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Parisi J, Martínez de Lagran I, Serra-Prat M, Roca Fontbona M, Merino R, de la Torre MªC, Campins L, Yébenes JC. Validation of the nutritrauma concept for the detection of potential harmful effects of medical nutritional treatment in critically ill patients in real life. NUTR HOSP 2024. [PMID: 38804970 DOI: 10.20960/nh.04993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
INTRODUCTION medical nutritional treatment (MNT) can be complex and may be associated with potential metabolic complications, which has been recently described as nutritrauma. OBJECTIVE the aim of our work is to describe whether the application of the nutritrauma concept in real life is feasible and useful to detect the metabolic complications associated with the prescription of MNT. MATERIAL AND METHODS in this descriptive, prospective study at a single center we enrolled 30 consecutive critically ill patients in a 14-bed medical-surgical intensive care unit. The nutritrauma strategy implementation was based in four "M" steps: Metabolic screening, MNT prescription, biochemical Monitoring, and nutritional Management. RESULTS we analyzed 28 patients (mean age, 69.7 ± 11.3 years; APACHE II, 18.1 ± 8.1; SOFA, 7.5 ± 3.7; Nutric Score, modified, 4.3 ± 2.01, and mean BMI, 27.2 ± 3.8). The main cause of admission was sepsis (46.4 %). Length of ICU stay was 20.6 ± 15.1 days; 39.3 % of subjects died during their ICU stay. Enteral nutrition (82.1 %) was more frequent than parenteral nutrition (17.9 %). During nutritional monitoring, 54 specific laboratory determinations were made. Hyperglycemia was the most frequent metabolic alteration (83.3 % of measurements). Electrolyte disturbances included hypocalcemia (50 %), hypophosphatemia (29.6 %) and hypokalemia (27.8 %). The most frequent lipid profile abnormalities were hypocholesterolemia (64.8 %) and hypertriglyceridemia (27.8 %). Furthermore, nutritional prescription was modified for 53.6 % of patients: increased protein dosage (25 %), increased calorie dosage (21.4 %) and change to organ-specific diet (17.8 %). CONCLUSIONS in conclusion, the application of the nutritrauma approach facilitates detection of metabolic complications and an evaluation of the appropriate prescription of MNT.
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Affiliation(s)
- Jordi Parisi
- Department of Intensive Medicine. Hospital de Mataró
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Hoyer EH, Bhave A, Xue W, Haut ER, Lau BD, Kraus P, Turnbull AE, Shaffer D, Friedman LA, Young D, Brotman DJ, Streiff MB. Inaccuracy of Initial Clinical Mobility Assessment in Venous Thromboembolism Risk Stratification. Am J Med 2024:S0002-9343(24)00205-5. [PMID: 38649003 DOI: 10.1016/j.amjmed.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 03/13/2024] [Accepted: 04/02/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Venous thromboembolism risk increases in hospitals due to reduced patient mobility. However, initial mobility evaluations for thromboembolism risk are often subjective and lack standardization, potentially leading to inaccurate risk assessments and insufficient prevention. METHODS A retrospective study at a quaternary academic hospital analyzed patients using the Padua risk tool, which includes a mobility question, and the Johns Hopkins-Highest Level of Mobility (JH-HLM) scores to objectively measure mobility. Reduced mobility was defined as JH-HLM scores ≤3 over ≥3 consecutive days. The study evaluated the association between reduced mobility and hospital-acquired venous thromboembolism using multivariable logistic regression, comparing admitting health care professional assessments with JH-HLM scores. Symptomatic, hospital-acquired thromboembolisms were diagnosed radiographically by treating providers. RESULTS Of 1715 patients, 33 (1.9%) developed venous thromboembolism. Reduced mobility, as determined by the JH-HLM scores, showed a significant association with thromboembolic events (adjusted OR: 2.53, 95%CI:1.23-5.22, P = .012). In contrast, the initial Padua assessment of expected reduced mobility at admission did not. The JH-HLM identified 19.1% of patients as having reduced mobility versus 6.5% by admitting health care professionals, suggesting 37 high-risk patients were misclassified as low risk and were not prescribed thrombosis prophylaxis; 4 patients developed thromboembolic events. JH-HLM detected reduced mobility in 36% of thromboembolic cases, compared to 9% by admitting health care professionals. CONCLUSION Initial mobility evaluations by admitting health care professionals during venous thromboembolism risk assessment may not reflect patient mobility over their hospital stay. This highlights the need for objective measures like JH-HLM in risk assessments to improve accuracy and potentially reduce thromboembolism incidents.
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Affiliation(s)
- Erik H Hoyer
- Department of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine, Baltimore, Md; Department of Internal Medicine, School of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Md; Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Md.
| | - Aditya Bhave
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Md
| | - Wingel Xue
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Md
| | - Elliott R Haut
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Md; Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Md; Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Md; Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Md; Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Brandyn D Lau
- Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, Md; Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Md
| | - Peggy Kraus
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Md
| | - Alison E Turnbull
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Md; Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Md; Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Md
| | - Dauryne Shaffer
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Md
| | - Lisa Aronson Friedman
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Md
| | - Daniel Young
- Department of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine, Baltimore, Md; Department of Physical Therapy, University of Nevada Las Vegas, Nev
| | - Daniel J Brotman
- Department of Internal Medicine, School of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Md
| | - Michael B Streiff
- Department of Internal Medicine, School of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Md; Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Md
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Smythe MA, Koerber JM, Roberts A, Hoffman JL, Batke J. Hospital Acquired Venous Thromboembolism: A Preventability Assessment. Hosp Pharm 2024; 59:183-187. [PMID: 38450351 PMCID: PMC10913888 DOI: 10.1177/00185787231198164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
Background: The American Heart Association has a call to action to reduce hospital acquired venous thromboembolism (HA-VTE) by 20% by the year 2030. There is increasing recognition that quality improvement initiatives for VTE reduction should focus on reducing potentially preventable HA-VTE. The objective of our study was to determine what proportion of HA-VTE events are potentially preventable. Methods: This was a retrospective, single center pilot study of 50 patients with HA-VTE. Seven preventability factors were identified with a focus on VTE prescription and administration. Data were extracted through chart review using a systematic data collection form. The primary endpoint was the proportion of patients with potentially preventable HA-VTE. Descriptive statistics were used. Results: The median age was 66 years with an admission VTE risk level of moderate-high in 94%. Potentially preventable HA-VTE was found in 40% of cases. Missed doses occurred in 29.8% with a median of 2 missed doses and a range of 1 to 20. Patient refusal was the most common reason for missed doses in 71%. Delays in initiation occurred in 12.7%. Sixty percent of those on mechanical prophylaxis only had nonadherence. Conclusion: Forty percent of HA-VTE cases were potentially preventable. Missed doses was the most common preventability factor identified with patient refusal accounting for most missed doses.
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Affiliation(s)
- Maureen A. Smythe
- Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
- Wayne State University, Detroit, MI, USA
| | - John M. Koerber
- Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
- Wayne State University, Detroit, MI, USA
| | - Amanda Roberts
- Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
- Henry Ford Macomb Hospital, Clinton Township, MI, USA
| | - Janet L. Hoffman
- Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
- Wayne State University, Detroit, MI, USA
| | - Jason Batke
- Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
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Lam BD, Dodge LE, Datta S, Rosovsky RP, Robertson W, Lake L, Reyes N, Adamski A, Abe K, Panoff S, Pinson A, Elavalakanar P, Vlachos IS, Zwicker JI, Patell R. Venous thromboembolism prophylaxis for hospitalized adult patients: a survey of US health care providers on attitudes and practices. Res Pract Thromb Haemost 2023; 7:102168. [PMID: 37767063 PMCID: PMC10520566 DOI: 10.1016/j.rpth.2023.102168] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 06/07/2023] [Accepted: 06/21/2023] [Indexed: 09/29/2023] Open
Abstract
Background Venous thromboembolism (VTE) is a leading cause of preventable mortality among hospitalized patients, but appropriate risk assessment and thromboprophylaxis remain underutilized or misapplied. Objectives We conducted an electronic survey of US health care providers to explore attitudes, practices, and barriers related to thromboprophylaxis in adult hospitalized patients and at discharge. Results A total of 607 US respondents completed the survey: 63.1% reported working in an academic hospital, 70.7% identified as physicians, and hospital medicine was the most frequent specialty (52.1%). The majority of respondents agreed that VTE prophylaxis is important (98.8%; 95% CI: 97.6%-99.5%) and that current measures are safe (92.6%; 95% CI: 90.2%-94.5%) and effective (93.8%; 95% CI: 91.6%-95.6%), but only half (52.0%; 95% CI: 47.9%-56.0%) believed that hospitalized patients at their institution are on appropriate VTE prophylaxis almost all the time. One-third (35.4%) reported using a risk assessment model (RAM) to determine VTE prophylaxis need; 44.9% reported unfamiliarity with RAMs. The most common recommendation for improving rates of appropriate thromboprophylaxis was to leverage technology. A majority of respondents (84.5%) do not reassess a patient's need for VTE prophylaxis at discharge, and a minority educates patients about the risk (16.2%) or symptoms (18.9%) of VTE at discharge. Conclusion Despite guideline recommendations to use RAMs, the majority of providers in our survey do not use them. A majority of respondents believed that technology could help improve VTE prophylaxis rates. A majority of respondents do not reassess the risk of VTE at discharge or educate patients about this risk of VTE at discharge.
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Affiliation(s)
- Barbara D. Lam
- Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Laura E. Dodge
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Siddhant Datta
- Division of Hospital Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Rachel P. Rosovsky
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - William Robertson
- National Blood Clot Alliance, Philadelphia, Pennsylvania, USA
- Weber State University, Ogden, Utah, USA
| | - Leslie Lake
- National Blood Clot Alliance, Philadelphia, Pennsylvania, USA
| | - Nimia Reyes
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Alys Adamski
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Karon Abe
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Samuel Panoff
- Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Amanda Pinson
- Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Pavania Elavalakanar
- Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Ioannis S. Vlachos
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Bioinformatics Program, Cancer Research Institute, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jeffrey I. Zwicker
- Department of Medicine, Hematology Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Rushad Patell
- Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Sahle BW, Pilcher D, Peter K, McFadyen JD, Litton E, Bucknall T. Mortality data from omission of early thromboprophylaxis in critically ill patients highlights the importance of an individualised diagnosis-related approach. Thromb J 2023; 21:59. [PMID: 37221578 DOI: 10.1186/s12959-023-00499-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/03/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) prophylaxis is effective in reducing VTE events, however, its impact on mortality is unclear. We examined the association between omission of VTE prophylaxis within the first 24 h after intensive care unit (ICU) admission and hospital mortality. METHODS Retrospective analysis of prospectively collected data from the Australian New Zealand Intensive Care Society Adult Patient Database. Data were obtained for adult admissions between 2009 and 2020. Mixed effects logistic regression models were used to evaluate the association between omission of early VTE prophylaxis and hospital mortality. RESULTS Of the 1,465,020 ICU admissions, 107,486 (7.3%) did not receive any form of VTE prophylaxis within the first 24 h after ICU admission without documented contraindication. Omission of early VTE prophylaxis was independently associated with 35% increased odds of in-hospital mortality (odds ratios (OR): 1.35; 95% CI: 1.31-1.41). The associations between omission of early VTE prophylaxis and mortality varied by admission diagnosis. In patients diagnosed with stroke (OR: 1.26, 95% CI: 1.05-1.52), cardiac arrest (OR: 1.85, 95% CI: 1.65-2.07) or intracerebral haemorrhage (OR: 1.48, 95% CI: 1.19-1.84), omission of VTE prophylaxis was associated with increased risk of mortality, but not in patients diagnosed with subarachnoid haemorrhage or head injury. CONCLUSIONS Omission of VTE prophylaxis within the first 24 h after ICU admission was independently associated with increased risk of mortality that varied by admission diagnosis. Consideration of early thromboprophylaxis may be required for patients with stroke, cardiac arrest and intracerebral haemorrhage but not in those with subarachnoid haemorrhage or head injury. The findings highlight the importance of individualised diagnosis-related thromboprophylaxis benefit-harm assessments.
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Affiliation(s)
- Berhe W Sahle
- School of Nursing and Midwifery, Faculty of Health, Deakin University, Melbourne, VIC, Australia.
- Centre for Quality and Patient Safety Research, Alfred Health Partnership, Institute for Health Transformation, Melbourne, VIC, Australia.
| | - David Pilcher
- Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Melbourne, VIC, Australia
| | - Karlheinz Peter
- Atherothrombosis and Vascular Biology, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
- Department of Medicine, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, VIC, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC, Australia
| | - James D McFadyen
- Atherothrombosis and Vascular Biology, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
- Department of Medicine, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, VIC, Australia
- Department of Clinical Hematology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Edward Litton
- Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Melbourne, VIC, Australia
- Fiona Stanley Hospital, Perth, WA, Australia
- The University of Western Australia, Perth, WA, Australia
| | - Tracey Bucknall
- School of Nursing and Midwifery, Faculty of Health, Deakin University, Melbourne, VIC, Australia
- Centre for Quality and Patient Safety Research, Alfred Health Partnership, Institute for Health Transformation, Melbourne, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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6
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Influenza Vaccination in Perioperative Settings: A Teachable Moment. Anesthesiology 2022; 137:745-747. [PMID: 36269853 DOI: 10.1097/aln.0000000000004341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Haut ER, Owodunni OP, Wang J, Shaffer DL, Hobson DB, Yenokyan G, Kraus PS, Farrow NE, Canner JK, Florecki KL, Webster KLW, Holzmueller CG, Aboagye JK, Popoola VO, Kia MV, Pronovost PJ, Streiff MB, Lau BD. Alert-Triggered Patient Education Versus Nurse Feedback for Nonadministered Venous Thromboembolism Prophylaxis Doses: A Cluster-Randomized Controlled Trial. J Am Heart Assoc 2022; 11:e027119. [PMID: 36047732 DOI: 10.1161/jaha.122.027119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Many hospitalized patients are not administered prescribed doses of pharmacologic venous thromboembolism prophylaxis. Methods and Results In this cluster-randomized controlled trial, all adult non-intensive care units (10 medical, 6 surgical) in 1 academic hospital were randomized to either a real-time, electronic alert-triggered, patient-centered education bundle intervention or nurse feedback intervention to evaluate their effectiveness for reducing nonadministration of venous thromboembolism prophylaxis. Primary outcome was the proportion of nonadministered doses of prescribed pharmacologic prophylaxis. Secondary outcomes were proportions of nonadministered doses stratified by nonadministration reasons (patient refusal, other). To test our primary hypothesis that both interventions would reduce nonadministration, we compared outcomes pre- versus postintervention within each cohort. Secondary hypotheses were tested comparing the effectiveness between cohorts. Of 11 098 patient visits, overall dose nonadministration declined significantly after the interventions (13.4% versus 9.2%; odds ratio [OR], 0.64 [95% CI, 0.57-0.71]). Nonadministration decreased significantly (P<0.001) in both arms: patient-centered education bundle, 12.2% versus 7.4% (OR, 0.56 [95% CI, 0.48-0.66]), and nurse feedback, 14.7% versus 11.2% (OR, 0.72 [95% CI, 0.62-0.84]). Patient refusal decreased significantly in both arms: patient-centered education bundle, 7.3% versus 3.7% (OR, 0.46 [95% CI, 0.37-0.58]), and nurse feedback, 9.5% versus 7.1% (OR, 0.71 [95% CI, 0.59-0.86]). No differential effect occurred on medical versus surgical units. The patient-centered education bundle was significantly more effective in reducing all nonadministered (P=0.03) and refused doses (P=0.003) compared with nurse feedback (OR, 1.28 [95% CI, 1.0-1.61]; P=0.03 for interaction). Conclusions Information technology strategies like the alert-triggered, targeted patient-centered education bundle, and nurse-focused audit and feedback can improve venous thromboembolism prophylaxis administration. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03367364.
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Affiliation(s)
- Elliott R Haut
- Department of Surgery Johns Hopkins University School of Medicine Baltimore MD.,Department of Anesthesiology and Critical Care Medicine Johns Hopkins University School of Medicine Baltimore MD.,Department of Emergency Medicine Johns Hopkins University School of Medicine Baltimore MD.,The Johns Hopkins Surgery Center for Outcomes Research Johns Hopkins University School of Medicine Baltimore MD.,Armstrong Institute for Patient Safety and Quality Johns Hopkins Medicine Baltimore MD.,Department of Health Policy and Management Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | | | - Jiangxia Wang
- Department of Biostatistics Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Dauryne L Shaffer
- Department of Surgery Johns Hopkins University School of Medicine Baltimore MD.,Department of Nursing The Johns Hopkins Hospital Baltimore MD
| | - Deborah B Hobson
- Department of Surgery Johns Hopkins University School of Medicine Baltimore MD.,Armstrong Institute for Patient Safety and Quality Johns Hopkins Medicine Baltimore MD.,Department of Nursing The Johns Hopkins Hospital Baltimore MD
| | - Gayane Yenokyan
- Department of Biostatistics Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Peggy S Kraus
- Department of Pharmacy The Johns Hopkins Hospital Baltimore MD
| | - Norma E Farrow
- Department of Surgery Duke University Medical Center Durham NC
| | - Joseph K Canner
- The Johns Hopkins Surgery Center for Outcomes Research Johns Hopkins University School of Medicine Baltimore MD
| | | | - Kristen L W Webster
- Department of Anesthesiology and Critical Care Medicine Johns Hopkins University School of Medicine Baltimore MD
| | - Christine G Holzmueller
- Department of Surgery Johns Hopkins University School of Medicine Baltimore MD.,Armstrong Institute for Patient Safety and Quality Johns Hopkins Medicine Baltimore MD
| | - Jonathan K Aboagye
- Department of Surgery Johns Hopkins University School of Medicine Baltimore MD
| | - Victor O Popoola
- Department of Biostatistics Johns Hopkins Bloomberg School of Public Health Baltimore MD.,Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Mujan Varasteh Kia
- Department of Surgery Johns Hopkins University School of Medicine Baltimore MD
| | - Peter J Pronovost
- Department of Surgery Johns Hopkins University School of Medicine Baltimore MD.,Armstrong Institute for Patient Safety and Quality Johns Hopkins Medicine Baltimore MD.,Department of Health Policy and Management Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Michael B Streiff
- Division of Hematology, Department of Medicine Johns Hopkins University School of Medicine Baltimore MD.,Armstrong Institute for Patient Safety and Quality Johns Hopkins Medicine Baltimore MD
| | - Brandyn D Lau
- Division of Health Sciences Informatics, Russell H. Morgan Department of Radiology and Radiological Science Johns Hopkins University School of Medicine Baltimore MD.,Armstrong Institute for Patient Safety and Quality Johns Hopkins Medicine Baltimore MD.,Department of Health Policy and Management Johns Hopkins Bloomberg School of Public Health Baltimore MD
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Boyer N, Skinner R, Breck A. An impact evaluation of an education bundle for patients at risk of developing venous thromboembolism. J Comp Eff Res 2022; 11:563-574. [PMID: 35593109 DOI: 10.2217/cer-2021-0260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Among hospitalized patients, venous thromboembolism (VTE) is a preventable cause of morbidity and mortality. This study analyzed the effects of a large-scale adoption of a prompt response and education protocol to increase VTE prophylaxis adherence in the USA. Methods: A Markov model was developed that simulates outcomes and costs of delivering a VTE education bundle versus not, to hospitalized at-risk patients. Results: The education bundle could avert more than 134,000 VTEs, 552,000 hospital days and 19,000 deaths over 5 years. Patients could save 13 million hours in work absenteeism and travel time, valued at US$237 million. Total societal savings could amount to US$2.8 billion. In scenario analyses with assumed lower-effectiveness estimates, the bundle averts 16,000 VTEs, 67,000 hospital days and 2000 deaths. Conclusion: A nationwide rollout of an education bundle to reduce missed doses of prescribed prophylaxis could improve quality of care, resulting in a decline in VTEs and mortality.
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Affiliation(s)
- Nicole Boyer
- Insight Policy Research, Arlington, VA 22209, USA
| | | | - Andrew Breck
- Insight Policy Research, Arlington, VA 22209, USA
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Effects of Continuous Care Combined with Evidence-Based Nursing on Mental Status and Quality of Life and Self-Care Ability in Patients with Liver from Breast Cancer: A Single-Center Randomized Controlled Study. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:3637792. [PMID: 35529261 PMCID: PMC9071876 DOI: 10.1155/2022/3637792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 03/25/2022] [Accepted: 04/11/2022] [Indexed: 11/18/2022]
Abstract
Objective To explore the multidisciplinary collaborative extended care combined with EBN to improve breast cancer liver metastasis patients' psychological status and self-care ability. Background In the past ten years, the number of breast cancer patients with liver metastases has increased year by year, becoming a global public health problem. Studies have shown that 30% of breast cancer patients with liver metastases show varying degrees of anxiety and depression, and their quality of life is significantly lower than that of the normal population. Multidisciplinary collaborative continuous care can improve the prognosis of breast cancer treatment to a certain extent and is the key to meeting the needs of cancer patients. Materials and Methods The clinical data of 96 patients with liver metastases from breast cancer were selected as the study subjects and divided into a comparison group and an observation group of 48 cases each according to a random number table. Among them, the comparison group implemented evidence-based nursing (EBN) and the observation group implemented multidisciplinary collaborative extended care based on the comparison group. The effects of psychological status, quality of life, self-care ability, and sleep quality were compared between the two groups before and after nursing care. Results After nursing, the sleep quality scores, increased awakening scores, sleep quality that shows weakness because important things are not steady or strong scores, and night terrors scores of the two groups of breast cancer patients with liver the spread of diseases through the body were very much improved, and the sleep quality scores of the instance of watching, noticing, or making a statement group were much lower than those of the comparison group (P < 0.05). After nursing, the fear and stress-related score, depression score, tiredness and distress score, and anger score of the two groups of breast cancer patients with liver (the spread of diseases through the body) were very much improved, and the mental state score of the instance of watching, noticing, or making a statement group was much lower than that of the comparison group (P < 0.05). The scores of self-care skills, self-responsibility, health knowledge, and self-idea of patients in the instance of watching, noticing, or making a statement group after nursing were higher than those in the comparison group (P < 0.05). After nursing, the scores of mental energy, social interaction, emotional restriction, and mental status of patients in (instance of watching, noticing, or making a statement) were much higher than those in the comparison group (P < 0.05). Conclusion Multidisciplinary collaborative continuous nursing combined with EBN can effectively improve the sleep quality and psychological state of patients with breast cancer and liver metastases and improve self-care ability.
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10
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Rastogi R, Lattimore CM, Mehaffey JH, Turrentine FE, Maitland HS, Zaydfudim VM. Electronic Health Record Risk-Stratification Tool Reduces Venous Thromboembolism Events in Surgical Patients. Surg Open Sci 2022; 9:34-40. [PMID: 35620709 PMCID: PMC9127397 DOI: 10.1016/j.sopen.2022.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 04/13/2022] [Indexed: 11/28/2022] Open
Abstract
Background Venous thromboembolism is a preventable cause of morbidity and mortality after surgery. To ensure that patients receive appropriate venous thromboembolism chemoprophylaxis, a nonmandatory risk-stratification tool based on patient clinical condition was implemented through the electronic health record to stratify patient risk and recommend chemoprophylaxis. We hypothesized that implementing this tool would reduce postoperative venous thromboembolism events in general surgery as well as across all surgical services. Methods All adult patients undergoing inpatient surgical operations (January 2012–December 2019) at a single quaternary care center and Level 1 trauma center were abstracted from institutional electronic health record database and stratified into patients admitted before and after venous thromboembolism risk-stratification tool implementation. Bivariable analyses compared venous thromboembolism chemoprophylaxis prescription and venous thromboembolism events with implementation and screening among all surgical patients as well as in general surgery patient subset. Results A total of 64,377 adults underwent operations: 27,819 preimplementation and 36,558 postimplementation. A significant reduction in venous thromboembolism events occurred from pre- to post-tool implementation for all cases (0.77% vs 0.47%, P < .001). General surgery patients (n = 15,723) had a significant increase in chemoprophylaxis prescription (81.9% vs 86.0%, P < .001) and a significant reduction in venous thromboembolism events (1.41% vs 0.59%, P < .001). After tool implementation, use of extended postdischarge chemoprophylaxis was greater among general surgery patient subset than the entire patient cohort (46.7% vs 29.6%, P < .001). Conclusion The integration of a nonmandatory electronic health record risk-stratification tool was associated with a significant reduction in venous thromboembolism events. Extended chemoprophylaxis was prescribed in nearly half of general surgery patients at very high risk for postdischarge events. Implementing an electronic VTE risk-stratification tool reduced surgical VTE events. Even as a nonmandatory tool, risk stratification led to overall fewer VTE events. Postoperative VTE events were reduced by 39% after the tool was integrated in EHR. With the tool, general surgery had 58% less VTE events and improved prophylaxis use.
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Affiliation(s)
- Radhika Rastogi
- Department of Surgery, University of Virginia, Charlottesville, VA 22908
| | - Courtney M. Lattimore
- Department of Surgery, University of Virginia, Charlottesville, VA 22908
- Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA 22908
| | - J. Hunter Mehaffey
- Department of Surgery, University of Virginia, Charlottesville, VA 22908
| | - Florence E. Turrentine
- Department of Surgery, University of Virginia, Charlottesville, VA 22908
- Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA 22908
| | - Hillary S. Maitland
- Department of Medicine, Hematology/Oncology, University of Virginia, Charlottesville, VA 22908
| | - Victor M. Zaydfudim
- Department of Surgery, University of Virginia, Charlottesville, VA 22908
- Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA 22908
- Corresponding author at: Division of Surgical Oncology, Department of Surgery, PO Box 800709, Charlottesville, VA, 22908-0709. Tel.: + 1-434-924-2839; fax: + 1 434-982-4778. @vz_surgery
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11
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Hsiang Shawn Yuan P, Xu R, Maclean L, Muqaimi NA, Elmi M, Isaac KV. A call to bridge the divide in breast reconstruction research: A systematic review. J Plast Reconstr Aesthet Surg 2021; 75:77-84. [PMID: 34301512 DOI: 10.1016/j.bjps.2021.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 03/01/2021] [Accepted: 06/02/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Breast reconstruction is an important component of comprehensive breast cancer care. Although reconstructive plans require multidisciplinary clinical-decision making, research in cross-discipline collaborations is often limited. This study aims to evaluate multidisciplinary involvement in breast reconstruction outcomes research. METHODS A systematic review of breast reconstruction literature published from 2000 to 2019 using Ovid MEDLINE, Ovid EMBASE, and PubMed databases was conducted. English language articles published in North America or Europe with n ≥ 12 nonpediatric patients were included. Articles concerning procedures not performed in the context of breast cancer care or articles that did not evaluate at least one outcome, diagnostic test, or risk factor were excluded. Authors' affiliations were used to define multidisciplinary involvement. Quality of research was evaluated using the level of evidence, journal impact factor (IF), and altmetrics. RESULTS Of the 1679 articles screened, 784 met the stated eligibility criteria. Only half (50.6%) of these articles involved an author outside the discipline of plastic surgery. Compared to nonmultidisciplinary studies, multidisciplinary studies were more likely to be designated with a higher level of evidence (I or II) (p<0.001), published in journals with higher IF (p<0.05), have higher usage (p = 0.03), and mentions (p = 0.02). There was no difference in citations, captures, and social media posts (p>0.05). CONCLUSION Breast reconstruction outcomes research often fails to offer author collaborations from nonplastic surgery disciplines. Multidisciplinary involvement in breast cancer care research is strongly recommended to improve the quality and impact of clinical studies in breast reconstruction.
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Affiliation(s)
| | - Rebecca Xu
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Luke Maclean
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Nawaf Al Muqaimi
- Department of Surgery, Division of Plastic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Maryam Elmi
- UT Texas Health San Antonio MD Anderson Cancer Center, San Antonio, TX, United States
| | - Kathryn V Isaac
- Department of Surgery, Division of Plastic Surgery, University of British Columbia, Vancouver, British Columbia, Canada.
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12
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Missed Doses of Venous Thromboembolism Prophylaxis: a Growing Problem Without an Active Management Strategy. J Gen Intern Med 2021; 36:540-542. [PMID: 33140273 PMCID: PMC7878622 DOI: 10.1007/s11606-020-06303-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 10/07/2020] [Indexed: 11/27/2022]
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13
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Nana M, Shute C, Williams R, Kokwaro F, Riddick K, Lane H. Multidisciplinary, patient-centred approach to improving compliance with venous thromboembolism (VTE) prophylaxis in a district general hospital. BMJ Open Qual 2020; 9:bmjoq-2019-000680. [PMID: 32718914 PMCID: PMC7371024 DOI: 10.1136/bmjoq-2019-000680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 05/01/2020] [Accepted: 05/13/2020] [Indexed: 11/03/2022] Open
Abstract
Hospital-acquired venous thromboembolism (VTE) accounts for an estimated 25 000 preventable deaths per annum in the UK and is associated with significant healthcare costs. The National Institute for Health and Care Excellence guidelines on the prevention of VTE in hospitalised patients highlight the clinical and cost-effectiveness of VTE prevention strategies. A multidisciplinary quality improvement team (MD QIT) based in a district general hospital sought to improve compliance with VTE prophylaxis prescription to greater than 85% of patients within a 3-month time frame. Quality improvement methodology was adopted over three cycles of the project. Interventions included the introduction of a 'VTE sticker' to prompt risk assessment; educational material for medical staff and allied healthcare professionals; and patient information raising the awareness of the importance of VTE prophylaxis. Implementation of these measures resulted in significant and sustained improvements in rates of risk assessment within 24 hours of admission to hospital from 51% compliance to 94% compliance after cycle 2 of the project. Improvements were also observed in medication dose adjustment for the patient weight from 69% to 100% compliance. Dose adjustments for renal function showed similar trends with compliance with guidelines improving from 80% to 100%. These results were then replicated in a different clinical environment. In conclusion, this project exemplifies the benefits of MD QITs in terms of producing sustainable and replicable improvements in clinical practice and in relation to meeting approved standards of care for VTE risk assessment and prescription. It has been demonstrated that the use of educational material in combination with a standardised risk assessment tool, the 'VTE sticker', significantly improved clinical practice in the context of a general medical environment.
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Affiliation(s)
- Melanie Nana
- Department of General Medicine, Royal Glamorgan Hospital, Llantrisant, Rhondda Cynon Taf, UK
| | - Cherry Shute
- Department of General Medicine, Royal Glamorgan Hospital, Llantrisant, Rhondda Cynon Taf, UK
| | - Rhys Williams
- Department of Pharmacy, Royal Glamorgan Hospital, Llantrisant, Rhondda Cynon Taf, UK
| | - Flora Kokwaro
- Department of General Medicine, Royal Glamorgan Hospital, Llantrisant, Rhondda Cynon Taf, UK
| | - Kathleen Riddick
- Department of General Medicine, Royal Glamorgan Hospital, Llantrisant, Rhondda Cynon Taf, UK
| | - Helen Lane
- Department of General Medicine, Royal Glamorgan Hospital, Llantrisant, Rhondda Cynon Taf, UK
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14
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Lovely JK, Hickman JA, Johnson MG, Naessens JM, Morgenthaler TI. Impact of a Program to Improve Venous Thromboembolism Prophylaxis on Incidence of Thromboembolism and Bleeding Rates in Hospitalized Patients During Implementation of Programs to Improve Venous Thromboembolism Prophylaxis. Mayo Clin Proc Innov Qual Outcomes 2020; 4:159-169. [PMID: 32280926 PMCID: PMC7140013 DOI: 10.1016/j.mayocpiqo.2019.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 10/09/2019] [Accepted: 10/16/2019] [Indexed: 11/17/2022] Open
Abstract
Objective To study the impact of multiphase quality improvement efforts to enhance appropriate use of chemical and mechanical venous thromboembolism (VTE) prophylaxis (VTEP) on the rate of hospital-acquired VTE and determine whether efforts have been associated with increased bleeding complications. Patients and Methods All adult inpatients discharged between January 1, 2005, and December 31, 2015, were included in the study. Retrospective interrupted time series analysis compared VTEP performance, VTE outcomes, and unintended consequences (derived from linked administrative and clinical data) across 5 improvement phases: baseline (January 1, 2005-December 31, 2006), paper order set phase (January 1, 2007-February 9, 2009), electronic order set phase (February 10, 2009-December 16, 2009), active reminder phase (December 17, 2009-May 31, 2012), and maintenance phase (June 1, 2012-September 30, 2015). Results Guideline VTEP plan adherence at the end of the study period (including documenting contraindications) reached 88.8% (654,138 of 736,384 patient days). Delivery of pharmacological VTEP increased from 43.9% (49,155 of 111,906 patients) to 60.8% (75,784 of 124,676 patients); delivery of mechanical or pharmacological VTEP increased less (65.0% [431,791 of 664,087 patient days] to 67.4% [496,625 of 736,384 patient days]). Mean VTE rates decreased from 4.6 per 1000 hospitalizations (21.7 VTEs per month) at baseline to 4.3 per 1000 hospitalizations (18.0 VTEs per month) during the maintenance phase (P<.001). More than 97% of patients who had development of VTE (534 of 548) received VTEP, but 65.7% (360 of 548) experienced gaps of 1 or more days in VTEP delivery. Measured in-hospital bleeding rates were fairly consistent over the study (4.6% [5,198 of 111,906 patients] at baseline to 5.3% [6,662 of 124,676 patients] during the reminder phase). There was little change in rates of 7-day readmission with bleeding or VTE. Conclusion Our VTEP project improved guideline compliance, increased the proportion of patients receiving VTEP, and was associated with a decrease in VTE. Gaps in VTEP delivery occurred despite protocoled order sets and electronic feedback. Further improvements in VTE may require new approaches.
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Affiliation(s)
| | - Joel A Hickman
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Matthew G Johnson
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - James M Naessens
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.,Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN
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15
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Murray A. Comparison of long-term treatment options for venous thromboembolism. Br J Community Nurs 2020; 25:82-83. [PMID: 32040368 DOI: 10.12968/bjcn.2020.25.2.82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Adrienne Murray
- Director, Nursing Quality, Development and Professional Practice, University of Mississippi Medical Center, Jackson, USA
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16
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Owodunni OP, Haut ER, Shaffer DL, Hobson DB, Wang J, Yenokyan G, Kraus PS, Aboagye JK, Florecki KL, Webster KLW, Holzmueller CG, Streiff MB, Lau BD. Using electronic health record system triggers to target delivery of a patient-centered intervention to improve venous thromboembolism prevention for hospitalized patients: Is there a differential effect by race? PLoS One 2020; 15:e0227339. [PMID: 31945085 PMCID: PMC6964816 DOI: 10.1371/journal.pone.0227339] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 12/16/2019] [Indexed: 11/19/2022] Open
Abstract
Background Racial disparities are common in healthcare. Venous thromboembolism (VTE) is a leading cause of preventable harm, and disparities observed in prevention practices. We examined the impact of a patient-centered VTE education bundle on the non-administration of preventive prophylaxis by race. Methods A post-hoc, subset analysis (stratified by race) of a larger nonrandomized trial. Pre-post comparisons analysis were conducted on 16 inpatient units; study periods were October 2014 through March 2015 (baseline) and April through December 2015 (post-intervention). Patients on 4 intervention units received the patient-centered, nurse educator-led intervention if the electronic health record alerted a non-administered dose of VTE prophylaxis. Patients on 12 control units received no intervention. We compared the conditional odds of non-administered doses of VTE prophylaxis when patient refusal was a reason for non-administration, stratified by race. Results Of 272 patient interventions, 123 (45.2%) were white, 126 (46.3%) were black, and 23 (8.5%) were other races. A significant reduction was observed in the odds of non-administration of prophylaxis on intervention units compared to control units among patients who were black (OR 0.61; 95% CI, 0.46–0.81, p<0.001), white (OR 0.57; 95% CI, 0.44–0.75, p<0.001), and other races (OR 0.50; 95% CI, 0.29–0.88, p = 0.015). Conclusion Our finding suggests that the patient education materials, developed collaboratively with a diverse group of patients, improved patient’s understanding and the importance of VTE prevention through prophylaxis. Quality improvement interventions should examine any differential effects by patient characteristics to ensure disparities are addressed and all patients experience the same benefits.
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Affiliation(s)
- Oluwafemi P. Owodunni
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Elliott R. Haut
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, United States of America
- Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- * E-mail:
| | - Dauryne L. Shaffer
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Nursing, The Johns Hopkins Hospital, Baltimore, Maryland, United States of America
| | - Deborah B. Hobson
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, United States of America
- Department of Nursing, The Johns Hopkins Hospital, Baltimore, Maryland, United States of America
| | - Jiangxia Wang
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Gayane Yenokyan
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Peggy S. Kraus
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland, United States of America
| | - Jonathan K. Aboagye
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Katherine L. Florecki
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Kristen L. W. Webster
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Christine G. Holzmueller
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, United States of America
| | - Michael B. Streiff
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, United States of America
- Division of Hematology, Department of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, United States of America
| | - Brandyn D. Lau
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, United States of America
- Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Hospital, Baltimore, Maryland, United States of America
- Division of Health Sciences Informatics, The Johns Hopkins Hospital, Baltimore, Maryland, United States of America
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17
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Do What You Can, With What You Have, Where You Are. J Trauma Nurs 2020; 27:3-5. [PMID: 31895312 DOI: 10.1097/jtn.0000000000000475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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Defects in Processes of Care for Pharmacologic Prophylaxis Are Common Among Neurosurgery Patients Who Develop In-Hospital Postoperative Venous Thromboembolism. World Neurosurg 2019; 134:e664-e671. [PMID: 31698120 DOI: 10.1016/j.wneu.2019.10.163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 10/25/2019] [Accepted: 10/26/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a cause of considerable morbidity and mortality in hospitalized patients. An evidence-based algorithm was developed and implemented at our institution to guide perioperative VTE prophylaxis management. OBJECTIVE We evaluated compliance with prescription of risk-appropriate VTE prophylaxis and administration of prescribed VTE prophylaxis in neurosurgery patients. METHODS This was a retrospective analysis of postoperative neurosurgery patients at a single institution with subsequent diagnosis of acute VTE during their inpatient stay. Descriptive statistics were used to characterize pharmacologic VTE prophylaxis and prescribing patterns. RESULTS The incidence of VTE in our neurosurgery population was 248/13,913 (1.8%). Of the 123 patients, the median time to VTE diagnosis was 96 hours after surgery (interquartile range [IQR], 58-188 hours). A total of 108 patients (87.8%) were prescribed risk-appropriate VTE prophylaxis, among whom 61 (56.5%) received all doses as prescribed. Fifty-three patients (43.1%) missed ≥1 dose of prescribed prophylaxis and the median missed doses was 3 (IQR, 0-3). The median time to first dose of pharmacologic VTE prophylaxis was 42 hours (IQR, 28-51). More than half (n = 63, 51.2%) of the VTE risk assessments contained ≥1 error, of which 15 (23.8%) would have resulted in a change in recommendation. CONCLUSIONS Our evidence-based VTE prophylaxis algorithm was not accurately completed in more than half of patients. Many patients who developed VTE had a defect in their VTE prophylaxis management during their inpatient stay. Research to improve optimal VTE prevention practice in neurosurgery patients is needed.
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Aggarwal MV, Jarrell AS, Gilmore VT, Aboagye JK, Haut ER, Hobson DB, Lau BD, Kickler T, Kraus PS, Shaffer DL, Shermock KM, Streiff MB, Zheng G, Kruer RM. Anti-Xa activity by weight in critically ill patients receiving unfractionated heparin for venous thromboembolism prophylaxis. J Crit Care 2019; 52:180-185. [PMID: 31078999 DOI: 10.1016/j.jcrc.2019.04.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 04/25/2019] [Accepted: 04/26/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE This study compared anti-Xa activity in critically ill patients receiving UFH for VTE prophylaxis between two weight groups (<100 kg vs ≥100 kg). METHODS This prospective, observational study included critically ill patients on UFH 5000 or 7500 units every 8 h. A peak and trough anti-Xa activity assay was ordered for each patient at steady state. Goal peak anti-Xa activity was 0.1-0.3 units/mL. RESULTS From March 2017 to June 2018, 75 patients were enrolled with 44 in the <100 kg group and 31 in the ≥100 kg group. There was no significant difference in the percentage of patients with peak anti-Xa activity within goal range between patients <100 kg and ≥ 100 kg (55.3% vs 35.7%, p = 0.12). The odds ratio for achieving peak anti-Xa activity within goal range as weight-based dose increased was 1.03 (95% CI 0.99-1.07). No differences were found in trough anti-Xa activity, VTE, bleeding, length of stay, or death. CONCLUSIONS Though only one-third of patients ≥100 kg had peak anti-Xa activity within goal range, no significant difference was found between the weight groups. Additional prospective studies with adequate sample sizes are warranted to further investigate appropriate weight-based dosing of UFH in critically ill patients.
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Affiliation(s)
| | | | - Vi T Gilmore
- Department of Pharmacy, The Johns Hopkins Hospital, USA
| | - Jonathan K Aboagye
- Department of Surgery, The Johns Hopkins University School of Medicine, USA
| | - Elliott R Haut
- Department of Surgery, The Johns Hopkins University School of Medicine, USA; Armstrong Institute for Patient Safety and Quality, USA; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, USA; Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, USA; Department of Emergency Medicine, The Johns Hopkins University School of Medicine, USA
| | - Deborah B Hobson
- Department of Surgery, The Johns Hopkins University School of Medicine, USA; Armstrong Institute for Patient Safety and Quality, USA
| | - Brandyn D Lau
- Armstrong Institute for Patient Safety and Quality, USA; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, USA; Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, USA; Division of Health Sciences Informatics, The Johns Hopkins University School of Medicine, USA
| | - Thomas Kickler
- Department of Pathology, The Johns Hopkins University School of Medicine, USA
| | - Peggy S Kraus
- Department of Pharmacy, The Johns Hopkins Hospital, USA
| | - Dauryne L Shaffer
- Department of Surgery, The Johns Hopkins University School of Medicine, USA
| | | | - Michael B Streiff
- Armstrong Institute for Patient Safety and Quality, USA; Division of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, USA
| | - Gang Zheng
- Department of Pathology, The Johns Hopkins University School of Medicine, USA
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20
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Popoola VO, Lau BD, Tan E, Shaffer DL, Kraus PS, Farrow NE, Hobson DB, Aboagye JK, Streiff MB, Haut ER. Nonadministration of medication doses for venous thromboembolism prophylaxis in a cohort of hospitalized patients. Am J Health Syst Pharm 2019. [PMID: 29523536 DOI: 10.2146/ajhp161057] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Results of a study to characterize patterns of nonadministration of medication doses for venous thromboembolism (VTE) prevention among hospitalized patients are presented. METHODS The electronic records of all patients admitted to 4 floors of a medical center during a 1-month period were examined to identify patients whose records indicated at least 1 nonadministered dose of medication for VTE prophylaxis. Proportions of nonadministered doses by medication type, intended route of administration, and VTE risk categorization were compared; reasons for nonadministration were evaluated. RESULTS Overall, 12.7% of all medication doses prescribed to patients in the study cohort (n = 75) during the study period (857 of 6,758 doses in total) were not administered. Nonadministration of 1 or more doses of VTE prophylaxis medication was nearly twice as likely for subcutaneous anticoagulants than for all other medication types (231 of 1,112 doses [20.8%] versus 626 of 5,646 doses [11.2%], p < 0.001). For all medications prescribed, the most common reason for nonadministration was patient refusal (559 of 857 doses [65.2%]); the refusal rate was higher for subcutaneous anticoagulants than for all other medication categories (82.7% versus 58.8%, p < 0.001). Doses of antiretrovirals, immunosuppressives, antihypertensives, psychiatric medications, analgesics, and antiepileptics were less commonly missed than doses of electrolytes, vitamins, and gastrointestinal medications. CONCLUSION Scheduled doses of subcutaneous anticoagulants for hospitalized patients were more likely to be missed than doses of all other medication types.
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Affiliation(s)
- Victor O Popoola
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Brandyn D Lau
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, MD.,Division of Health Sciences Informatics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Esther Tan
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | | | - Peggy S Kraus
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
| | - Norma E Farrow
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | | | - Jonathan K Aboagye
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD.,Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD
| | - Michael B Streiff
- Division of Hematology, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD
| | - Elliott R Haut
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD .,Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD .,Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD
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21
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Improving the adoption of optimal venous thromboembolism prophylaxis in critically ill patients: A process evaluation of a complex quality improvement initiative. J Crit Care 2018; 50:111-117. [PMID: 30529419 DOI: 10.1016/j.jcrc.2018.11.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 11/05/2018] [Accepted: 11/21/2018] [Indexed: 11/20/2022]
Abstract
PURPOSE This study evaluated a complex initiative to increase evidence-based use of low molecular weight heparin for venous thromboembolism prophylaxis among adult medical-surgical ICU patients. MATERIALS AND METHODS This study included: quantitative survey and interviews. Participants were healthcare providers within four ICUs. Surveys collected knowledge of evidence underpinning best practice, exposure to the implementation strategies and their perceived utility, and recommendations. The interview expanded on survey topics. Descriptive statistics summarized the data and chi-squared tests were used to compare groups. Qualitative data were analyzed using a blended deductive and inductive coding approach. RESULTS Providers had good knowledge of the evidence (range = 58% to 94%). Pharmacist-to-physician reminders (80%), other reminders (50%), and local guidelines (50%) were the most commonly observed strategies. Local champions (76%), on-site education (74%), and computerized decision support system (69%) were perceived to be most helpful. Interviews elicited five themes: provider roles, perceptions of the implementation strategies, facilitators and barriers to uptake of best practice, and recommendations. Assessment of the implementation strategies varied by professional group. CONCLUSIONS The findings of this process evaluation identified implementation strategies that can improve the use of evidence-informed practices, help interpret outcomes in the context of interventions and guide future quality improvement initiatives.
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Haut ER, Aboagye JK, Shaffer DL, Wang J, Hobson DB, Yenokyan G, Sugar EA, Kraus PS, Farrow NE, Canner JK, Owodunni OP, Florecki KL, Webster KLW, Holzmueller CG, Pronovost PJ, Streiff MB, Lau BD. Effect of Real-time Patient-Centered Education Bundle on Administration of Venous Thromboembolism Prevention in Hospitalized Patients. JAMA Netw Open 2018; 1:e184741. [PMID: 30646370 PMCID: PMC6324387 DOI: 10.1001/jamanetworkopen.2018.4741] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
IMPORTANCE Numerous interventions have improved prescription of venous thromboembolism (VTE) prophylaxis; however, many prescribed doses are not administered to hospitalized patients, primarily owing to patient refusal. OBJECTIVE To evaluate a real-time, targeted, patient-centered education bundle intervention to reduce nonadministration of VTE prophylaxis. DESIGN, SETTING, AND PARTICIPANTS This nonrandomized controlled, preintervention-postintervention comparison trial included 19 652 patient visits on 16 units at The Johns Hopkins Hospital, Baltimore, Maryland, from April 1 through December 31, 2015. Data analysis was performed from June 1, 2016, through November 30, 2017, on an intention-to-treat basis. INTERVENTIONS Patients on 4 intervention units received a patient-centered education bundle if a dose of VTE prophylaxis medication was not administered. Patients on 12 control units received no intervention. MAIN OUTCOMES AND MEASURES Conditional odds of nonadministration of doses of VTE prophylaxis (primary outcome) before and after the intervention on control vs intervention units. Reasons for nonadministration (ie, patient refusal and other) and VTE event rates (secondary outcomes) were compared. RESULTS A total of 19 652 patient visits where at least 1 dose of VTE prophylaxis was prescribed were included (51.7% men; mean [SD] age, 55.6 [17.1] years). Preintervention and postintervention groups were relatively similar in age, sex, race, and medical or surgery unit. From the preintervention period to the postintervention period, on intervention units, the conditional odds of VTE prophylaxis nonadministration declined significantly (9.1% [95% CI, 5.2%-16.2%] vs 5.6% [95% CI, 3.1%-9.9%]; odds ratio [OR], 0.57; 95% CI, 0.48-0.67) compared with no change on control units (13.6% [95% CI, 9.8%-18.7%] vs 13.3% [95% CI, 9.6%-18.5%]; OR, 0.98; 95% CI, 0.91-1.07; P < .001 for interaction). The conditional odds of nonadministration owing to patient refusal decreased significantly on intervention units (5.9% [95% CI, 2.6%-13.6%] vs 3.4% [95% CI, 1.5%-7.8%]; OR, 0.53; 95% CI ,0.43-0.65) compared with no change on control units (8.7% [95% CI, 5.4%-14.0%] vs 8.5% [95% CI, 5.3%-13.8%]; OR, 0.98; 95% CI, 0.89-1.08; P < .001 for interaction). On intervention units, the conditional odds of nonadministration owing to reasons other than patient refusal decreased (2.3% [95% CI, 1.5%-3.4%] vs 1.7% [95% CI, 1.1%-2.6%]; OR, 0.74; 95% CI, 0.58-0.94), with no change on control units (3.4% [95% CI, 2.7%-4.4%] vs 3.3% [95% CI, 2.6%-4.2%]; OR, 0.98; 95% CI, 0.87-1.10; P = .04 for interaction). No differential effect occurred on medical vs surgical units (OR, 0.86; 95% CI, 0.60-1.23; P = .41 for interaction). There was no statistical difference in the proportion of VTE events among patients on intervention vs control units (0.30% vs 0.18%; OR, 0.60; 95% CI, 0.16-2.23). CONCLUSIONS AND RELEVANCE In this study, a targeted patient-centered education bundle significantly reduced nonadministration of pharmacologic VTE prophylaxis in hospitalized patients. This novel strategy improves health care quality by leveraging electronic data to target interventions in real time for at-risk patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02402881.
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Affiliation(s)
- Elliott R. Haut
- Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
- Johns Hopkins Surgery Center for Outcomes Research, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jonathan K. Aboagye
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Dauryne L. Shaffer
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Nursing, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Jiangxia Wang
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Deborah B. Hobson
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Nursing, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Gayane Yenokyan
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Elizabeth A. Sugar
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Peggy S. Kraus
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Norma E. Farrow
- Department of Surgery, Duke University, Durham, North Carolina
| | - Joseph K. Canner
- Johns Hopkins Surgery Center for Outcomes Research, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Oluwafemi P. Owodunni
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Katherine L. Florecki
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kristen L. W. Webster
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christine G. Holzmueller
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Peter J. Pronovost
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Michael B. Streiff
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
- Division of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brandyn D. Lau
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Division of Health Sciences Informatics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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23
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Bauer TM, Johnson AP, Dukleska K, Beck J, Dworkin MS, Patel K, Cowan SW, Merli GJ. Adherence to Inpatient Venous Thromboembolism Prophylaxis: A Single Institution’s Concurrent Review. Am J Med Qual 2018; 34:402-408. [DOI: 10.1177/1062860618808378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Hospital-acquired venous thromboembolism (VTE) affects morbidity and mortality and increases health care costs. Poor adherence to recommended prophylaxis may be a potential cause of ongoing events. This study aims to identify institutional adherence rates and barriers to optimal VTE prophylaxis. The authors performed patient and nurse interviews and a concurrent review of clinical documentation, utilizing a cloud-based, HIPAA-compliant tool, on a convenience sample of hospitalized patients. Adherence and agreement between different assessment modalities were calculated. Seventy-six patients consented for participation. Nurse documented adherence was 66% (29/44), 44% (27/61), and 89% (50/56) for mechanical, ambulatory, and chemoprophylactic prophylaxis, respectively. Patient report and nurse documentation showed moderate agreement for mechanical and no agreement for ambulatory adherence (κ = 0.51 and 0.07, respectively). Concurrent review using a cloud-based tool can provide robust, timely, and relevant information on adherence to recommended VTE prophylaxis. Iterative concurrent reviews can guide efforts to improve adherence and reduce rates of hospital-acquired VTE.
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Affiliation(s)
| | | | | | - Johanna Beck
- Thomas Jefferson University Hospital, Philadelphia, PA
| | | | - Kamini Patel
- Thomas Jefferson University Hospital, Philadelphia, PA
| | | | - Geno J. Merli
- Thomas Jefferson University Hospital, Philadelphia, PA
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24
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Myers MK, Jansson-Knodell CL, Schroeder DR, O'Meara JG, Bonnes SL, Ratelle JT. Using knowledge translation for quality improvement: an interprofessional education intervention to improve thromboprophylaxis among medical inpatients. J Multidiscip Healthc 2018; 11:467-472. [PMID: 30271162 PMCID: PMC6149937 DOI: 10.2147/jmdh.s171745] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Background Low-molecular-weight heparin (LMWH) is an effective means of preventing venous thromboembolism (VTE) among medical inpatients. Compared with unfractionated heparin, LMWH is equivalent or superior in efficacy and risk of bleeding. Despite its advantages, LMWH is underused in VTE prophylaxis for general-medicine patients hospitalized at our institution. Thus, a quality improvement (QI) initiative was undertaken to increase LMWH use for VTE prophylaxis among medical patients hospitalized on resident teaching services. Methods A QI team was formed, consisting of resident and attending physicians with pharmacy leaders. A systems analysis was performed, which showed gaps in resident knowledge as the greatest barrier to LMWH use. A knowledge translation framework was used to improve prescribing practices. Several Plan–Do–Study–Act cycles were executed, including resident-of-resident and pharmacist-of-resident education with performance audit and feedback. Results Pharmacist-of-resident education elicited the largest improvement and was sustained through a recurring pharmacist-led, interprofessional educational session as part of the monthly hospital orientation for incoming residents. Data analysis showed a statistically significant increase in LMWH use among treatment-eligible hospitalized medical patients, from 12.1% to 69.2%, following intervention (P<0.001). Extrapolated over 1 year, this improvement conserved 9,490 injections and nearly 791 hours of nurse time. Conclusions This QI project indicates that an interprofessional education intervention can lead to sustainable improvement in resident prescribing practices. This project also highlights the value of knowledge translation for the design of tailored interventions in QI initiatives.
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Affiliation(s)
| | | | - Darrell R Schroeder
- Department of Health Sceinces Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - John G O'Meara
- Department of Pharmacy Services, Mayo Clinic, Rochester, MN, USA
| | - Sara L Bonnes
- Department of Medicine, Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - John T Ratelle
- Department of Medicine, Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA,
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25
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Farrow NE, Aboagye JK, Lau BD, Najjar P, Orgill DP, Popoola VO, Kraus PS, Hobson DB, Shaffer DL, Safar B, Gearhart S, Efron JE, Streiff MB, Haut ER. The role of extended/outpatient venous thromboembolism prophylaxis after abdominal surgery for cancer or inflammatory bowel disease. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2018. [DOI: 10.1177/1356262217753427] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Background Current guidelines recommend in-hospital venous thromboembolism prophylaxis for many patients and extended/outpatient prophylaxis in high-risk patients undergoing abdomino-pelvic surgery for cancer. Despite these guidelines, extended venous thromboembolism prophylaxis is not used uniformly at all institutions. This study aimed to evaluate the impact of postdischarge prophylaxis practices at two academic medical centers on the rate of postdischarge venous thromboembolism. Methods We retrospectively analyzed data from the Brigham and Women’s Hospital and the Johns Hopkins Hospital’s American College of Surgeons, National Surgical Quality Improvement Program registries from 1 August 2014 to 30 June 2015. Brigham and Women’s Hospital patients received four weeks supply of extended/outpatient venous thromboembolism prophylaxis, while Johns Hopkins Hospital patients did not. We determined the proportion of patients in each cohort that developed venous thromboembolism within 30 days of surgery. Results Four hundred and eighty-nine patients underwent abdominal surgery for cancer and inflammatory bowel disease; 181 (37.0%) patients from Brigham and Women’s Hospital and 308 (63.0%) patients from Johns Hopkins Hospital. Fourteen patients developed postoperative venous thromboembolism. Seven patients developed in-hospital venous thromboembolism and seven developed venous thromboembolism postdischarge. All postdischarge venous thromboembolism occurred in the Johns Hopkins group, and this difference was statistically significant (p = 0.0498). There was no difference in postdischarge bleeding rates between the groups. Conclusions Extended prophylaxis likely prevents postdischarge venous thromboembolism after major abdominal surgery without an increased risk of bleeding.
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Affiliation(s)
- Norma E Farrow
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Jonathan K Aboagye
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Brandyn D Lau
- Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Baltimore, MD
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Division of Health Sciences Informatics, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
- The Armstrong Institute for Patient Safety, Johns Hopkins Medicine, Johns Hopkins University, Baltimore, USA
| | - Peter Najjar
- Department of Surgery, Brigham and Women’s Hospital, Boston, USA
| | - Dennis P Orgill
- Department of Surgery, Brigham and Women’s Hospital, Boston, USA
| | - Victor O Popoola
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Peggy S Kraus
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Deborah B Hobson
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Dauryne L Shaffer
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Bashar Safar
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Susan Gearhart
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Jonathan E Efron
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Michael B Streiff
- The Armstrong Institute for Patient Safety, Johns Hopkins Medicine, Johns Hopkins University, Baltimore, USA
- Department of Medicine, Johns Hopkins University, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Elliott R Haut
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Division of Health Sciences Informatics, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
- The Armstrong Institute for Patient Safety, Johns Hopkins Medicine, Johns Hopkins University, Baltimore, USA
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
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26
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Fernando SM, Neilipovitz D, Sarti AJ, Rosenberg E, Ishaq R, Thornton M, Kim J. Monitoring intensive care unit performance-impact of a novel individualised performance scorecard in critical care medicine: a mixed-methods study protocol. BMJ Open 2018; 8:e019165. [PMID: 29358441 PMCID: PMC5781100 DOI: 10.1136/bmjopen-2017-019165] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Patients admitted to a critical care medicine (CCM) environment, including an intensive care unit (ICU), are susceptible to harm and significant resource utilisation. Therefore, a strategy to optimise provider performance is required. Performance scorecards are used by institutions for the purposes of driving quality improvement. There is no widely accepted or standardised scorecard that has been used for overall CCM performance. We aim to improve quality of care, patient safety and patient/family experience in CCM practice through the utilisation of a standardised, repeatable and multidimensional performance scorecard, designed to provide a continuous review of ICU physician and nurse practice, as well as departmental metrics. METHODS AND ANALYSIS This will be a mixed-methods, controlled before and after study to assess the impact of a CCM-specific quality scorecard. Scorecard metrics were developed through expert consensus and existing literature. The study will include 19 attending CCM physicians and approximately 300 CCM nurses. Patient data for scorecard compilation are collected daily from bedside flow sheets. Preintervention baseline data will be collected for 6 months for each participant. After this, each participant will receive their scorecard measures. Following a 3-month washout period, postintervention data will be collected for 6 months. The primary outcome will be change in performance metrics following the provision of scorecard feedback to subjects. A cost analysis will also be performed, with the purpose of comparing total ICU costs prior to implementation of the scorecard with total ICU costs following implementation of the scorecard. The qualitative portion will include interviews with participants following the intervention phase. Interviews will be analysed in order to identify recurrent themes and subthemes, for the purposes of driving scorecard improvement. ETHICS AND DISSEMINATION This protocol has been approved by the local research ethics board. Publication of results is anticipated in 2019. If this intervention is found to improve patient- and unit-directed outcomes, with evidence of cost-effectiveness, it would support the utilisation of such a scorecard as a quality standard in CCM.
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Affiliation(s)
- Shannon M Fernando
- Department of Critical Care Medicine, The Ottawa Hospital, Ottawa, Canada
| | - David Neilipovitz
- Department of Critical Care Medicine, The Ottawa Hospital, Ottawa, Canada
| | - Aimee J Sarti
- Department of Critical Care Medicine, The Ottawa Hospital, Ottawa, Canada
| | - Erin Rosenberg
- Department of Critical Care Medicine, The Ottawa Hospital, Ottawa, Canada
| | - Rabia Ishaq
- Department of Critical Care Medicine, The Ottawa Hospital, Ottawa, Canada
| | - Mary Thornton
- Department of Critical Care Medicine, The Ottawa Hospital, Ottawa, Canada
| | - John Kim
- Department of Critical Care Medicine, The Ottawa Hospital, Ottawa, Canada
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27
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Jenders RA. Advances in Clinical Decision Support: Highlights of Practice and the Literature 2015-2016. Yearb Med Inform 2017; 26:125-132. [PMID: 29063552 PMCID: PMC6239223 DOI: 10.15265/iy-2017-012] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Indexed: 12/30/2022] Open
Abstract
Introduction: Advances in clinical decision support (CDS) continue to evolve to support the goals of clinicians, policymakers, patients and professional organizations to improve clinical practice, patient safety, and the quality of care. Objectives: Identify key thematic areas or foci in research and practice involving clinical decision support during the 2015-2016 time period. Methods: Thematic analysis consistent with a grounded theory approach was applied in a targeted review of journal publications, the proceedings of key scientific conferences as well as activities in standards development organizations in order to identify the key themes underlying work related to CDS. Results: Ten key thematic areas were identified, including: 1) an emphasis on knowledge representation, with a focus on clinical practice guidelines; 2) various aspects of precision medicine, including the use of sensor and genomic data as well as big data; 3) efforts in quality improvement; 4) innovative uses of computer-based provider order entry (CPOE) systems, including relevant data displays; 5) expansion of CDS in various clinical settings; 6) patient-directed CDS; 7) understanding the potential negative impact of CDS; 8) obtaining structured data to drive CDS interventions; 9) the use of diagnostic decision support; and 10) the development and use of standards for CDS. Conclusions: Active research and practice in 2015-2016 continue to underscore the importance and broad utility of CDS for effecting change and improving the quality and outcome of clinical care.
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Affiliation(s)
- R. A. Jenders
- Center for Biomedical Informatics and Department of Medicine, Charles Drew University, Los Angeles, California, USA
- Clinical and Translational Science Institute and Department of Medicine, University of California, Los Angeles, California, USA
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28
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Jackups R, Szymanski JJ, Persaud SP. Clinical decision support for hematology laboratory test utilization. Int J Lab Hematol 2017; 39 Suppl 1:128-135. [DOI: 10.1111/ijlh.12679] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 03/08/2017] [Indexed: 12/01/2022]
Affiliation(s)
- R. Jackups
- Department of Pathology and Immunology; Washington University School of Medicine; St. Louis MO USA
| | - J. J. Szymanski
- Department of Pathology and Immunology; Washington University School of Medicine; St. Louis MO USA
| | - S. P. Persaud
- Department of Pathology and Immunology; Washington University School of Medicine; St. Louis MO USA
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29
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Kentner AC, Grace SL. Between mind and heart: Sex-based cognitive bias in cardiovascular disease treatment. Front Neuroendocrinol 2017; 45:18-24. [PMID: 28232227 DOI: 10.1016/j.yfrne.2017.02.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 02/14/2017] [Accepted: 02/16/2017] [Indexed: 01/01/2023]
Abstract
Given that both men and women experience cardiovascular disease (CVD), a common misconception is that they have similar risk factors and clinical presentation, receive comparable treatment, and have equivalent clinical outcomes; in reality differences are observed between men and women for each of these endpoints. Moreover, these differences occur as a function of both gender and sex. A review of the literature reveals widespread bias in the selection of research subjects based on these factors, in addition to implicit patient and provider biases that impede the access of women to recommended primary and secondary CVD management. In this perspective, we identify strategies to eliminate such biases and improve women's access to CVD treatments to ensure their care is consistent with current guidelines.
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Affiliation(s)
- Amanda C Kentner
- Massachusetts College of Pharmacy and Health Sciences, Health Psychology Program, Boston, MA, United States.
| | - Sherry L Grace
- York University, School of Kinesiology and Health Science, Toronto, Ontario, Canada; University Health Network, Toronto General Hospital Research Institute, Peter Munk Cardiac Centre, Toronto, Ontario, Canada; University of Toronto, Faculty of Medicine, Toronto, Ontario, Canada
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