Presented at the Academic Surgical Congress 2016| Volume 160, ISSUE 5, P1202-1210, November 2016

Correlation of venous thromboembolism prophylaxis and electronic medical record alerts with incidence among surgical patients


      Venous thromboembolism events are potentially preventable adverse events. We investigated the effect of interruptions and delays in pharmacologic prophylaxis on venous thromboembolism incidence. Additionally, we evaluated the utility of electronic medical record alerts for venous thromboembolism prophylaxis.


      Venous thromboembolisms were identified in surgical patients retrospectively through Core Measure Venous ThromboEmbolism-6-6 and Patient Safety Indicator 12 between November 2013 and March 2015. Venous thromboembolism pharmacologic prophylaxis and prescriber response to electronic medical record alerts were recorded prospectively. Prophylaxis was categorized as continuous, delayed, interrupted, other, and none.


      Among 10,318 surgical admissions, there were 131 venous thromboembolisms; 23.7% of the venous thromboembolisms occurred with optimal continuous prophylaxis. Prophylaxis, length of stay, age, and transfer from another hospital were associated with increased venous thromboembolism incidence. Compared with continuous prophylaxis, interruptions were associated with 3 times greater odds of venous thromboembolism. Delays were associated with 2 times greater odds of venous thromboembolism. Electronic medical record alerts occurred in 45.7% of the encounters and were associated with a 2-fold increased venous thromboembolism incidence. Focus groups revealed procedures as the main contributor to interruptions, and workflow disruption as the main limitation of the electronic medical record alerts.


      Multidisciplinary strategies to decrease delays and interruptions in venous thromboembolism prophylaxis and optimization of electronic medical record tools for prophylaxis may help decrease rates of preventable venous thromboembolism.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Agency for Healthcare Research and Quality
        AHRQ quality indicators: Guide to patient safety indicators.
        Department of Health and Human Services, 2003 (Available from:
      1. Centers for Medicare & Medicaid Services. Centers for Medicare & Medicaid Services hospital compare website. 2015. Hospital Compare. Available from:

        • Gould M.K.
        • Garcia D.A.
        • Wren S.M.
        • Karanicolas P.J.
        • Arcelus J.I.
        • Heit J.A.
        • et al.
        Prevention of VTE in nonorthopedic surgical patients: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines.
        Chest. 2012; 141: e227S-e277S
        • Guyatt G.H.
        • Akl E.A.
        • Crowther M.
        • Schunemann H.J.
        • Gutterman D.D.
        • Zelman Lewis S.
        • et al.
        Introduction to the ninth edition: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines.
        Chest. 2012; 141: 48S-52S
        • Caprini J.A.
        Risk assessment as a guide for the prevention of the many faces of venous thromboembolism.
        Am J Surg. 2010; 199: S3-S10
        • Louis S.G.
        • Sato M.
        • Geraci T.
        • Anderson R.
        • Cho S.D.
        • Van P.Y.
        • et al.
        Correlation of missed doses of enoxaparin with increased incidence of deep vein thrombosis in trauma and general surgery patients.
        JAMA Surg. 2014; 149: 365-370
        • Nathens A.B.
        • McMurray M.K.
        • Cuschieri J.
        • Durr E.A.
        • Moore E.E.
        • Bankey P.E.
        • et al.
        The practice of venous thromboembolism prophylaxis in the major trauma patient.
        J Trauma. 2007; 62 (discussion 562-563): 557-562
        • Ramanathan R.
        • Gu Z.
        • Limkemann A.J.
        • Chandrasekhar S.
        • Rensing E.
        • Mays C.
        • et al.
        Association between interruptions in chemical prophylaxis and VTE formation.
        Am Surg. 2015; 81: 732-737
        • Umscheid C.A.
        • Hanish A.
        • Chittams J.
        • Weiner M.G.
        • Hecht T.E.
        Effectiveness of a novel and scalable clinical decision support intervention to improve venous thromboembolism prophylaxis: A quasi-experimental study.
        BMC Med Inform Decis Mak. 2012; 12: 92
        • Kucher N.
        • Koo S.
        • Quiroz R.
        • Cooper J.M.
        • Paterno M.D.
        • Soukonnikov B.
        • et al.
        Electronic alerts to prevent venous thromboembolism among hospitalized patients.
        N Engl J Med. 2005; 352: 969-977
        • Galanter W.L.
        • Thambi M.
        • Rosencranz H.
        • Shah B.
        • Falck S.
        • Lin F.J.
        • et al.
        Effects of clinical decision support on venous thromboembolism risk assessment, prophylaxis, and prevention at a university teaching hospital.
        Am J Health Syst Pharm. 2010; 67: 1265-1273
        • Nwulu U.
        • Brooks H.
        • Richardson S.
        • McFarland L.
        • Coleman J.J.
        Electronic risk assessment for venous thromboembolism: Investigating physicians' rationale for bypassing clinical decision support recommendations.
        BMJ Open. 2014; 4: e005647
      2. Agency for Healthcare Research and Quality. Postoperative pulmonary embolism or deep vein thrombosis rate. 2015. Available from:

      3. The Joint Commission. Venous thromboembolism. 2015. Available from:

        • Bilimoria K.Y.
        • Chung J.
        • Ju M.H.
        • Haut E.R.
        • Bentrem D.J.
        • Ko C.Y.
        • et al.
        Evaluation of surveillance bias and the validity of the venous thromboembolism quality measure.
        JAMA. 2013; 310: 1482-1489
        • Ramanathan R.
        • Leavell P.
        • Stockslager G.
        • Mays C.
        • Harvey D.
        • Duane T.M.
        Validity of ICD-9-CM screening for sepsis in surgical mortalities.
        Surg Infect (Larchmt). 2014; 15: 513-516
        • Ramanathan R.
        • Leavell P.
        • Stockslager G.
        • Mays C.
        • Harvey D.
        • Duane T.M.
        Validity of agency for healthcare research and quality patient safety indicators at an academic medical center.
        Am Surg. 2013; 79: 578-582
        • Chung J.W.
        • Ju M.H.
        • Kinnier C.V.
        • Sohn M.W.
        • Bilimoria K.Y.
        Postoperative venous thromboembolism outcomes measure: Analytic exploration of potential misclassification of hospital quality due to surveillance bias.
        Ann Surg. 2015; 261: 443-444
        • Salottolo K.
        • Offner P.
        • Levy A.S.
        • Mains C.W.
        • Slone D.S.
        • Bar-Or D.
        Interrupted pharmocologic thromboprophylaxis increases venous thromboembolism in traumatic brain injury.
        J Trauma. 2011; 70 (discussion 25-26): 19-24
        • Hill J.
        • Treasure T.
        Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients having surgery: Summary of NICE guidance.
        BMJ. 2007; 334: 1053-1054
        • Leonardi M.J.
        • McGory M.L.
        • Ko C.Y.
        The rate of bleeding complications after pharmacologic deep venous thrombosis prophylaxis: A systematic review of 33 randomized controlled trials.
        Arch Surg. 2006; 141 (discussion 797-799): 790-797
        • Falck-Ytter Y.
        • Francis C.W.
        • Johanson N.A.
        • Curley C.
        • Dahl O.E.
        • Schulman S.
        • et al.
        Prevention of VTE in orthopedic surgery patients: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines.
        Chest. 2012; 141: e278S-e325S
        • Shojania K.G.
        • Jennings A.
        • Mayhew A.
        • Ramsay C.
        • Eccles M.
        • Grimshaw J.
        Effect of point-of-care computer reminders on physician behaviour: A systematic review.
        CMAJ. 2010; 182: E216-E225
        • Kawamoto K.
        • Houlihan C.A.
        • Balas E.A.
        • Lobach D.F.
        Improving clinical practice using clinical decision support systems: A systematic review of trials to identify features critical to success.
        BMJ. 2005; 330: 765
        • Schedlbauer A.
        • Prasad V.
        • Mulvaney C.
        • Phansalkar S.
        • Stanton W.
        • Bates D.W.
        • et al.
        What evidence supports the use of computerized alerts and prompts to improve clinicians' prescribing behavior?.
        J Am Med Inform Assoc. 2009; 16: 531-538