Factors Associated with Pharmaceutical Venous Thromboembolism Prophylaxis in Hospitalized Surgical Patients.

Abstract

Despite evidence that venous thromboembolism (VTE) is one of the most preventable causes of death, pharmaceutical prophylaxis is underused. It is unclear why such evidence-based risk assessment and treatment is often omitted or delayed. One unexamined factor is nursing’s role in the administration of prophylaxis, and the nursing work environment. This study applied a theoretical framework of situational awareness, recognized by high reliability organizations (HROs) as a critical component in daily operations, to an important problem: VTE prophylaxis. This retrospective cohort study, utilizing data from the Michigan Surgical Quality Collaborative (MSQC), the electronic medical record, and the staffing system, aimed to examine environmental factors associated with 1) the administration of pharmaceutical VTE prophylaxis, 2) VTE occurrences, and 3) other postoperative occurrences. The sample included patients from a single institution in the MSQC database who were hospitalized for at least 24 hours and remained on the same unit (N=1,370). Correlations and logistic regressions were used to analyze the data. Nearly one-third of patients experienced an error. Significant predictors included VTE risk score, the difference between actual and budgeted RN hours per patient day (RN HPPD), census, workload, education, and unit type, all in expected directions. As the gap in RN HPPD decreased, patients were 12.4% more likely to receive prophylaxis. Patients were less likely to receive prophylaxis as nursing workload increased. The more baccalaureate-prepared nurses on the unit, the more likely patients received prophylaxis; a 1% increase corresponded to a 4% decrease in patients not receiving necessary prophylaxis. Patients admitted to surgical units were four times more likely to receive the prophylaxis. Patients who received prophylaxis were less likely to have a VTE occurrence. This is the first study to examine the environmental factors of situational awareness and patient outcomes. Situational awareness is recognized as a contributing factor in HROs to manage and reduce risk. Future work is needed to extend this research and contribute to an understanding of how the nursing work environment impacts patient outcomes in a high reliability organization. The findings from this study have potential to extend our understanding of the complex work in nursing.