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The Impact of a Best Practice Alert (BPA) on Executing the “Enhanced Caprini” Postoperative Venous Thromboembolism (VTE) Prevention Protocol
Khu Aten Maaneb de Macedo
*2, Anna J. Kobzeva-Herzog
2, Jeffrey Franks
2, Sing Chau Ng
2, Pamela Rosenkranz
1, Jeffrey J. Siracuse
2, Alik Farber
2, Aaron Richman
2, David McAneny
21Department of Nursing, Boston Medical Center, Boston, MA; 2Department of Surgery, Boston Medical Center, Boston, MA
Background: Traditional Caprini Scores guide
extended courses of chemoprophylaxis beyond hospital discharge to prevent postoperative venous thromboembolism (VTE) events. However, we demonstrated that patients with a combination of two or more factors of sepsis, multiple operations, and emergency operations had an increased likelihood of VTE events prior to discharge and did not have the opportunity to benefit from extended prophylaxis. As a result, we designed the “enhanced Caprini” protocol, incorporating dose escalation of low molecular weight heparin (LMWH) based on anti-Factor Xa levels. A Best Practice Alert (BPA) was introduced in the electronic medical record (EMR) in 2018 to promote adherence to the protocol, but its use declined during the COVID-19 pandemic. This study evaluates the effectiveness of the BPA after a 2022 protocol update aimed at restoring compliance.
Study Design: We compared ACS NSQIP and EMR data for the interval from July 2019 to October 2022 (cohort 1) to November 2022 to April 2024 (cohort 2). The primary outcomes were compliance with the BPA and risk-adjusted VTE events.
Results: The BPA appropriately identified patients with two or more risk factors in 391 cases (cohort 1: 246 and cohort 2: 145). The BPA generated 3002 alerts throughout the study, with a range of 1-126 events per patient. BPA alerts occurred more frequently in intensive care units. The rates of complete compliance, partial compliance, and non-compliance with all of the protocol’s components (BPA response, ordering anti-Factor Xa levels, and dose escalation of LMWH ) were 47.4%, 50.9% and 0.01% in cohort 1 and 15%, 81.6%, and 0.03% in cohort 2, respectively. There were 82 VTE events during the study period, 58 (44 DVT and 14 PE) in cohort 1 and 24 (16 DVT and 8 PE) in cohort 2. The risk-adjusted odds of VTE in cohort 2, compared to cohort 1, was 0.873 (95% CI: 0.394–1.938).
Conclusion: Despite the BPA update, lapses persist with compliance, particularly in lab monitoring and medication management. Clinician adherence to BPAs remains a challenge, often related to factors such as alert fatigue. Furthermore, risk-adjusted analyses do not demonstrate a significant reduction in postoperative VTE events. Therefore, refinements of the BPA and clinician adherence strategies may be necessary to optimize post-operative VTE prevention.
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