Highlight
- Missed doses of pharmacologic VTE prophylaxis significantly declined following implementation of a nurse-focused and patient-centered education bundle in a community hospital setting.
- Patient refusal rates for VTE prophylaxis decreased by nearly half, illustrating the impact of real-time patient education and nurse engagement.
- The intervention demonstrated that evidence-based strategies developed in academic centers can be effectively deployed and sustained in community hospitals with diverse patient populations.
Study Background
Venous thromboembolism (VTE), encompassing deep vein thrombosis and pulmonary embolism, represents a leading cause of preventable morbidity and mortality in hospitalized patients globally. Prophylactic pharmacologic regimens markedly reduce VTE incidence; however, a substantial proportion of prescribed doses are missed due to patient refusal or logistical failures in administration. Prior research in academic hospitals has established nurse and patient education interventions to reduce missed prophylaxis doses, but their scalability to community hospitals — where most inpatient care occurs — remains uncertain. Given the burden of VTE and the potential to improve patient safety, understanding and expanding effective implementation strategies in community settings is crucial.
Study Design
This prospective cohort study was conducted at a large health system’s community hospital, spanning seven inpatient floors. It included all adult patients who were hospitalized and prescribed at least one dose of pharmacologic VTE prophylaxis between July 1, 2018, and December 31, 2019. The preintervention period covered July 1, 2018, to June 30, 2019, and the postintervention period July 1 to December 31, 2019. Interventions comprised a dynamic, scenario-based educational module targeted at nurses, coupled with a patient-centered education bundle delivered in real time. A key operational element was a live alert sent to the charge nurse whenever a prescribed VTE dose was not administered, triggering just-in-time communication with patients. The primary outcome was the proportion of missed doses of VTE prophylaxis. Secondary outcomes included categorization of missed doses into patient refusals and other reasons unrelated to refusal. Data were analyzed from January 2020 to January 2022.
Key Findings
The study enrolled 15,752 patients (55.3% female; mean age 63.9 years). During the preintervention period, 12.9% (10,643 of 82,269) of prescribed doses were missed, which dropped significantly to 9.3% (2,718 of 29,338) postintervention (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.55–0.66). The reduction was driven largely by a marked decrease in patient refusals, which fell from 8.8% to 5.8% of doses (OR, 0.51; 95% CI, 0.46–0.58). Doses missed for reasons other than refusal were also reduced from 4.1% to 3.5% (OR, 0.87; 95% CI, 0.77–0.99). Notably, there was no significant difference in the incidence of VTE events between the two periods (0.08% preintervention vs 0.1% postintervention, P = .58), although event rates were very low overall.
These results highlight that engaging frontline nursing staff through comprehensive education and leveraging patient-centered communication at the time of dose administration can effectively elevate prophylaxis adherence. Importantly, the study demonstrates success in a typical community hospital environment, which often faces different logistical and cultural challenges relative to tertiary academic institutions.
Expert Commentary
This study reinforces the critical role of nurses as intermediaries in medication adherence and patient safety interventions. By equipping nurses with scenario-based knowledge and embedding real-time alerts, the study created a robust feedback loop to ensure timely administration of VTE prophylaxis.
Reducing patient refusals may hinge on personalized education, addressing patient misconceptions or discomfort that contribute to nonadherence. The lack of increase in VTE despite fewer missed doses suggests that improvements were achieved without jeopardizing patient safety.
However, the study’s observational design may be susceptible to confounding factors, such as concurrent institutional initiatives or seasonal variations affecting prophylaxis practices and VTE risk. Generalizability beyond this single community hospital warrants cautious optimism; replication in diverse settings will further validate scalability.
Additionally, the intervention’s reliance on electronic health record alerts and dedicated nurse resources introduces potential barriers in settings with limited informatics infrastructure or staffing shortages. Future research should explore cost-effectiveness and long-term sustainability.
Conclusion
Implementing a multifaceted, patient-centered education bundle targeted at frontline nurses and patients significantly reduced missed and refused doses of VTE prophylaxis across an entire community hospital. These findings illustrate that effective interventions from academic hospitals can be adapted and successfully integrated into community hospital workflows. Broad adoption could markedly enhance patient safety by ensuring that hospitalized patients receive essential thromboprophylaxis. Ongoing efforts should focus on tailoring such interventions to different healthcare contexts and evaluating their impact on clinical outcomes over longer durations.
References
Haut ER, Owodunni OP, Shaffer DL, McQuigg D, Samuel D, Hobson DB, Kraus PS, Wang J, Webster KLW, Kantsiper M, Harris JE Jr, Holzmueller CG, Varasteh Kia M, Streiff MB, Lau BD. Implementing a Patient-Centered Education Bundle to Improve Venous Thromboembolism Prevention. JAMA Surg. 2025 Oct 8. doi: 10.1001/jamasurg.2025.4136. Epub ahead of print. PMID: 41060638.
Kahn SR, Lim W, Dunn AS, et al. Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2_suppl):e195S-e226S.
Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of Venous Thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008 Jun;133(6 Suppl):381S-453S.
