All methods were conducted accordance with (Strengthening the Reporting of Observational studies in Epidemiology) STROPE guidelines for this study. This is a cross-sectional study to assess the effect of a real-time CDSS for recommendation VTE prophylaxis within CPOE on adherence to VTE prophylaxis guideline in nonsurgical patients. this study was conducted at the three ICUs (General ICU, Central ICU, and Emergency ICU) of Nemazee hospital, which is located in Shiraz, and is the largest academic hospital in southern Iran. Data related to before intervention have been collected from April 20, 2020, to 21 November 2020 and post-intervention have been collected form 7 April 2021, to 9 July 2021). It is a teaching hospital, with 850 beds. Three ICUs of Nemazee hospital uses the homegrown electronic medical record (EMR) with a CPOE system since 2015(28). The Homegrown EMR implemented in Nemazee hospital has not equipment the VTE prophylaxis CDSS. In three ICUs serviced by one medical team, with similar services. All ICUs was administered by intensivists with a closed system. The inclusion criteria included nonsurgical patients aged over 18 years and having been hospitalized in General ICU, Central ICU, and emergency ICU of Nemazee hospital. another hand pregnancy, and surgical patients and patients' current use of anticoagulation were excluded because surgical and pregnancy populations were used different guidelines.
For Real-Time computerized clinical decision support systems on the use of Appropriate Prophylaxis for VTE in nonsurgical patients’ intervention
First step:
modified VTE prophylaxis guidelines nonsurgical for use at ICU in Iran. Intensivists (three individuals), clinical pharmacy (one individual), and health informatics (two individuals) from Shiraz University of Medical Science(SUMS) were invited to attend the panel. In three sessions panel members discuss VTE prophylaxis guideline use in Iran. VTE risk assessment model and appropriate prophylaxis in nonsurgical patients at ICU in Iran country and contraindication of VTE prophylaxis was modified and established by this panel. Local VTE prophylaxis guidelines based on American College of Chest Physicians (ACCP) prophylaxis in nonsurgical patients are being in the supplementary file. Appendix 1.
The second step
design, development, and implement CDS for recommendation VTE prophylaxis within the CPOE system. Common UML (unified model language) diagrams included use case, activity diagram, and sequence diagram were designed for the VTE prophylaxis CDSS (as can be seen in UML diagrams in supplementary file2 appendix 2). The knowledge base of VTE prophylaxis CDSS in nonsurgical patient consists of 26 rule sets. After that, the VTE prophylaxis CDSS was developed in CPOE (as can be seen in Screen of this CDSS in supplementary file3 appendix 3). In the next step, chairman of the ICU and CDSS committee in the hospital was assessment and tested the VTE prophylaxis CDSS. All major bugs or changes in functionality or content have been fixed after the testing system. After approval VTE prophylaxis system by the CDS committee, all end-users (clinicians) have been trained to use the VTE prophylaxis CDSS in class and one by one. Finally, the VTE prophylaxis CDSS has been installed in three ICUs of Nemazee hospitals. The physician has completed the VTE risk factors checklist and contradiction document for the nonsurgical patient, then CDSS based on VTE risk score, contraindication VTE prophylaxis, patient weight, and renal functions recommended VTE prophylaxis order sets. The content of VTE prophylaxis CDS was changed by consensus of the CDS committee includes three ICU attending, a clinical pharmacist, and two health information management specialists. The unexpected bug in the VTE prophylaxis CDSS resolves each day.
The third step
The researcher’s measurement clinician adherence to VTE prophylaxis guidelines in nonsurgical patients after implemented VTE prophylaxis CDS. The pharmacist in the research team evaluated adherence to VTE prophylaxis guidelines in nonsurgical patients.
A VTE risk assessment model for hospitalized nonsurgical patients, the Padua Score, has been established and recommended using the 2012 ACCP evidence-based clinical practice guideline for VTE prevention in nonsurgical patients (9). This tool includes 11 risk factors including age, Body Mass Index(BMI), history of VTE, a surgical procedure during present hospitalization, acute myocardial infarction or ischemic stroke, presence of malignancy, heart or respiratory failure, and hormonal treatment. The score of each VTE risk factor in nonsurgical patients recommended VTE prophylaxis based on VTE score, and contraindication of each VTE prophylaxis is presented in the supplementary file. appendix 1. A Padua Prediction Score was calculated for each patient. The patient was identified as high risk if they had a calculated score > 3.
Variables that were collected from the patients' interviews and completed from the medical file for all patients from the adult ICU included demographics (age, and sex), ICU length of stay, mortality in ICU, and risk factors of VTE.
For the baseline period, researchers reviewed each patient’s medical record to collect the following VTE-related variable: provider documentation of Padua risk stratification, patient VTE risk factors, contraindications to pharmacological prophylaxis, and written orders for prophylaxis within 24 h of admission. For the post-implementation period, these variables were extracted directly from the EMR and CPOE system. Compliance with appropriate best practice VTE prophylaxis guidelines was defined as adherence to local VTE prevention algorithm. The primary outcome was appropriate VTE prophylaxis or adherence to the local VTE prophylaxis algorithm. The secondary outcome was ICU mortality and ICU length of stay.
Continuous variables are summarized with means and standard deviation, and categorical variables are summarized with numbers and proportions. Adherence to VTE prophylaxis guidelines in the group without VTE prophylaxis CDS compared to the group using CDSS for recommendation VTE prophylaxis, by using the 2-sided X2 test for categorical variables and Student t-test was used to the evaluated effect of CDS on appropriate VTE prophylaxis and patient’s outcome. Value of P < 0.05 was considered statistically significant. All statistical analysis was performed by SPSS version 24.