhD, FCCP; Nerina Harley, MBBS, PhD; Alan Wolff, MD
Author and Funding Information

From the Department of General Surgery (Dr Liu), Department of Medicine (Dr Lee), and Intensive Care Unit (Drs Spelman, MacIsaac, Cade, and Harley), The Royal Melbourne Hospital, Parkville; and Medical Administration (Dr Wolff), Wimmera Health Care Group, Horsham, VIC, Australia.

Correspondence to: David S. H. Liu, MBBS (Hons), BMedSc, Department of General Surgery, The Royal Melbourne Hospital, Level 2, Grattan St, Parkville 3050, VIC, Australia; e-mail: dshliu@bigpond.com


For editorial comment see page 578

Funding/Support: This study was supported by The Royal Melbourne Hospital, Intensive Care Unit Education and Research Grant.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2012 American College of Chest Physicians


Chest. 2012;141(3):632-641. doi:10.1378/chest.10-3162
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Background:  Inpatient VTE prophylaxis is underused. This study evaluated the effectiveness of the low-cost, multifaceted Australian National Inpatient Medication Chart (NIMC) intervention on improving the quality of VTE prophylaxis and reducing disease. The NIMC intervention incorporated (1) a VTE risk stratification and appropriate prophylaxis guidance tool, (2) a prophylaxis contraindication screening instrument, and (3) a prophylaxis prescription prompt.

Methods:  Retrospective analysis of 2,371 consecutive medical and surgical admissions was performed at a regional referral hospital over 1 year both before and after the intervention. Outcomes measured included the frequency of prophylaxis use, timing of prophylaxis initiation, adherence of the prescribed prophylaxis regimen to guidelines, incidence of VTE disease, and prophylaxis-related complications.

Results:  Following NIMC intervention, prophylaxis use increased from 52.7% to 66.5% in medical patients and from 77.5% to 89.1% in surgical patients (P < .001). This increase was still evident 12 months postintervention. After intervention, prophylaxis initiated on admission increased from 65.0% to 83.6% in medical patients and from 60.7% to 78.0% in surgical patients (P < .01); adherence rates to recommended guidelines increased from 55.6% to 71.0% in medical patients and from 53.6% to 75.6% in surgical patients (P < .01). More VTE risk factors independently triggered prophylaxis usage postintervention. The improved quality of prophylaxis did not significantly reduce VTE incidence (risk ratio, 0.88; 95% CI, 0.48-1.62). The rate of prophylaxis-related complications remained similar before and after intervention.

Conclusions:  The multifaceted NIMC intervention resulted in a sustained increase in appropriate and timely VTE prophylaxis in medical and surgical inpatients.

Figures in this Article

Inpatient VTE, encompassing DVT and pulmonary embolism, significantly contributes to mortality and morbidity among patients who were hospitalized.1 VTE can be safely prevented with low-dose unfractionated heparin (LDUH), low molecular weight heparin (LMWH), or graduated compression stockings, which are strongly endorsed by national and international consensus guidelines.24 Despite the prevalence of VTE disease and availability of prophylaxis strategies, multiple studies continue to demonstrate suboptimal prophylaxis usage.5

Numerous strategies to improve prophylaxis uptake have been proposed. These include clinician education,6,7 continuous nursing surveillance,8 computer decision-support systems,9,10 prophylaxis alert mechanisms,11 VTE risk assessments,12 and audit and feedback cycles.13 Although these strategies are successful in augmenting short-term use, their sustained effects are less certain. Recent studies have shown that multifaceted approaches to VTE prevention are superior to single interventions,1416 but they often are resource intensive to implement, and data about their efficacy presently are limited to academic centers.17

An inexpensive multifaceted strategy involving modification of the Australian National Inpatient Medication Chart (NIMC) was introduced at the Wimmera Base Hospital, a regional referral center in Victoria, Australia. This study evaluated the effectiveness of this intervention on prophylaxis uptake, adequacy, timing, sustainability, and prescribing behavior and the impact on VTE incidence and prophylaxis-related adverse outcomes.

Setting

This study was undertaken at the Wimmera Base Hospital, Victoria, Australia. The hospital is a regional referral center for the Wimmera and Southern Mallee regions of Victoria, serving a population of ∼54,000 people with an 80-bed capacity and 12,000 admissions per year.

The Australian NIMC

The NIMC was commissioned by the Australian Council on Safety and Quality in Health Care. Its aim was to standardize inpatient medication prescription in all Australian public hospitals and has been in practice since June 2006. The NIMC is a paper-based, five-page collapsible document that allows medical staff to record patient identifiers and any known adverse drug reactions and preexisting medications and to prescribe regular, once-off, and as required drug regimens. The prescribing physician specifies the name, dose, route, frequency, commencement date, and duration of therapy for all medications; the bedside nurse then documents the date and time when each medication is given to the patient and if not given, the reasons why this is so. The NIMC is kept with other ancillary patient charts and reviewed daily on ward rounds.

NIMC VTE Intervention

The Australian NIMC was modified to incorporate three elements: (1) a VTE risk stratification and appropriate prophylaxis guidance tool (e-Fig 1), (2) a prophylaxis contraindication screening instrument (e-Fig 2), and (3) a prophylaxis prescription prompt (e-Fig 3). VTE risk stratification and prophylaxis contraindications were adapted from Best Practice Guidelines developed by The Australian and New Zealand Working Party on the Management and Prevention of Venous Thromboembolism,2 which are in accordance with the American College of Chest Physicians18 and the international consensus statement for the prevention of VTE.3 Assessment of VTE risk and contraindications to prophylaxis was manually undertaken by a medical officer through clinical history taking and examination. The risk assessment tool then functioned as a clinical pathway and provided recommendations for the optimal prophylaxis regimen for that patient. Prophylaxis was considered adherent to guidelines when the prescribed regimen was appropriate to the risk category at admission. When either prophylaxis type was contraindicated, adherence was defined as the usage of an alternate recommended form of prophylaxis. Receipt of mechanical and pharmacologic prophylaxis was documented by nursing staff in the patient’s NIMC and progress notes.

Study Design

This retrospective cohort study was conducted over a 25-month period to evaluate the effectiveness of the NIMC intervention. In July 2008, the NIMC intervention was launched alongside a hospital-wide forum to educate medical and allied health staff. The study population consisted of inpatients consecutively admitted under medical and surgical units between July 1, 2007, and July 31, 2009, selected to characterize prophylaxis use for 1 year before and after intervention. Patients were excluded if they were aged < 16 years, pregnant, prescribed anticoagulants or thrombolyzed within 48 h of admission, or whose hospital length of stay was < 3 days. The last exclusion criterion represented patients receiving ambulatory care who were admitted to the hospital for elective day procedures (eg, endoscopy, radioimaging, dialysis, chemotherapy) and were not assigned an NIMC. This study was approved by the Wimmera Health Care Group Clinical Research Committee as a registered audit (No. 08/4).

Data Collection

A standard form was developed for data extraction from patient medical records, including patient demographics, referral source and date of hospital admission, length of stay, discharge destination, principal admission diagnosis and type of surgery performed, VTE risk factors and patient risk category at admission, method of prophylaxis used, timing of prophylaxis prescription, and contraindications to prophylaxis. High-risk medical patients were further subdivided into those with one risk factor and those with more than one risk factor for VTE. For patients with more than one admission during the study period, each was considered an individual analysis entity. Two investigators were responsible for data collection. A random sample of 100 records demonstrated an interobserver agreement of 95% for all data parameters. We estimated that to detect a 20% increase in prophylaxis use between the preintervention and postintervention groups, at least 70 patients within each cohort were required to achieve 80% power. Because on average a similar number of patients were admitted into both medical and surgical units quarterly, this study was powered to examine quarterly differences between preintervention and postintervention cohorts within medical or surgical subgroups.

Identification of Symptomatic VTE Cases

Cases of VTE were identified through searching the hospital’s electronic database using International Classification of Diseases, Ninth Revision, codes for VTE and hospital mortality secondary to VTE. We anticipated that this method would capture all events coded either as a complication during the index hospital admission or as the main diagnosis in a readmission or ED attendance within 90 days from a previous hospital admission. All VTE diagnoses were clinically symptomatic and verified by CT scan, pulmonary angiography, or compression ultrasonography, which were reported by radiologists blinded to the study hypothesis. As the authors, we had no influence over decisions on whether radiographic studies were performed. Each VTE event was reviewed by the first two authors to determine whether appropriate prophylaxis, according to risk assessment, had been prescribed.

Identification of Prophylaxis-Related Complications

The hospital’s electronic database was searched for adverse events attributable to VTE prophylaxis. These included bleeding requiring blood transfusion, heparin-induced thrombocytopenia (HIT), thrombocytopenia without a positive HIT immunoassay, heparin injection site hematoma, and soft tissue necrosis. Bleeding attributable to anticoagulant prophylaxis was defined as occurring within 72 h after receiving prophylaxis. Major bleeding was classified as cerebrovascular hemorrhage or decreasing hemoglobin level > 20 mg/L associated with hypotension (systolic BP < 90 mm Hg), tachycardia (heart rate > 110 beats/min), or packed cell transfusion of > 2 units. Minor bleeding was classified as a decreasing hemoglobin level < 20 mg/L. HIT was defined as a > 50% fall in platelet count from baseline or a platelet count of < 150 × 109/L within 15 days of receiving heparin prophylaxis and a positive immunoassay in the absence of another attributable cause.

Data Analysis

The data were analyzed individually in surgical and medical groups. Frequencies and proportions were calculated for categorical variables. Medians and interquartile ranges were calculated for continuous variables. Categorical variables were compared using the χ2 or Fisher exact test. Continuous variables were assessed for skew, and because all demonstrated nonnormality, they were compared using the Wilcoxon rank sum test. Before- and after-intervention groups were compared with regard to the frequency of prophylaxis use, timing of initiation, adherence to guidelines, and rates of VTE disease and prophylaxis-related complications. The temporal pattern of prophylaxis usage following NIMC intervention also was assessed. Comparisons of demographic characteristics before vs after intervention were made to identify confounders for the primary analyses. Clustered logistic regression was used to adjust for bias created by multiple admissions of the same patient. A multivariable analysis of VTE risk factors evaluated independent predictors of prophylaxis prescription while controlling for potential confounders identified on univariate comparison of demographic characteristics, thus demonstrating any alteration in prescribing behavior. Because only an increase in prophylaxis usage would provide evidence of the effectiveness of NIMC intervention, a one-sided P < .05 was considered statistically significant. All statistical analyses were conducted using STATA, version 11 (StataCorp LP).

Patient Population

Overall, 1,478 (806 preintervention, 672 postintervention) medical and 893 (450 preintervention, 443 postintervention) surgical patients were reviewed over the 25-month study period. Preintervention and postintervention cohorts shared similar baseline characteristics (Table 1). The preintervention medical cohort had a larger number of active malignancies (16.3% vs 11.0%, P = .004) and patients with more than one VTE risk factor (39.5% vs 29.5%, P = .001) but a lower number of endocrine and metabolic illnesses (1.6% vs 3.4%, P = .004) than the postintervention cohort. The preintervention surgical cohort had a lower number of gynecologic (1.6% vs 3.1%, P = .013) and soft tissue illnesses (1.7% vs 3.1%, P = .026) than the postintervention cohort.

Table Graphic Jump Location
Table 1 —Characteristics of Medical and Surgical Patients

Data are presented as median (interquartile range) or No. (%).

a 

P < .05, Fisher exact test or χ2 test for categorical variables, Wilcoxon rank sum test for continuous variables.

Frequency of Prophylaxis Use

Following NIMC intervention, the overall rate of prophylaxis increased from 52.7% to 66.5% for medical patients and from 77.5% to 89.1% for surgical patients (P < .001). Medical patients with more than one risk factor (48.0%- 79.8%) and those with decompensated cardiac failure (54.7%-92.7%) had the greatest increase in prophylaxis use (Table 2, 3). Surgical patients at high risk experienced significantly increased pharmacologic and mechanical prophylaxis (Table 2), whereas patients at moderate risk received significantly greater pharmacologic prophylaxis, and those at low risk received significantly greater mechanical prophylaxis.

Table Graphic Jump Location
Table 2 —Overall Prophylaxis Use for Medical and Surgical Admissions

Pharmacologic and mechanical subgroups are not mutually exclusive.

a 

Significant at P < .05, Fisher exact test or χ2 test for univariate comparisons.

Table Graphic Jump Location
Table 3 —Prophylaxis Use Among Medical Patients by Risk Factor

Risk factors are not mutually exclusive of one another.

a 

Significant at P < .05, Fisher exact test or χ2 test for univariate comparisons.

Timing of Prophylaxis Initiation

Following NIMC intervention, prophylaxis initiated on the day of hospital admission increased by 18.7% in the medical cohort and by 17.3% in the surgical cohort (P < .01). Medical patients with one or more risk factors and surgical patients at high and moderate risk demonstrated the greatest increase in timely prophylaxis initiation (Table 4).

Table Graphic Jump Location
Table 4 —Day of Admission Prophylaxis Usage for Medical and Surgical Admissions
a 

Significant at P < .05, Fisher exact test or χ2 test for univariate comparisons.

Prophylaxis Adherence to Practice Guidelines

Following NIMC intervention, the overall rate of adherence to practice guidelines increased by 15.4% in medical patients and by 22.1% in surgical patients (P < .01). Medical patients with one or more risk factors (48.9%-82.8%) and surgical patients across all risk categories demonstrated significantly higher adherence rates (Table 5).

Table Graphic Jump Location
Table 5 —Adherence to Guidelines for Medical and Surgical Admissions
a 

Significant at P < .05, Fisher exact test or χ2 test for univariate comparisons.

Factors Associated With Prophylaxis Prescription

Preintervention, age and ischemic stroke were the only predictors of prophylaxis prescription (Table 6). Postintervention, decompensated cardiac failure, malignancy, acute exacerbations of chronic lung disease, immobility, and age independently predicted pharmacologic prophylaxis prescription. The latter three risk factors also predicted the use of mechanical prophylaxis.

Table Graphic Jump Location
Table 6 —Predicting Pharmacologic and Mechanical Prophylaxis Use by Risk Factor

Other covariates include endocrine and metabolic conditions and risk category.

a 

Significant at P < .05.

Acute and Sustained Effects From NIMC Intervention

Acute and sustained effects from NIMC intervention were examined by comparing the rates of prophylaxis usage at preintervention to 1, 2 to 3, 4 to 6, 7 to 9, and 10 to 12 months postintervention (Fig 1). In medical patients, prophylaxis usage increased from an average of 52.7% preintervention to a peak of 80.9% (P < .001) at 1 month postintervention before stabilizing at 62.9% (P = .019). In surgical patients, prophylaxis usage increased from an average of 77.5% preintervention to a peak of 92.5% (P < .001) at 1 month postintervention before stabilizing at 90.6% (P < .001).

Figure Jump LinkFigure 1. Prophylaxis use over the 12 months postintervention. Prophylaxis use within medical and surgical groups postintervention is significantly higher and sustained over a 12-month period compared with their respective preintervention cohorts. *P < .05 Wilcoxon rank sum test. ***P < .001 Wilcoxon rank sum test.Grahic Jump Location
Symptomatic VTE

Twenty-three (1.8%) preintervention patients (16 medical and seven surgical) and 18 (1.6%) postintervention patients (11 medical and seven surgical) developed symptomatic VTE within 90 days of their index hospital admission. Of these, 17 postintervention patients (94.4%) received appropriate prophylaxis compared with 14 preintervention patients (60.9%) (P = .014). The overall and subgroup incidence of VTE did not decline significantly following NIMC intervention (overall risk ratio [RR], 0.88; 95% CI, 0.48-1.62; medical RR, 0.82; 95% CI, 0.39-1.77; surgical RR, 1.02; 95% CI, 0.36-2.87).

Prophylaxis-Related Complications

Six preintervention patients (0.5%) and six postintervention patients (0.5%) developed minor postoperative bleeding. These patients had received either prophylactic LMWH or prophylactic LDUH perioperatively and at the time of their complication in accordance to guidelines. The preintervention group consisted of four lower-limb fracture repairs and two major abdominal surgeries. The postintervention group included four lower-limb fracture repairs and two mastectomies for breast malignancies. No cases of HIT were confirmed, but 13 preintervention patients (1.0%) and 19 postintervention patients (1.7%) developed thrombocytopenia in the setting of a negative immunoassay following heparin prophylaxis. The rate of thrombocytopenia was not significantly different (P = .218) between the two groups. No cases of major bleeding or other adverse outcomes attributable to pharmacologic prophylaxis were identified. Overall, NIMC intervention did not result in a significant increase in the incidence of pharmacologic prophylaxis-related complications (RR, 1.13; 95% CI, 0.36-3.48). No mechanical prophylaxis-related complications were found over the 25-month study period.

This study demonstrated that the NIMC intervention resulted in a sustained increase in appropriate prophylaxis use initiated in a timely manner and without compromising patient safety. The incidence of VTE was not significantly reduced following NIMC intervention.

VTE prophylaxis was underused in the preintervention cohort, with < 50% of medical and 60% of surgical patients receiving prophylaxis according to Best Practice Guidelines despite > 80% of these patients being at moderate to high risk for VTE.2 This finding is consistent with national and international reports.5,1921 Accumulating evidence endorses multifaceted approaches to improving the quality of VTE prophylaxis in hospitals,2,22,23 and the present intervention embraced this by providing a prompt to assess VTE risk, guidance in selecting appropriate prophylaxis and subsequent documentation of use, or reasons it is not required or contraindicated. Decision-support strategies have proven to be most effective when integrated with daily workflow.16,24 Therefore, by embedding our intervention into a standard NIMC that is accessed by the admitting medical officer and reviewed at least daily by medical or surgical teams, the present intervention becomes part of the daily routine. Although this study joins others that have used VTE risk stratification and prescription alert strategies to improve prophylaxis uptake,14,2527 it is the first to our knowledge that has incorporated all these elements into an NIMC.

The present study found that NIMC intervention was well accepted by both medical and surgical units. It accurately predicted the risk for VTE, with 93% of cases being categorized as high risk. There was a marked increase in appropriate prophylaxis, which exceeded other studies that relied on documentation aids alone as their primary intervention.12,26,28 Furthermore, NIMC intervention did not lead to an increase in inappropriate pharmacologic prophylaxis in low-risk medical and surgical patients; however, there is overuse in high-risk medical patients, with 42.7% of patients receiving mechanical prophylaxis in addition to chemoprophylaxis when chemoprophylaxis alone was sufficient. The timely initiation of prophylaxis, which has been shown to reduce the incidence of VTE,29,30 also improved significantly postintervention.

Increased prophylaxis was sustained at 12 months postintervention, despite an early peak in usage rates that subsequently plateaued. The combination of a Hawthorne effect with the positive impact from a single education session may explain higher prophylaxis usage in the first month postintervention compared with subsequent months. Interestingly, the temporal pattern of prophylaxis usage differed considerably between the medical and the surgical cohorts. Vallano et al31 also observed a similar dichotomy in their cross-sectional audit of adherence rates to guidelines. The relatively higher prophylaxis usage among surgical patients may be explained by several reasons. First, there likely is to be a greater vigilance toward VTE risk and prophylaxis by surgeons because the literature traditionally has placed stronger emphasis on the effectiveness of prophylaxis in the perioperative setting. Comparatively, because of less evidence and agreement among physicians regarding appropriate prophylaxis, there may be some inertia to overcome previous practices. Second, different patient demographics and presenting illnesses may contribute to different prophylaxis prescribing behavior between medical and surgical practices. The risk of VTE and indications for prophylaxis usually are obvious in a surgical patient but less so in a medical patient. Typically, medical patients present with risk factors that are preexisting in the community, they are easily mistaken to be at baseline risk for VTE, and they are not prescribed prophylaxis despite being acutely unwell. Third, medical registrars at the Wimmera Base Hospital rotated quarterly, whereas surgical registrars rotated biannually. Consequently, the effects of the initial education session would have been significantly more diluted with each medical registrar rotation compared with their surgical counterparts.

Multivariable analysis demonstrated an expansion in the number of VTE risk factors that independently predicted prophylaxis use in the postintervention cohort, suggesting that the combination of an initial education session and the availability of a risk stratification instrument enhanced clinician awareness of patient-specific risk factors for VTE. However, the relative fall in prophylaxis uptake after an early peak suggests that the effects from the education session diminished with time, supporting the value of regular interventions, such as an audit and feedback cycle, to maintain high prophylaxis usage. Importantly, ischemic stroke did not predict prophylaxis use postintervention. The relatively higher rate of prophylaxis use in preintervention patients with ischemic stroke compared with those with other risk factors may explain the inability to demonstrate a significant increase in prophylaxis uptake postintervention. Furthermore, the lack of chemoprophylaxis may reflect clinician apprehension regarding the risk of anticoagulant-induced hemorrhagic transformation after an ischemic event. Although some studies caution against chemoprophylaxis in this setting because of a 0.8% increased risk of intracranial bleeding following administration of LDUH or LMWH, this needs to be weighed against a 56% risk of VTE in patients with stroke not prescribed prophylaxis.32 Consequently, guidelines recommend the use of prophylactic levels of anticoagulation in this population.3,18 Having identified this, the hospital educated its staff regarding the importance of VTE prophylaxis in patients with ischemic stroke. An audit and feedback cycle in this setting may help to reveal the low rate of prophylaxis-related complications and emphasize the minimal risk of chemoprophylaxis-induced cerebral bleeding after an ischemic stroke, which may further encourage providers to prescribe prophylaxis.

The failure of increased prophylaxis to lower the rate of symptomatic VTE suggests that a larger response to intervention is required. This response possibly could be achieved through further educational sessions strategically placed throughout the year or regular audit and feedback cycles, with both aimed at maintaining a constant awareness of VTE. Supporting this strategy, Maynard et al14 demonstrated a significant reduction in symptomatic VTE after implementing a multifaceted strategy that increased prophylaxis uptake from 53% to 94%. Importantly, the present study illustrated that hospital processes and patient care can be improved by the use of clinical reminder systems, complementing previous quality improvement studies conducted at the Wimmera Base Hospital.33

We noted that NIMC intervention failed to achieve near-100% prophylaxis use, whereas other studies that used computerized systems in combination with other strategies have reported higher rates of use.14,25 A potential limitation of our paper-based system is that prophylaxis can be prescribed without prior risk assessment, which may lead to noncompliance to guidelines. Furthermore, many computerized approaches are defaulted to prescribe prophylaxis, and clinicians are required to opt out should contraindications arise. Another key difference is our lack of an audit and feedback mechanism to constructively leverage the Hawthorne effect.15 The drawbacks of computerized systems include high implementation costs and demands for ongoing maintenance and support. NIMC intervention represents one alternative strategy that if combined with an audit and feedback process, is highly effective at enhancing the quality of VTE prophylaxis22; economical to implement; easy to use, audit, and upgrade; and applicable to both regional and tertiary centers. Indeed, to our knowledge, at least three academic and regional hospitals in Victoria, Australia, have adopted NIMC interventions since the commencement of the present study.

The major limitations of the present study are inherent in its retrospective design. First, preintervention and postintervention cohorts were studied sequentially and may be exposed to factors that could have biased the results, although observed differences between cohorts were corrected for using logistic regression analysis to minimize this. Second, adequate documentation in patient notes was critical for data accuracy; thus, for this reason, obesity and use of estrogen-containing therapies could not be assessed as risk factors for VTE. Third, the incidence of VTE events may have been underestimated because our hospital’s electronic database does not capture diagnoses made external to the hospital. Despite this limitation, our event rates correlated with other studies,21 and any underestimation of VTE incidence should be the same for preintervention and postintervention cohorts. In conclusion, NIMC intervention is an inexpensive, multifaceted strategy that enhances the quality of inpatient VTE prophylaxis without compromising patient safety.

Author contributions: Dr Liu had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Dr Liu: contributed to the concept and design of the study and interpretation of the data, revised the manuscript critically for important intellectual content, and approved the final version of the manuscript.

Dr Lee: contributed to the concept and design of the study and interpretation of the data, revised the manuscript critically for important intellectual content, and approved the final version of the manuscript.

Dr Spelman: contributed to the concept and design of the study and interpretation of the data, revised the manuscript critically for important intellectual content, and approved the final version of the manuscript.

Dr MacIsaac: contributed to the concept and design of the study and interpretation of the data, revised the manuscript critically for important intellectual content, and approved the final version of the manuscript.

Dr Cade: contributed to the concept and design of the study and interpretation of the data, revised the manuscript critically for important intellectual content, and approved the final version of the manuscript.

Dr Harley: contributed to the concept and design of the study and interpretation of the data, revised the manuscript critically for important intellectual content, and approved the final version of the manuscript.

Dr Wolff: contributed to the concept and design of the study and interpretation of the data, revised the manuscript critically for important intellectual content, and approved the final version of the manuscript.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Drs MacIsaac, Cade, and Harley are consultant physicians of the Intensive Care Unit, The Royal Melbourne Hospital. Drs Liu, Lee, Spelman, and Wolff have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or in the preparation of the manuscript.

Other contributions: We thank all Health Information System staff members at the Wimmera Base Hospital.

Additional information: The e-Figures can be found in the Online Supplement at http://chestjournal.chestpubs.org/content/141/3/632/suppl/DC1.

HIT

heparin-induced thrombocytopenia

LDUH

low-dose unfractionated heparin

LMWH

low-molecular-weight heparin

NIMC

National Inpatient Medication Chart

RR

risk ratio

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Mosen D, Elliott CG, Egger MJ, et al. The effect of a computerized reminder system on the prevention of postoperative venous thromboembolism. Chest. 2004;1255:1635-1641. [PubMed]
 
O’Connor C, Adhikari NK, DeCaire K, Friedrich JO. Medical admission order sets to improve deep vein thrombosis prophylaxis rates and other outcomes. J Hosp Med. 2009;42:81-89. [PubMed]
 
Kucher N, Koo S, Quiroz R, et al. Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med. 2005;35210:969-977. [PubMed]
 
Fagot JP, Flahault A, Fodil M, et al. Prophylactic prescription of low-molecular-weight heparin in the non-surgical setting: impact of recommendations [in French]. Presse Med. 2001;305:203-208. [PubMed]
 
Hull RD, Pineo GF, Stein PD, et al. Timing of initial administration of low-molecular-weight heparin prophylaxis against deep vein thrombosis in patients following elective hip arthroplasty: a systematic review. Arch Intern Med. 2001;16116:1952-1960. [PubMed]
 
Raskob GE, Hirsh J. Controversies in timing of the first dose of anticoagulant prophylaxis against venous thromboembolism after major orthopedic surgery. Chest. 2003;124suppl 6:379S-385S. [PubMed]
 
Vallano A, Arnau JM, Miralda GP, Pérez-Bartolí J. Use of venous thromboprophylaxis and adherence to guideline recommendations: a cross-sectional study. Thromb J. 2004;21:3-11. [PubMed]
 
Shorr AF, Jackson WL, Sherner JH, Moores LK. Differences between low-molecular-weight and unfractionated heparin for venous thromboembolism prevention following ischemic stroke: a metaanalysis. Chest. 2008;1331:149-155. [PubMed]
 
Wolff AM, Taylor SA, McCabe JF. Using checklists and reminders in clinical pathways to improve hospital inpatient care. Med J Aust. 2004;1818:428-431. [PubMed]
 

Figures

Figure Jump LinkFigure 1. Prophylaxis use over the 12 months postintervention. Prophylaxis use within medical and surgical groups postintervention is significantly higher and sustained over a 12-month period compared with their respective preintervention cohorts. *P < .05 Wilcoxon rank sum test. ***P < .001 Wilcoxon rank sum test.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 —Characteristics of Medical and Surgical Patients

Data are presented as median (interquartile range) or No. (%).

a 

P < .05, Fisher exact test or χ2 test for categorical variables, Wilcoxon rank sum test for continuous variables.

Table Graphic Jump Location
Table 2 —Overall Prophylaxis Use for Medical and Surgical Admissions

Pharmacologic and mechanical subgroups are not mutually exclusive.

a 

Significant at P < .05, Fisher exact test or χ2 test for univariate comparisons.

Table Graphic Jump Location
Table 3 —Prophylaxis Use Among Medical Patients by Risk Factor

Risk factors are not mutually exclusive of one another.

a 

Significant at P < .05, Fisher exact test or χ2 test for univariate comparisons.

Table Graphic Jump Location
Table 4 —Day of Admission Prophylaxis Usage for Medical and Surgical Admissions
a 

Significant at P < .05, Fisher exact test or χ2 test for univariate comparisons.

Table Graphic Jump Location
Table 5 —Adherence to Guidelines for Medical and Surgical Admissions
a 

Significant at P < .05, Fisher exact test or χ2 test for univariate comparisons.

Table Graphic Jump Location
Table 6 —Predicting Pharmacologic and Mechanical Prophylaxis Use by Risk Factor

Other covariates include endocrine and metabolic conditions and risk category.

a 

Significant at P < .05.

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Mosen D, Elliott CG, Egger MJ, et al. The effect of a computerized reminder system on the prevention of postoperative venous thromboembolism. Chest. 2004;1255:1635-1641. [PubMed]
 
O’Connor C, Adhikari NK, DeCaire K, Friedrich JO. Medical admission order sets to improve deep vein thrombosis prophylaxis rates and other outcomes. J Hosp Med. 2009;42:81-89. [PubMed]
 
Kucher N, Koo S, Quiroz R, et al. Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med. 2005;35210:969-977. [PubMed]
 
Fagot JP, Flahault A, Fodil M, et al. Prophylactic prescription of low-molecular-weight heparin in the non-surgical setting: impact of recommendations [in French]. Presse Med. 2001;305:203-208. [PubMed]
 
Hull RD, Pineo GF, Stein PD, et al. Timing of initial administration of low-molecular-weight heparin prophylaxis against deep vein thrombosis in patients following elective hip arthroplasty: a systematic review. Arch Intern Med. 2001;16116:1952-1960. [PubMed]
 
Raskob GE, Hirsh J. Controversies in timing of the first dose of anticoagulant prophylaxis against venous thromboembolism after major orthopedic surgery. Chest. 2003;124suppl 6:379S-385S. [PubMed]
 
Vallano A, Arnau JM, Miralda GP, Pérez-Bartolí J. Use of venous thromboprophylaxis and adherence to guideline recommendations: a cross-sectional study. Thromb J. 2004;21:3-11. [PubMed]
 
Shorr AF, Jackson WL, Sherner JH, Moores LK. Differences between low-molecular-weight and unfractionated heparin for venous thromboembolism prevention following ischemic stroke: a metaanalysis. Chest. 2008;1331:149-155. [PubMed]
 
Wolff AM, Taylor SA, McCabe JF. Using checklists and reminders in clinical pathways to improve hospital inpatient care. Med J Aust. 2004;1818:428-431. [PubMed]
 
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