Can Nurse and Patient Education Reduce Missed Doses of Medications to Prevent Blood Clots in Hospitals?

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What was the research about?

Blood clots that develop inside veins can cause serious health problems or even death. Although anyone can get a blood clot, more than half of blood clots happen after a hospital stay or surgery. Medicine to thin the blood can help prevent this problem, but missing even one dose can lead to blood clots. Hospitals want to do a better job of making sure patients don’t miss any doses.

The research team wanted to see if teaching hospital patients and nurses about medicine to prevent blood clots would lower the number of missed doses. Patient education took place right after a patient missed a dose of their medicine at the hospital. The team created three options to teach patients about blood clots. The patient could choose a 2-page handout, a 10-minute video, or talking with a patient educator. The research team also compared two ways to teach nurses about blood clots. One way was an interactive online training program. The other was an online training program that had a slide show with a voice recording.

What were the results?

Compared with patients who didn’t learn about blood clots, patients who learned about blood clots right after a missed dose were less likely to refuse medicine to prevent blood clots. They were also less likely to miss receiving the medicine for other reasons.

After nurses took part in training about how to prevent blood clots, fewer patients missed a dose of medicine to prevent blood clots compared to before the training. The study didn’t find that one way to train nurses was better than the other.

Who was in the study?

The study included 19,652 patient visits at a hospital in Baltimore, Maryland, who were prescribed medication to prevent blood clots. Half of the patients were men and half were women. Almost half of the patients were white, and a little less than half were African American.

The study also included 933 nurses who worked full-time at the hospital.

What did the research team do?

When a patient missed a dose of medicine to prevent blood clots, the research team received an alert. If a patient refused the medicine, the team asked the patient if he or she wanted to learn about blood clots and why taking the medicine is important. If a patient missed their medicine for a reason other than refusing it, then the research team told the patient’s nurse to make sure the patient received their medicine. The research team counted the patients who took or refused the medicine before and after the hospital offered to teach patients about blood clots.

Nurses took one of the two online training programs about medicine to prevent blood clots. After the training, the research team looked at how many times the nurses’ patients missed a dose of medicine to prevent blood clots.

What were the limits of the study?

This study took place at one hospital. The results may not be the same at other hospitals. Not all patients who missed their medicine for blood clots took part in the study. Some patients went home before the research team could talk with them, and others didn’t want to be part of the study.

Future research could test the nurse training and patient education at different types of hospitals and in different locations.

How can people use the results?

These results show that when patients and nurses know more about blood clots and how to prevent them with medicine, patients are less likely to miss doses of this medicine. Hospitals can consider teaching patients who don’t take their medicine about how to avoid blood clots right after patients refuse their medicine. Hospitals can also consider training for nurses.

Objective

To compare the effectiveness of usual care versus educational interventions for nurses and patients on nonadministration and patient refusal of anticoagulants for venous thromboembolism (VTE) prevention among hospitalized patient.

Study Design

This study included two components:

• A double-blind cluster randomized controlled trial of two web-based modules—static versus interactive—to educate nurses about the harms of VTE, the benefits and risks of anticoagulants, and strategies for communicating with patients about anticoagulants
• A controlled pre- versus postintervention comparison of a patient-education bundle delivered when a patient missed a prescribed dose of anticoagulants

The primary outcome for both study components was the proportion of anticoagulants not administered. The secondary outcome for both study components was the proportion of anticoagulants not administered due to refusal by patients or family.

The nurse education study included 933 permanent nursing staff from the departments of internal medicine and surgery at a hospital in Baltimore, Maryland. The research team cluster randomized nurses by floor to receive one of two online trainings on anticoagulants: a static PowerPoint presentation with a voiceover to present concepts, or a dynamic module with positive reinforcement and corrective feedback. The research team monitored anticoagulant administration practices using electronic health records over one year, stratified into time periods: baseline (preintervention) and postintervention.

The patient-education study included hospitalized patients on 16 adult nonintensive care nursing floors of the hospital. There were 4 intervention floors and 12 control floors. Patients were close to evenly split between men and women in the intervention and control groups. Almost half were white and a little less than half were African American. In response to a real-time alert, patients on intervention floors who missed a dose of anticoagulants received at least one component of an educational bundle, according to their preference. The patient-education bundle included a one-on-one conversation with a health-educator nurse, a 2-page paper handout, and a 10-minute video. Patients on control floors received usual care. The research team compared anticoagulants not administered pre- and postintervention.

Patients and caregivers, some of whom had experience with VTE, and other stakeholders helped create the educational materials.

Results

Nurse educational intervention.

• Medication not administered. Among nurses in either education arm, the proportion of nonadministration was significantly lower following nurse education (12.4% versus 11.1%, conditional odds ratio (OR) 0.87, 95% confidence interval (CI), 0.80-0.95, p=0.002). The difference between the dynamic and static arms was not statistically significant.
• Medication not administered because of patient refusal. Following nurse education, there was no change overall or in either education arm in the proportion of doses that patients or family refused.

Patient educational intervention.

• Medication not administered. The odds of missing doses of anticoagulants declined by 43% on intervention floors (OR 0.57, 95% CI, 0.48-0.67). There was no change on control floors (OR 0.98, 95% CI, 0.91-1.07).
• Medication not administered because of patient refusal. The odds of missing doses of anticoagulants due to patient or family refusal decreased by 47% on intervention floors (OR 0.53, 95% CI, 0.43-0.65). There was no change in patient or family refusal of doses on control floors (OR 0.98, 95% CI, 0.89-1.08).

Limitations

The study took place at only one hospital, so results may not be generalizable to other hospitals. For the patient-education component, not all patients who missed doses took part in the study; the hospital discharged some patients before the intervention began, and others were unable or unwilling to meet with a health-educator nurse.

Conclusions and Relevance

This study found that both nurse and patient education reduced nonadministration of anticoagulants. The study did not find evidence that one type of nurse education is better than another, because both reduced the proportion of missed doses among patients.

Future Research Needs

Future research could examine optimal strategies for training nurses or the effect of nurse- or patient-education interventions on VTE events. Future research could also focus on implementing the education interventions in hospitals in other locations.