HAVE A FACE-TO-FACE CONVERSATION
A health care provider visits the patient to discuss their risk of VTE and to understand why they refused prophylaxis. A nurse usually takes on this role, but the physician or pharmacist may be the patient’s preferred provider of the VTE-related education.  Other prescribers (nurse practitioner, physician assistant) who are part of a patient’s care team may be included in the intervention.
In preparation for delivery of the education, review the following steps:
- Address the patient’s concerns regarding prophylaxis (see “Patients May Ask” link)
- Review side effects of prophylaxis
- Correct misconceptions (for example, ambulation is a substitute for prescribed pharmacologic VTE prophylaxis 
- Address other issues, such as religious objections (see “Patients May Ask” link)
- Discuss alternatives (if appropriate), such as a once a day shot, sequential compression device (SCDs), or thromboembolic deterrent stockings (TEDs)
- Have Bundle materials (handout, device to access video) easily accessible
Documentation: Document the educational intervention and, if necessary, ongoing dose refusal in the EHR.
Communication: Communicate the intervention and the refusal of prophylaxis during patient handoffs, multidisciplinary rounds, and reports.
Policies: Follow any institutional policy regarding patient refusal of medications.
REVIEW THE HANDOUT
The handout answers questions patients have voiced regarding VTE prevention, diagnosis, and treatment. It is one, 2-sided page that lists online sites for additional resources, and many patients prefer to receive a paper handout. Click the links below to download the handout in various languages.
Strategies for Use of the Handout
- Upload the handout to a patient-accessed health record portal to make it available before a scheduled admission and after discharge.
- Give the handout to family members who routinely visit at the bedside. They often read the form and may be instrumental in-patient discussions and provide further support for prophylaxis use.
- Offer patients the handout in their native language, even if they are English proficient. Reading medical information in the language they are more comfortable with is a more patient centered approach and a better educational opportunity.
- Include the handout in admission packets.
Leave a handout with patients who refuse the other bundle components. They may be more comfortable or willing to read it if they are given time alone.
- English Large-print
PLAY THE VIDEO
This is a 10-minute video featuring both patients and providers describing experiences with a clot, diagnosis and treatment options, and preventative measures Delivery options: rolling workstation, hospital platform for educational video viewing, hospital-provided tablet, or via a QR code for a personal smart phone or tablet.
Pointers for Delivering the Bundle
- Ask patients what they want; they may not be willing to engage in all three offerings. Tailor the intervention to the patient’s requests.
- Enlist Health care team members (for example: clinical technicians, physical therapists, and occupational therapists) in roll out plans and staff education. They can reinforce the need to wear SCDs and dispel the concept that ambulation is effective prophylaxis.
- Enlist unit champions or charge nurses to assist newer or temporary nurses when doing their initial face-to-face intervention.
- Establish clear lines of communication with the multidisciplinary team caring for the patient.
- Read the “Patients May Ask” for strategies and scripts for talking to patients
- Badge card of strategies to communicate with patients, and delivery steps for the bundle
- Poster about process of bundle
Why is patient education important?
Patients often do not understand their risk of a VTE while hospitalized. Patient refusal of medication doses is common in the hospital, and much higher for subcutaneous anticoagulants compared to other medication categories. [9,10] Missed doses of subcutaneous VTE prophylaxis are more frequent than doses of infectious disease or cardiac prophylaxis or treatment medications. 
Evidence that the interventions work
While a patient has the right to refuse any treatment, they need to make an informed decision. When delivery of the patient education bundle was tested with medicine and surgery patient populations, overall nonadministration and refusal of pharmacologic VTE prophylaxis doses were dramatically reduced.  Delivering every prescribed prophylaxis dose is prudent to decrease the patient’s risk of a VTE.
Educating patients has been shown to improve understanding of the necessity of prescribed medication, and the potential to prevent adverse clinical outcomes.
We have previously reported on our experience with the implementation and dissemination of the patient education bundle. Our results have consistently shown that when patients and nurses know more about blood clots and how to prevent them with prescribed medication, patients are less likely to miss doses of their prescribed medication.
Furthermore, we highlight the importance of targeted education intervention, for only patients in most need of education based on the alert that they had missed a dose of their prescribed medication, contributes to addressing missed doses.
How these education materials were developed
Development of the Bundle followed the tenets of patient-centered care as part of a grant funded by PCORI(Patient-Centered Outcomes Research Institute). ( https://www.pcori.org/research-results/about-our-research/patient-centered-outcomes-research). A modified Delphi study was performed to determine patient preferences on how patients preferred to receive education and what information they wanted to learn about VTE. 
The handout was developed with input from patients, practitioners, the Johns Hopkins Hospital Patient Family Advisory Council (PFAC) , and members of the National Blood Clot Alliance (NBCA).  Participants provided input on formatting, content, language, and length. After each refinement, patients reviewed the handout to ensure it maintained the integrity of a patient-centered document. The handout incorporates adult learning theory, which considers health literacy and visual design, both vital for communicating health information to a general lay audience. [5,6,7]
An Oscar®-winning documentary filmmaker directed and produced the video. The content and length of the video followed patient preferences identified in the Delphi study (How Do I Prevent Blood Clots? – YouTube ). Members of the Johns Hopkins PFAC and NBCA reviewed and approved the video.
Providers should work with patients to implement the most effective prophylaxis they are willing to take. Include Health Care Buddies or a family member in the intervention, per patient wishes. They may be helpful for the patient’s decision-making.
- Haut ER, Aboagye JK, Shaffer DL, et al. Effect of real-time patient-centered education bundle on venous thromboembolism prevention in hospitalized patients. JAMA Netw Open. 2018;1(7):e184741. doi:10.1001/jamanetworkopen.2018.4741
- Popoola VO, Lau BD, Shihab HM, et al. Patient preferences for receiving education on venous thromboembolism prevention-a survey of stakeholder organizations. PLoS One. 2016;11(3): e0152084. doi:10.1371/journal.pone.0152084
- The Johns Hopkins Patient and Family Advisory council. Patient and Family Advisory Councils, The Johns Hopkins Hospital. https://www.hopkinsmedicine.org/patient_care/patients-visitors/patient-family-advisory-councils/jhh.html
- National Blood clot alliance. https://www.stoptheclot.org/about-clots/
- Health Literacy Universal Precautions Toolkit, 2nd Edition. https://www.ahrq.gov/health-literacy/improve/precautions/toolkit.html
- Health literacy. Plain language materials & resources. https://www.cdc.gov/healthliteracy/developmaterials/plainlanguage.html
- Health literacy studies. Developing materials. https://www.hsph.harvard.edu/healthliteracy/developing-materials/
- Lau BD, Murphy P, Nastasi AJ, et al. Effectiveness of ambulation to prevent venous thromboembolism in patients admitted to hospital: a systematic review. CMAJ Open. 2020;8(4):E832-E843. Published 2020 Dec 8. doi:10.9778/cmajo.20200003
- Popoola VO, Lau BD, Tan E, et al. Nonadministration of medication doses for venous thromboembolism prophylaxis in a cohort of hospitalized patients. Am J Health Syst Pharm. 2018;75(6):392-397. doi: 10.2146/ajhp161057
- Popoola VO, Tavakoli F, Lau BD, et al. Exploring the impact of route of administration on medication acceptance in hospitalized patients: implications for venous thromboembolism prevention. Thromb Res. 2017;160:109-113. doi: 10.1016/j.thromres.2017.10.012