Background: Venous thromboembolism (VTE) – a hematologic condition encompassing deep venous thrombosis (DVT) and pulmonary embolism (PE) – poses a significant health burden in hospitalized pediatric patients. Although there are fewer cases than in the adult population, pediatric VTE incidence has been increasing over the past decade with notable morbidity and mortality in affected children. It is important to screen patients with limited mobility for VTE risk factors, but there are no nationally validated consensus guidelines for pediatric hospitals. This project analyzes data from the first 6 months of a newly implemented Pediatric VTE Prophylaxis order set at UCLA Medical Centers in Westwood and Santa Monica. The order set is intended to automatically populate for patients between the ages of 10-25 years admitted to a pediatric service, and asks providers to stratify patients as “low,” “moderate,” or “high” risk for developing VTE.
Methods: Utilizing a real-time clarity report generated by the Inpatient Quality and Medical Informatics team, we analyzed the feasibility, efficacy, and safety of a risk-stratified thromboprophylaxis order set. First, we calculated compliance with the VTE order set as the percentage of eligible pediatric patients it was used on. Second, we performed an intensive chart review on “moderate” and “high” risk patients to determine if our evaluation of their VTE risk factors agreed with risk stratification at admission. Third, we verified if the proper mechanical prophylaxis (sequential compression device, or SCD) and/or pharmacologic prophylaxis (enoxaparin, an anticoagulant) was ordered. Finally, “moderate” and “high” risk patients were monitored for adverse effects of VTE prophylaxis, including bruising or pressure ulcers from SCD usage and bleeding due to enoxaparin administration.
Results: Between November 2017 and May 2018, 552 patients between the ages of 10-25 years were admitted to a pediatric service. 472 patients (85.5%) were assessed using the Pediatric VTE Prophylaxis order set. 18 pediatric patients (3.2%) were risk-stratified using other admission orders, and 62 patients (11.2%) were never stratified at all. Of the 472 patients admitted using the correct Pediatric VTE Prophylaxis order set, 467 (98.9%) were categorized as “low” risk, 0 (0%) as “moderate” risk, and 5 (1.1%) as “high” risk. Upon review of the patients stratified to “moderate” or “high” risk, we found that 4 (80.0%) were stratified correctly. Our reviewers disagreed with 1 (20.0%) of these stratifications. Patients in the “high” risk group were intended to receive both mechanical and pharmacologic VTE prophylactic measures. However, none of the 5 patients did, due to a design flaw in the order set. Instead, 3 patients received solely pharmacologic prophylaxis and 2 received neither mechanical nor pharmacologic prophylaxis (due to reasons documented by their providers). No patients were found to have adverse effects related to their prophylaxis.
Conclusions: This study demonstrates that usage of a standardized Pediatric VTE Prophylaxis order set within UCLA Medical Centers is possible if measures are taken to improve compliance amongst providers and to correct technical errors within the order set. For the majority of hospitalized pediatric patients, risk stratification and risk reduction (if necessary) were performed correctly. To ensure that all hospitalized pediatric patients are properly assessed in the future, we analyzed the 80 patients who were missed between November 2017 and May 2018.. We found that the majority of these misses resulted from the use of admission order sets to which Pediatric VTE Prophylaxis orders were not appropriately attached, or to patients being admitted without an order set (i.e., the admitting physician used manual order entry rather than a standardized order set). Further education for pediatric providers is needed to emphasize the use of available admission order sets in order to prevent omission of VTE prophylaxis orders. Additionally, patients need to be re-assessed when they are transferred from one service to another. In order to ensure appropriate measures are ordered for “high” risk patients, a flaw in the design of the order set needs to be corrected. Finally, the Pediatric VTE Prophylaxis order set needs to be reprogrammed to populate with 8 additional admission order sets that were missed in its initial roll-out.