Alert-Triggered Patient Education Versus Nurse Feedback for Nonadministered Venous Thromboembolism Prophylaxis Doses: A Cluster-Randomized Controlled Trial

Abstract

BACKGROUND: Many hospitalized patients are not administered prescribed doses of pharmacologic venous thromboembolism prophylaxis. METHODS AND RESULTS: In this cluster-randomized controlled trial, all adult non–intensive care units (10 medical, 6 surgical) in 1 ac-ademic hospital were randomized to either a real-time, electronic alert–triggered, patient-centered education bundle intervention or nurse feedback intervention to evaluate their effectiveness for reducing nonadministration of venous thromboembolism proph-ylaxis. Primary outcome was the proportion of nonadministered doses of prescribed pharmacologic prophylaxis. Secondary outcomes were proportions of nonadministered doses stratified by nonadministration reasons (patient refusal, other). To test our primary hypothesis that both interventions would reduce nonadministration, we compared outcomes pre-versus postintervention within each cohort. Secondary hypotheses were tested comparing the effectiveness between cohorts. Of 11 098 patient visits, overall dose nonadministration declined significantly after the interventions (13.4% versus 9.2%; odds ratio [OR], 0.64 [95% CI, 0.57–0.71]). Nonadministration decreased significantly (P<0.001) in both arms: patient-centered education bundle, 12.2% versus 7.4% (OR, 0.56 [95% CI, 0.48–0.66]), and nurse feedback, 14.7% versus 11.2% (OR, 0.72 [95% CI, 0.62–0.84]). Patient refusal decreased significantly in both arms: patient-centered education bundle, 7.3% versus 3.7% (OR, 0.46 [95% CI, 0.37–0.58]), and nurse feedback, 9.5% versus 7.1% (OR, 0.71 [95% CI, 0.59–0.86]). No differential effect occurred on medical versus surgical units. The patient-centered education bundle was significantly more effective in reducing all nonadministered (P=0.03) and refused doses (P=0.003) compared with nurse feedback (OR, 1.28 [95% CI, 1.0–1.61]; P=0.03 for interaction). CONCLUSIONS: Information technology strategies like the alert-triggered, targeted patient-centered education bundle, and nurse-focused audit and feedback can improve venous thromboembolism prophylaxis administration. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03367364.