Retrospective Clinical Audit of Adherence to a Protocol: DISCUSSION part 2
Introduction of a formal risk assessment tool for venous thromboembolism, including a checklist for risk factors, may increase rates of adequate thromboprophylaxis. Byrne and others described a risk assessment table for deep vein thrombosis, which was included on order forms. Nurses were educated to contact prescribers if the risk assessment was not completed, which increased appropriate thromboprophylaxis from 51% to 90% of patients. Thus, modifying the thrombo- prophylaxis protocol to include a checklist of risk factors for venous thromboembolism and bleeding may improve adherence rates.
Education of practitioners about risk stratification and the benefits of thromboprophylaxis may also help to improve compliance. Studies evaluating the effect of practitioner education on thromboprophylaxis have shown improvement in adherence to the hospital’s protocol in subsequent audits. The following educational interventions have been used: meetings with the hospital’s surgical and anesthesia executive committees; grand rounds or articles in the hospital’s drugs and therapeutics bulletin highlighting baseline audit results and providing information about the hospital’s thromboprophylaxis guidelines; and production of posters, laminated cards, or handouts incorporating the hospital’s thromboprophylaxis guidelines and the risk assessment process. Peterson and others found that educational interventions improved the rate of adequate prophylaxis against venous thromboembolism among surgical patients from 59% to 70% at 2 weeks after implementation. Hence, education about a thromboprophylaxis protocol may improve compliance, which can be documented through sequential quality assurance audits.
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The main limitations of this clinical audit were the small sample size, reliance on the documented patient history, and the retrospective nature of the study. In addition, the study design did not permit any statistical analyses. However, in light of the findings, future clinical audits of adherence to thromboprophylaxis guidelines should be designed to include statistical analyses and should use a sample size sufficient to assess the statistical significance of the findings.
In conclusion, among surgical patients treated at the VIHA-SI, the use of adequate thromboprophylaxis, as defined by the thromboprophylaxis protocol, was low. Revision of the protocol to include the recommended time of initiation, the recommended duration of therapy, and a thrombosis risk assessment checklist, as well as education of practitioners about risk stratification and the benefits of thromboprophylaxis, may improve adherence rates. revatio 20 mg
