Improving VTE prophylaxis adherence among hospitalized adolescents using Human-Centered Design

Background/Problem Statement

Venous thromboembolism (VTE) is the leading cause of preventable hospital mortality in the United States, with estimates of up to 1.6 Million VTEs occurring yearly. ¹ Of hospitalized VTEs, up to 70% are considered preventable with the use of anticoagulants or compression devices. ² Consequently, VTE prophylaxis is a hallmark of care for hospital inpatients. ³ Yet implementation of prevention for VTE remains incomplete, with poor compliance with pharmacologic VTE prophylaxis^4,5 and large variation in adherence to intermittent pneumatic compression devices (IPCD) (40%–89%, median 78%). ⁶ VTE rates are lower in children than in adults, but rise markedly for sick children in the hospital. Leading risk factors for VTE in adolescent inpatients include malignancy, surgery, autoimmune disease, inherited thrombophilia, and central venous catheters.^7–9 Adolescent VTE prophylaxis guidelines differ from adult guidelines, with less emphasis on pharmacologic VTE prophylaxis and most patients getting IPCD and encouragement to ambulate early.^8–13

In 2018, the high rate of VTE reports at University of Illinois Hospital and Health Sciences System (UI Health) led hospital leadership to begin an urgent campaign to reduce VTE. Nurses on all hospital inpatient units were tasked with VTE prophylaxis adherence. The hospital campaign provided adult wards with tools and guidelines, but pediatric nurses could find no VTE educational tools suitable for their adolescent patients within the institution or in internet searches. The pediatric nurses reported that this gap was detrimental to care of sick adolescents, especially the care of adolescents with chronic diseases. For example, when adolescents with sickle cell disease (SCD) reach adulthood, they will have 2–8 times the risk of blood clots as other adults,^14–16 and adult SCD accounts for one-third of VTEs at UI Health. Thus, the effort invested in building good adherence for an adolescent with chronic disease could result in a lifetime of adherence in future hospitalizations as an adult. In response to both the urgency and the gap, we proposed to apply a rapid design-led process to develop educational materials tailored to 10–17 year-olds and ensure tools for use by nurses to improve patient awareness of VTE and agreement with thromboprophylaxis.

Methods

An interdisciplinary team of physicians, nurses, communication and service designers, quality experts and medical students applied human-centered design (HCD) methods ¹⁷ to define, iteratively prototype, and pilot patient education tools for nurses fit to the patient and the clinician context of use. Human-centered design, also called “design thinking,” is an established method for examining the real-world context and behaviors of individuals, engaging stakeholders, and rapidly prototyping and testing solutions optimized for specific end-user needs. ¹⁸ An increasing number of health systems are applying human-centered design to improve frontline care delivery^19,20 and addressing “last mile” problems, such as care coordination, patient communication and quality improvement efforts.^21–23 The primary goal was nursing satisfaction with educational tools for adolescent VTE prophylaxis. Secondary goals were IPCD adherence rates over 78% (median from systematic review ^{24 )} and resident physician satisfaction with the educational tools. Given the high prevalence of SCD on the pediatric ward and the related inappropriateness of interviewing adolescents who are hospitalized in intense pain and on narcotic analgesics, and the urgency of improving VTE prophylaxis for these patients, direct engagement of adolescents was not pursued.

The team engaged in a six week design “sprint” from kick-off to pilot test. To define stakeholder needs and contextual requirements methods from contextual inquiry were used to gather data. Contextual Inquiry is a design paradigm that prioritizes direct observation of people in their usual performance of work to understand their real-world behaviors. ²⁵ Iterative prototyping ²⁶ was used throughout the stakeholder engagement process to refine concepts for improved fit and feasibility. The design process was followed by a six week pilot test of stakeholder-preferred solutions.

Defining design requirements: Our contextual inquiry protocol targeted VTE prophylaxis activities and workflows using direct observation of morning rounds and routine care processes on the pediatric floor. Medical students were trained by designers in observation and documentation with templated field notebooks. Over 105 hours of data captured clinician roles in VTE prophylaxis; resources and communication strategies employed when engaging patients and families in VTE prophylaxis education; and challenges and workarounds promoting adherence. Additionally, the team engaged in role-play with a pediatric nurse to receive VTE prevention instruction and experience first-hand wearing IPCDs in the patient room. Data was analyzed in team debrief sessions using nurse workflow mapping and a multi-level requirements framework to structure stakeholder needs into content, user and contextual levels.^27,28

Thirteen semi-structured interviews were conducted with health system stakeholders: three quality leadership, three pediatric nurses and nurse administrators, one pediatric physician, and one child life specialist with experience in the developmental needs of inpatient children. Interviews targeted current VTE prophylaxis strategies; the effectiveness and fit with UI Health's pediatric population; and opportunities to support providers and engage pediatric patients in VTE prevention. Two external subject matter experts (pediatric hematologist, physical therapist for adolescents) discussed best practices, programs and strategies for motivating child movement and adherence to VTE prophylaxis. Two adults and one adolescent with histories of childhood hospitalization at UI Health for sickle cell disease were asked about their inpatient experiences and for feedback to early-stage prototypes. Interview candidates were recruited in part for their ability to serve as proxies for inpatient adolescents through their lived or professional experiences.

A pre-pilot survey was sent to over 60 pediatric floor nurses, physicians and residents to assess staff experiences with, and confidence using, current VTE support tools and protocols.

Concept development: An inventory of existing VTE prophylaxis tools identified no materials specifically targeting adolescents, but found 16 adult patient-facing tools that evidenced effective communication and behavioral design strategies. Behavioral design applies theories of behavioral economics to develop solutions that actively engineer better decision-making on the part of users.^29,30 Based on design choices, tools were clustered into: (1) action-oriented materials featuring checklists; (2) infographic materials highlighting statistics about VTE incidents; and (3) pictorial materials depicting VTE prevention methods. All three strategies were marked for potential inclusion in concept development.

Principles of behavioral design were also incorporated into concept development. Principles selected were: (1) build “choice architecture” ³¹ into materials to give adolescents options and a greater sense of agency and control; 2) linguistic strategies that translate behavior into identity (e.g. “I am a voter” as opposed to “I voted”) ³² to align clinicians and patients around a common goal; and 3) promote “social norming” ³³ of VTE prophylaxis adherence across the pediatric population (e.g. make it visible to adolescents that their hospitalized peers are engaging in the desired preventative actions). Combining these principles with identified communication strategies and guideline-based VTE prophylaxis recommendations generated 22 early-stage concepts.

Intercept interviews (10–30 min each) were conducted with 12 physicians, nurse practitioners, nurses, and physical therapists on the pediatric ward using convenience sampling. Participants provided feedback on overall concept; convenience of form factor (size, shape and ease of use); appropriateness of language and graphics for children; and fit with provider role in VTE prophylaxis. Iterations generated a process of continuous refinement, each responding to content errors or when two or more participants made similar comments related to acceptability and usability. An additional 10 intercepts used A/B testing—a design method where two versions of a concept are presented to elicit preference—were conducted to select final solutions.

Final tools: Six solutions were selected for pilot-testing. Each was designed to incentivize or simplify desired behaviors in VTE prophylaxis: (1) an in-room education poster illustrated four VTE prevention tactics that patients and families could perform in their room; IPCDs were reframed as “massagers”; posters were designed at a 4th grade reading level and optimized for patient viewing from a bed in the dim lighting conditions often preferred by people experiencing acute sickle cell pain; (2) a “mobility menu” organized age-appropriate movement options by pain level to help nurses and patients negotiate daily goals; (3) a patient education handout illustrated the biomechanics of VTE to help residents and nurses speak simply about the need for VTE prophylaxis; (4) a nurse checklist organized tasks in promoting VTE prevention; (5) “I am a blood clot preventer” doorway badges were visible rewards for patients who had met their VTE prevention movement goals; (6) “I am a blood clot preventer” lapel buttons for use by all pediatric clinicians helped naturalize VTE prophylaxis as a shared, system-level goal.

Pilot-testing: All six solutions were pilot-tested over a six week period (Nov-Dec 2018). The pilot was launched by pediatric nursing and physician leadership and rolled out across the pediatric floor. Posters were installed within five feet of all beds and at patient eye level, ensuring all patients “received” the poster; other tools were used at nurse discretion. In response to nurse reports of patient feedback, two sets of corrections were made to in-room posters during the first week to modify messaging about injections (Figure 1).

Pilot Measurement: A post-pilot survey was sent to pediatric nurses and residents to evaluate their experiences with the six concepts. Frequency data on patients’ use of IPCDs in the PICU and pediatric ward was collected from January 2018 through June 2019 through chart review. Nurses documented whether pediatric patients were wearing their IPCDs during routine checks every 4-8 hours. Direct observation of IPCD by a second observer during weekdays confirmed the accuracy of IPCD documentation.

Per institutional protocol, each patient was classified as low, moderate or high risk for DVT according to a pediatric risk assessment tool.^34,35 Moderate-risk adolescent patients were ordered to have IPCD, with provision that IPCD would not be applied to a leg with SCD vaso-occlusive pain or surgical pain. Low-risk adolescent patients had no IPCD ordered, only early mobilization to get out of bed. For the analysis, high-risk patients were excluded, since hospital protocol stipulates all high-risk patients receive subcutaneous heparin rather than IPCD for their thromboprophylaxis. Excluding this high-risk category dropped one or fewer patients per month from analysis.

Based on results of risk assessment, a total of 169 patients were included in pilot measurement. Patient compliance with IPCDs was calculated as a percentage of times the patient was documented wearing an IPCD during routine checks, data are grouped by hospitalization site (ward vs. pediatric intensive care unit (PICU)). The intervention began November 2018, and the data was divided into months for analysis using standard Statistical Process Control methods. A control chart had control limits set at 3SD from the mean. Changes in the mean were made when monthly data met criteria for special cause, conferring statistical significance.

Ethical review: After Institutional Review Board determination that this activity was not human subjects research, it was set up as a Quality Improvement project under supervision of the hospital Pediatric VTE Committee.

Results

Chart Reviews

Data from chart reviews of all pediatric patients in the PICU and Pediatrics floor showed an overall increase in IPCD usage after the intervention. Monthly compliance rose from 69% pre-intervention to 79% post-intervention, and this change was statistically significant using Statistical Process Control methods. Figure 2 shows the control chart, with control limits set at 3SD from the mean. Changes in the mean were made when data met criteria for special cause, conferring statistical significance. In this case, 8 consecutive points above the mean for the first change (hospital VTE campaign in early 2018) established a mean of 69% prior to the design project. This design project was associated with a change in the mean adherence to 79% when 2 out of 3 consecutive points were >2 SD from the mean. In contrast, IPCD training for nurses (August 2018) and a second hospital VTE campaign (Feb-April 2019) were not associated with changes in the mean.

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Figure 1.

The final pilot-tested poster was written at a 4th grade level, repositioned IPCDs as massagers, invoked personal identity to promote new behavior, and provided VTE prevention choices to adolescents. Presented here is the progression of modifications made week 1 of the pilot in response to patient feedback: First, an image modification substituted the hypodermic needle with an illustration of the injection site; second, a text modification changed “receive a shot” to the nurse-preferred “get a medicine.”

Discussion

At our PICU and Pediatrics ward, all clinicians were expected to promote and reinforce VTE prophylaxis, but a lack of age-appropriate tools to help standardize that education resulted in significant practice variation. Further, frequently hospitalized adolescents reported frustration with their chronic health conditions and consequently were more resistant to engaging in VTE prevention while inpatient. As nurses were accountable for implementing physician orders for VTE education and prevention, patient adherence failures accrued to them. Our pediatric nurses and residents were familiar with VTE prophylaxis and causes, but were not able to translate their knowledge into successful motivation for adolescents to adhere. No VTE prevention materials we found specifically targeted the developmental needs and cultural diversity of our adolescent population. This project aimed to fill this gap with support tools designed to the satisfaction of clinicians, particularly nursing staff, and to raise the IPCD adherence rate. To achieve these goals and meet an urgent institutional prioritization of VTE across all hospital units, a human-centered design approach was used for its ability to rapidly identify and translate the real-world needs of stakeholders into risk-reduced, fit-to-purpose concepts.

The team created interventions that followed relevant principles of design, including workflow fit, shared priority, agency and choice, and adaptability. Busy clinician schedules pose difficulties in ensuring VTE prophylaxis education, so all interventions were created to fit into the existing clinician workflow. Further, interventions framed VTE prophylaxis as an enactment of personal identity to unify clinicians, staff and patients as problem owners. To address the challenge of patient resistance to VTE prophylaxis, our poster and mobility menu integrated framing language and movement options to provide adolescents a sense of agency and choice. This addresses a gap in current VTE prevention supports.

The intervention was associated with an increase in IPCD adherence from 69% to 79% in the pediatric units. The control chart (Figure 2) shows that this change is statistically significant. The hospital pediatric VTE committee regarded this change as clinically meaningful and attaining the benchmark of 78%. ²⁴ This increase could be due to multiple factors other than the tools developed, but the IPCD adherence was the secondary outcome. Based on results from the post-pilot survey, nurses chose the in-room poster as the material that most improved the process and effectiveness of motivating adolescent adherence to VTE prevention strategies. Given that the burden of VTE prophylaxis falls on nurses, the in-room poster should be considered essential if these communication tools are adapted to more hospital settings. Nurses and residents reported feeling more supported by others in VTE prevention efforts, suggesting the poster changed the sense of ownership within care teams. Residents also reported greater efficacy in educating and enforcing VTE prophylaxis with patients post-intervention. Levels of staff engagement and adoption of fit-to-purpose education tools suggest using a human-centered design development process can be an effective catalyst when part of a multi-prong effort to address VTE prophylaxis.

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Figure 2.

Percentage of eligible hospitalized patients ages 10-17 years old documented as wearing IPDCs, January 2018–June 2019, and timeline of VTE education promotion activities.

Conclusion

Human-centered design was the framework for observations, interviews, and surveys, through which we gain insight into the challenges of providing effective patient education regarding VTE prophylaxis. VTE prophylaxis education for adolescents was expected from all clinicians, although the implementation of orders and accountability for patient adherence fell to nurses. The piloted materials, specifically the in-room poster, increased nurse satisfaction with tools for educating adolescent patients regarding the importance of VTE prevention. We attained the secondary goal of IPCD adherence >78%. The piloted materials also helped to create an environment of shared priority among all the clinicians. Patient education tools, created collaboratively with frontline users, can contribute to multi-pronged efforts to improve adherence with VTE prophylaxis.