Can Nurse and Patient Education Reduce Missed Doses of Medications to Prevent Blood Clots in Hospitals? [Internet]

Excerpt

Background: Although hospital-acquired venous thromboembolism (VTE) is largely preventable with risk-appropriate prophylaxis, VTE continues to be an important cause of morbidity and mortality. Numerous interventions aimed at improving prescription, including computerized decision support, have been implemented, resulting in improved ordering of VTE prophylaxis. However, ordering prophylaxis does not ensure patients—even hospitalized patients—receive every dose. A surprisingly high proportion (12%-16%) of doses is not administered, largely due to patient refusal accounting for more than half of missed doses. Nonadministration of VTE prophylaxis is associated with VTE events. To address this problem, we hypothesize that nurse-specific and patient-centered education can reduce rates of nonadministered pharmacologic prophylaxis.

Objectives: We sought to engage patients and stakeholders to create educational materials for patients and nurses that could be studied to examine the effect on missed doses of VTE prophylaxis.

Methods: We undertook a multitier, multidisciplinary intervention at the Johns Hopkins Hospital (JHH) from March 2014 to December 2015 to improve administration of VTE pharmacologic prophylaxis. The first stage involved the development of a patient-centered VTE education bundle with input from nationally representative patient stakeholders and a local patient advocacy group using a modified Delphi method. In the second stage, we initiated a nurse education intervention, which was a cluster randomized clinical trial of 2 web-based modules (dynamic scenario-based education and linear static education) to educate nurses about the harms of VTE, benefits of VTE prophylaxis, and strategies to better communicate with patients about VTE prophylaxis. In the third stage, we implemented a patient education intervention on selected floors at JHH by using a novel real-time alert built into our electronic medical record system to notify a health educator any time a patient missed a dose of pharmacologic VTE prophylaxis. Any patient who refused a dose of VTE prophylaxis received 1 or more component of an education bundle as an intervention, which included (1) a 1:1, face-to-face engagement with a health educator; (2) a 2-page patient education sheet; and (3) a 10-minute patient education video.

Results: Participants engaged in the development of the educational bundle wanted to learn about VTE symptoms, risk factors, prevention, and complications in a context that emphasized harm. Most of them preferred to receive education in the context of a doctor–patient encounter followed by video and paper educational materials. Overall, nurse education reduced the frequency of VTE prophylaxis nonadministration (12.4% to 11.1%, P = .002). The patient education intervention resulted in a large, statistically significant improvement in VTE prophylaxis. The odds of VTE prophylaxis nonadministration decreased by 42% (OR, 0.58; 95% CI, 0.50-0.68), and the odds of patient refusal decreased by 45% (OR, 0.55; 95% CI, 0.90-1.09). The corresponding frequency of VTE prophylaxis nonadministration changed from 9.0% to 5.6%.

Conclusions: Patients want to be educated on VTE, specifically to recognize the signs and symptoms of VTE, their personal risk for VTE, and the consequences of developing VTE. Educating bedside nurses and providing a targeted patient-centered education intervention bundle significantly reduces nonadministration of pharmacologic VTE prophylaxis.