Can Eliminating Risk Stratification Improve Medical Residents' Adherence to Venous Thromboembolism Prophylaxis?

Nebraska Western Iowa Veterans Affairs Health Care System and Division of General Internal Medicine, Creighton University School of Medicine, Omaha, Nebraska, USA.
Academic medicine: journal of the Association of American Medical Colleges (Impact Factor: 2.93). 12/2011; 86(12):1518-24. DOI: 10.1097/ACM.0b013e318235c3f6
Source: PubMed


Hospital-acquired venous thromboembolism (VTE) is a common and preventable adverse event that most patients are at risk of developing during their hospital stay. VTE prophylactic anticoagulation (chemoprophylaxis) is the preferred pharmacological assignment for reducing risk of VTE, but it is underused in current practices involving risk stratification (RS) for VTE prevention. The purpose of this study was to determine whether a protocol that eliminates the RS step (non-RS protocol) is more likely to lead residents to evidence-based VTE assignment than the currently used RS protocol. The non-RS protocol follows a methodology that reduces complexity by assuming that the risk of VTE is present and uses contraindications to determine appropriate VTE assignment.
In 2009, 41 medicine residents at the Nebraska Western Iowa Veterans Affairs clinic participated in an online comparison of two different protocols (RS and non-RS) for assigning chemoprophylaxis for VTE. Six validated, hypothetical patient scenarios were used to compare appropriate (evidence-based) VTE assignments for VTE and completion times for each protocol.
Statistical analyses found that the non-RS protocol produced significantly faster (P < .001) scenario completion times and significantly more (P < .001) appropriate VTE assignments than the RS protocol for four of the six patient scenarios.
This study used a new, streamlined protocol (non-RS), which improved VTE assignment and the use of chemoprophylaxis and simplified the process when compared with the use of a traditional RS protocol.

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    ABSTRACT: Aim-Background To summarize and critically evaluate the variety of risk stratification methods for VTE prophylaxis in non-orthopaedic surgical patients. Methods A literature search was made using the Medline/Pubmed database. Results Current approaches to the stratification of patients into defined risk categories include a. Risk Assessment Models (RAMs), b. use of scoring systems and c. use of operation type. A wealth of data supports their use, although some have not undergone rigorous assessment, including external validation. An incremental risk increase in patients with a higher score supports the use of scoring systems, but similar findings have also been reported for RAMs. More complex systems have been developed in an effort to reclassify patients previously thought to be at low risk, and not in need of specific or complex thromboprophylaxis regimens. Similarly, many patients previously thought to be at moderate risk are reclassified to the high risk group. Conclusions The increase in VTE risk among patients with a very high risk score calls for research into methods that can effectively reduce this, not only during hospitalization or at 30 days, but for the entire three-month hazard period. Equally warranted is the head to head comparison of the various risk stratification methods, including ease of use and VTE reduction efficacy.
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