This study is the first to assess the cumulative impact of a series of interventions to improve full guideline compliant prescribing for VTE prophylaxis over a prolonged (nine-year) period, in a large NHS Trust which already offered a suite of educational tools such as lectures and videos and with high, and target compliant VTE assessment rates. This study highlights several important points.

First, that risk assessments do not automatically convert into an appropriate action following the assessment. Even after the introduction of the EPS system to mandate VTE risk assessment and appropriate prescribing, there was still a difference between completed risk assessments and prophylaxis prescribing. Altering reporting criteria to assess full guideline compliance may be a more effective means to improve patient safety.

Second, the interventions with demonstrable impact (the doctors dashboard clinic and rules based prescribing algorithms) require an EPS which supports dynamic evidence generation and application, enabling rapid learning and improvement based on data flowing from routine patient care. Both of these interventions were based upon the principles of a learning healthcare system, defined by the United States Institute of Medicine (now the National Academy of Medicine) as systems where “science, informatics, incentives, and culture are aligned for continuous improvement and innovation, with best practices seamlessly embedded in the delivery process and new knowledge captured as an integral by-product of the delivery experience” [21].

The most impactful intervention was a systems approach, with an EPS tool which mandated VTE assessment and prescribing as part of the admission process. These improvements were maintained at a higher level than seen following the individual feedback intervention, for the entire follow up period.

Our learning healthcare system included re-evaluating the PICS EPS to see where further improvements could be made. Feedback from prescribers and an assessment using the principles of human factors [22] suggested that the placement of “no reduced mobility” at the top of the risk assessment algorithm potentially suggested that this was true for many patients and an audit of care records suggested that this was being erroneously applied in some instances. In light of this, the EPS was altered to place this option at the end of the list of contraindications, to ensure the prescriber considered co-morbidities and reason for admission prior to considering this option. This change did not have the impact expected on VTE compliance, and in fact contributed to a small, but significant, step decrease in full compliance. The reason for this is unclear and requires further study.

In this real-world study, there was a change in national LMWH availability, requiring a change in drug and prescribing rules (from enoxaparin to tinzaparin and then back to enoxaparin). These were introduced with traditional education but also necessitated a change in the EPS with a new series of prompts and rules. Despite the changes in prescribing practice, there was no significant change to full VTE guideline compliance, highlighting the resilience of the EPS systems-based approach.

This study did not assess why the systems approach was more effective than other interventions, but there are a number of potential reasons. As the Doctors Clinical Dashboard only identifies statistical outliers, only repeated failures to comply with guidelines will be identified. It is likely that many prescribing errors are made singularly and on an ad hoc basis, and these would not necessarily trigger a review. Educational and training events are one -off, and repetition in training has been shown to enhance performance [23, 24]. Healthcare is increasingly complex in terms of organisation and delivery [25] and our ageing population often are multi-morbid and poly-medicated, making healthcare decisions more complex [26]. The complexity of healthcare and of patients might increase the potential for prescribing errors. A systems-based approach with prescribing support tools, that provides the same support for all prescribers on all occasions, is therefore more likely to impact on practice.

The current paper highlights the difference between VTE assessment compliance and full VTE guideline compliance (an assessment and appropriate prescribing action). While both are important, only the latter will reduce risk from hospital acquired thrombosis, but this information is not nationally collected or reported.

This study highlights the benefit of a paperless system, where real-time prescribing prompts can be given which account for clinical information, as opposed to static prompts, and where analysis includes all records overs a prolonged period. Some quality improvement papers in this field are based on standard audit procedures, where only a proportion of records are reviewed over a short period, leading to a significant risk of bias and making it unclear whether improvements were maintained [27, 28].

Of note, the systems in place were unable to raise full VTE guideline compliance to 100%, and full VTE guideline compliance plateaued at approximately 92% (with risk assessment completion remaining > 95% throughout). The reason for the small but important discordance in VTE risk assessment completion and subsequent correct action are unclear, but a further suite of electronically delivered tools are in development to determine if this can be improved.

This study has many strengths. It includes all patients within the hospital, and thus captures a high number of prescriber events in an unbiased manner. It also describes practices for a sustained period of time (nine years in total) which provides considerable reassurance that the changes in prescriber behaviour were sustained even as the workforce changed.

The paperless EHS deployed at the NHS Trust provides real-time, instantaneous feedback to all prescribers, highlighting the need for a VTE risk assessment, preventing further prescribing until this is completed and the suggested prescription is either approved or deleted. There are then further, automatically generated prompts every 24 h to review the risk assessment. There are a number of reported interventions which provide retrospective feedback on VTE risk assessment and prescribing practices. These include a mandatory field within the electronic discharge system that record whether a VTE risk assessment on admission took place, the study of hospital coding on discharge or through audit [29]. These provide the opportunity for learning but do not improve compliance or reduce risk for the patient included in the event. Other studies have suggested a VTE nurse specialist can provide real time feedback, reviewing notes in areas of low compliance and high risk [30]. This requires a significant workforce investment to operationalise a twenty-four hours a day, seven days a week service. An EPS solution is available to all, at all times.

This study also has limitations. All prescribing episodes were considered the same, while some guideline-discordant prescribing behaviour may be appropriate depending on the clinical circumstance. The study did not assess whether the improvement in prescribing practices benefited some patient groups or some specialities more than others. Nor did it assess whether the change in prescribing practices was associated with an improvement in patient outcomes (such as a reduction in VTE events) or reduced healthcare costs. Other studies have focused on in-patient HAT events and shown a reduction in the proportion of HAT attributable to inadequate thromboprophylaxis following an intervention with increased guideline compliance [14] suggesting there would be significant clinical benefit from these interventions. The study did not report the reasons for non-compliance, be it omission (a failure to prescribe low molecular weight heparin when the risk score suggested it was indicated) or commission (where low molecular weight was prescribed when the risk score suggested it was not needed). The clinical system in place required the prescription of low molecular weight heparin to be completed by a consultant-level doctor if the prescription was contraindicated by the risk score, while a suggested prescription of low molecular weight heparin could be deleted by medical staff if thought not indicated, even when supported by the risk score. This would make omission more likely, but further studies would be needed to assess the reason for non-compliance.

In summary, the use of mandatory assessment rules for VTE prophylaxis within an electronic prescribing system and continuous monitoring and feedback was successful in delivering and sustaining improved concordance between guidelines and prescribing practices in a large secondary and tertiary care hospital. Further work is required to determine whether these methods can be translated to other hospitals and whether these tools can be successfully used to improve performance in other areas. However, the significant and sustained impact demonstrated suggests this learning health systems approach, applied using routine clinical data to inform and refine practice, may demonstrate patient benefit across all areas of prescribing.

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