Safety Insider
April 28, 2016

Johns Hopkins nurses find ways to ensure more patients receive vital medication.

Why do preventive treatments go unused? At The Johns Hopkins Hospital, nurse clinician Deb Hobson is part of a research team that is pushing to find out. “I learned that 12 to 14 percent of our patients weren’t receiving the doses of heparin or other blood thinners that their doctors had ordered for them,” says Hobson. “As a nurse. I thought to myself, ‘Wow, that’s a lot!’”

With funding from the Patient-Centered Outcomes Research Institute (PCORI), Hobson and her collaborator, nurse educator Dauryne Shaffer, are developing training sessions for nurses aimed at ensuring that more patients receive medications to prevent venous thromboembolisms (VTEs). Their involvement is crucial to the overall success of the three-year project to avoid these deadly blood clots, notes principal investigator Elliott Haut, a Johns Hopkins trauma surgeon.

“Without a multidisciplinary team, there’s no way you’re going to get buy-in from front-line providers,” says Haut. “We all want to hear from our peers. Surgeons like to listen to surgeons. Nurses like to listen to nurses. When it comes to teaching, educating and giving advice, nurses want someone like them.”

Haut, who is also an associate professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health, says that over the past decade, he’s seen nurses become increasingly valued members of multidisciplinary research teams. “Science without collaboration doesn’t work,” he says. “If you try to do any [research] work in quality and patient safety without nurses having a voice, you’re dead in the water.”

Haut’s assessment appears to be shared by today’s grant funding organizations, from the National Institutes of Health, to PCORI, to the National Institute of Nursing Research. Increasingly, these agencies apportion their sought-after dollars to projects that cross disciplines and demand collaboration.

Twice each week, Hobson and Shaffer attend meetings at The Johns Hopkins Hospital with other members of their VTE prevention team. In their research to find out why a significant number of patients at the hospital were refusing doctor-prescribed blood thinners, the team found some surprises. Among them: Some nurses believed that as long as their patients were ambulatory, the risk of blood clots was minimal, so they counseled patients against taking the prescribed medication. In other cases, nurses would make the decision to hold off on blood-thinning doses if patients were about to undergo a procedure, such as having a feeding tube inserted, out of concern that the medication could cause excessive bleeding.

While well-intentioned, both courses of action had the potential to put patients at unnecessary risk of a deadly blood clot. To set the record straight and bring floor nurses up to date on the latest evidence-based practice in VTE prevention, Shaffer worked with other members on the research team to create several e-learning modules. In addition, the team set up a technology-based system—tied to the electronic medical record—that alerts Shaffer or another VTE collaborative member when a patient refuses a dose of prescribed preventive treatment. When she gets paged, Shaffer makes a visit to the patient’s bedside to talk through his or her concerns. She’s found that many people don’t realize how serious a blood clot can be or that its effects can linger for many months.

“We still have patients who will refuse [the blood-thinning] medication,” says Shaffer. “But at least it’s an educated refusal.”

The VTE prevention team has come up with a one-page fact sheet—available in multiple languages—that is now given to many hospitalized patients. It also produced a short video in which patients who’ve suffered blood clots share their cautionary tales.

Study leader Haut says his team is on track to produce a “blueprint” for multitiered strategies that can be adopted by hospitals across the country. The ultimate objective: to reduce the 100,000 deaths caused annually by VTE—more than AIDS, breast cancer and motor vehicle accidents combined.

“Without nurse representation in our group, it would have been impossible for us to work on any [of this],” says Haut. “When you’re doing quality and safety research on interventions for real patients on surgical floors, it’s absolutely critical to have nurses on the team.”