Routine Use of Low-Molecular-Weight Heparin For Deep Venous Thrombosis Prophylaxis After Foot and Ankle Surgery: A Cost-Effectiveness Analysis

Patient Safety Indicators at an Academic Veterans Affairs Hospital: Addressing Dual Goals of Clinical Care and Validity

BACKGROUND

Hospital-acquired complications add to patient morbidity and mortality, costs, length of stay, and negative patient experience. Patient Safety Indicators (PSIs) are a validated and widely used metric to evaluate hospital administrative data on preventing these events. Although many studies have addressed PSI validity, few have aimed to reduce PSI through clinical care. The authors aimed to reduce PSI events by addressing both validity and clinical care.

METHODS

Frontline clinicians used a deep dive template to provide input on all PSI cases, which were then reviewed by a PSI task force to identify performance gaps. After analyzing the frequency of gaps and cost-vs.-impact of potential solutions, five interventions were implemented to address the three most common, highly weighted PSIs: pressure ulcers, postoperative venous thromboembolism (VTE), and postoperative sepsis. Clinical care interventions included increasing patient mobility by creating a specialized mobility technician position, skin care audits to prevent pressure ulcers, and increasing use of pharmacologic VTE prophylaxis. Administrative interventions addressed improving clinician-coding concordance for sepsis and increasing documentation of comorbidities.

RESULTS

After interventions, the number of PSI events for composite PSI, VTE, and sepsis decreased by 41.3% (p = 0.039), 85.2% (p = 0.0091), and 51.5% (p = 0.063), respectively, relative to the preintervention period. Pressure ulcers increased by 33.3% (p = 0.0091).

CONCLUSION

Hospital complications cause substantial burden to hospitals, patients, and caregivers. Addressing administrative and clinical factors with targeted interventions led to reduction in composite PSI. Further efforts are needed locally to reduce the pressure ulcer PSI.

Prospective Surgical Cohort Analysis

A well-conducted prospective cohort study has the potential to change the way in which surgeons practice. However, not all are equal. In this article, we provide many of the tools needed to critically appraise this powerful study design. We advocate for using a 3-step approach that centers on understanding the study's generalizability, results, and validity. We illustrate how this process is applied into practice regularly at our hospital section's journal club sessions.

Pulmonary Embolism, Mortality, and Medical Complications Following a Total Ankle Replacement: A Systematic Review and Meta-analysis

BACKGROUND

There is sparse data on the incidence of thromboembolic and medical complications following total ankle replacements. The aim of this systematic review was to determine the risk of deep vein thrombosis and pulmonary embolism as well as mortality and medical complications following ankle replacements.

METHODS

A systematic review was undertaken using all levels of evidence following PRISMA guidelines. Of the 1657 articles identified, 25 met the inclusion criteria. The inclusion criteria were a primary total ankle replacement with the recording of medical complications and/or thromboembolic events and/or mortality data. Two reviewers independently reviewed all articles. Quantitative methods were used to pool the percentages with complications across studies.

RESULTS

The pooled percentage with reported symptomatic deep vein thrombosis across 18 studies was 0.07% (95% CI 0.001%-0.59%). The pooled percentage with reported postoperative pulmonary embolism across 8 studies was 0.01% (95% CI 0.001%-0.03%). The pooled postoperative reported mortality was 0.06% (95% CI 0.001%-0.24%). Other medical complications had low incidences.

CONCLUSION

Our study indicates rates of reported thromboembolic events of less than 1 in 1000. Notably the level of evidence analyzed was mainly Level III and IV, likely underestimating the true incidence of these events because of recall and medical record limitations, and we had insufficient information on usage of chemoprophylaxis among these patients.

LEVEL OF EVIDENCE

Level IV, systematic review based on all levels of evidence including case series.

Enhanced recovery (fast-track surgery) after total ankle replacement: The state of the art

The post-operative results of a total ankle replacement are not determined solely by an optimal surgical technique, but by an appropriate anesthesiological and rehabilitative post-operative approach. Enhanced functional recovery often depends on a multidisciplinary approach based on a correct framework of the patient and his needs, requests, and characteristics. Extensive bibliographical research has been performed on Pubmed, Google Scholar, Scopus. This comprehensive and inclusive review of the literature aims to examine the state of the art of "fast-track" protocols employed in total ankle replacement (TAR), considering pre-operative preparation, anesthetic management, intraoperative and surgical factors, post-operative rehabilitative care and reduction of hospitalization time.

Extended-duration thromboprophylaxis after ventral hernia repair: a risk model to predict venous thrombotic events after hospital discharge

BACKGROUND

Venous thromboembolism (VTE) is a major source of morbidity and mortality after ventral hernia surgery, but the risk of VTE after discharge has not been reported.

STUDY DESIGN

Data from the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) were used to investigate the risk of post-discharge VTE. Current procedural terminology (CPT) codes identified all reported patients who underwent ventral hernia repair from 2011 to 2017. We created a multivariable regression model for post-discharge VTE, using the 2011-2016 dataset to develop the model and 2017 as a validation set. The prediction model was used to create a risk calculator as a mobile application.

RESULTS

The rate of VTE after surgery was 0.62% (878 of 141,065) with 48% occurring after discharge from the hospital. The final predictor model consisted of eight variables: age > 60 years, male sex, body mass index (BMI) ≥ 35 kg/m2), operative time > 2 h, concurrent panniculectomy, post-operative hospitalization > 1 day, presence of bleeding disorder, and emergency operation. The model had good calibration and discrimination (Hosmer-Lemeshow goodness-of-fit test, p = 0.71; c-statistic = 0.71). Threshold analysis showed a strategy of extended-duration thromboprophylaxis was optimized when the risk of post-discharge VTE was > 0.3%.

CONCLUSION

Forty-eight percent of VTEs after ventral hernia repair occur after discharge, particularly in older, male, obese patients undergoing longer and complex operations that require hospitalization > 1 day. Post-discharge thromboprophylaxis should be considered in these patients, particularly when risk of VTE exceeds 0.3%.

Influence of Lower Extremity Deep Venous Thrombosis in Cerebral Infarction on Coagulation Index and Thromboelastogram and Its Risk Factors

Cerebral infarction is a serious brain injury disease, which is mainly caused by the blockage of blood circulation in patients’ brains; thus, the patient’s brain appears ischemia and hypoxia state, and large-scale nerve cell death occurs immediately. The aim of this study was to explore the influence of lower extremity deep venous thrombosis (LEDVT) on coagulation indexes and thromboelastogram (TEG) after cerebral infarction. Altogether, 67 patients with cerebral infarction complicated with LEDVT in our hospital from April 2017 to August 2019 were collected as the observation group (OG) and 58 patients with cerebral infarction without lower extremity deep venous thrombosis as the control group (CG). The R, K, angle, and MA values in PT, APTT, TT, FIB, and TEG indexes were compared between the two groups. The ROC curve was applied to analyze the diagnostic value of R value, K value, angle value, and MA value in the occurrence of LEDVT in patients with cerebral infarction. Logistic regression analysis was applied to analyze the independent risk factors of lower extremity deep venous thrombosis in cerebral infarction. PT, APTT, and TT in the OG were evidently lower than those in the CG, while FIB in the OG was evidently higher than that in the CG, R value and K value of the OG were evidently lower than those of the CG, and angle and MA values were higher than those in the CG. The AUC of R value, K value, angle value, and MA value of the ROC curve of LEDVT in patients with cerebral infarction was 0.735, 0.713, 0.790, and 0.819. Multivariate analysis showed that high FIB, angle, and MA were risk factors, while R and K values were protective factors. PT, APTT, and TT are lower and FIB is higher in patients with cerebral infarction with LEDVT. TEG has a certain diagnostic value. FIB value, angle value, and MA value are independent risk factors of LEDVT in patients with cerebral infarction, while R value and K value are protective factors.

Alternative physical treatments for deep venous thrombosis prophylaxis in surgical patients: a systematic review

INTRODUCTION

Venous thromboembolism (VTE) represents a major cause of morbidity and mortality. A variety of novel physical therapies have been proposed for patients in whom standard prophylaxis, including early mobilisation, is contraindicated. This article presents a systematic literature review of alternative physical treatments for VTE prophylaxis, focusing on surgical and trauma patients.

METHODS

Following protocol registration in PROSPERO, a systematic review was conducted in accordance with PRISMA. MEDLINE and EMBASE databases were searched for all studies indexed before 27th of July 2019. Two authors independently screened these articles. Data gathering for eligible articles was also undertaken in parallel by two authors. A formal risk of bias assessment was conducted for each study along with an assessment on the quality of the evidence using the GRADE framework.

RESULTS

A total of 272 abstracts were identified. After exclusion of duplicates and non-eligible articles, 10 publications were reviewed in detail. Two studies involving electrostimulation, another using a portable intermittent compression device and one study using postoperative calf massage reported a statistically significant reduction in the incidence of deep venous thrombosis when used in conjunction with LMWH. The remaining six articles did not show any significant benefits.

DISCUSSION

All studies reporting significant benefits have methodological flaws, with a high risk of bias. The evidence base informing alternative physical treatments as prophylactic measures in VTE is limited. Our data suggest that the use of these physical modalities can be beneficial in patients who also received LMWH, whilst these alone are of no benefit.

LEVEL OF EVIDENCE

II - Systematic Review Systematic Review Registration Number PROSPERO CRD42019133684.

Thromboembolic risk stratification by TRiP(cast) score to rationalise thromboprophylaxis in patients with lower leg trauma requiring immobilisation: a study protocol of the casting stepped-wedge cluster randomised trial

INTRODUCTION

Patients with lower limb trauma requiring orthopaedic immobilisation may be at risk of venous thromboembolism but opinions differ about who may benefit from thromboprophylactic anticoagulant treatment.The aim of this CASTING study is to demonstrate the safety of thromboprophylaxis based on the Thrombosis Risk Prediction for patients with cast immobilisation (TRiP(cast) score with regards to the 3-month incidence of symptomatic venous thromboembolism events in low-risk patients not receiving thromboprophylaxis, as well as the usefulness of this strategy on the rate of patients receiving anticoagulant treatment in comparison to current practice.

METHODS AND ANALYSIS

CASTING will be a stepped-wedge cluster randomised controlled clinical trial, performed in 15 emergency departments in France and Belgium. With their informed consent, outpatients admitted to one of the participating emergency departments for a lower limb trauma requiring orthopaedic immobilisation without surgery will be included. All centres will begin the trial with the 'observational period' and, every 2 weeks, 1 centre will be randomly assigned to switch to the 'interventional period' and to apply the TRiP(cast) score, in which only patients with a score ≥7 will receive thromboprophylactic anticoagulant treatment. The primary endpoint is the rate of clinical thromboembolic events within 90 days following the inclusion of low-risk patients not receiving thromboprophylaxis.

ETHICS AND DISSEMINATION

The protocol has been approved by the Comité de Protection des Personnes Sud I (Ethics Review ID-RCB: 2019-A01829-48) for France and the Comité d'éthique hôpital-facultaire Saint Luc (N° B403201941338) for Belgium. It is carried out in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. The findings of this study will be disseminated in peer-reviewed journals and at scientific conferences.

TRIAL REGISTRATION NUMBER

NCT04064489.

Effects of rehabilitation nursing care on deep vein thrombosis of the lower limbs following spinal fractures

OBJECTIVE

To explore the preventive effect of rehabilitation nursing care for deep vein thrombosis (DVT) of the lower limbs following spinal fractures, and to analyze its influence on the hemorheology of patients.

METHODS

A total of 99 patients with spinal fractures were allocated into a study group (n=50) and control group (n=49), and they were treated with internal fixation plus vertebroplasty. Afterwards, patients in the control group were given routine care and postoperative rehabilitation, and those in the study group received rehabilitation nursing care on the day after surgery, including posture guidance, massage of both lower limbs, and functional training. The functional training was consecutively performed until free movement of the legs was possible. All patients were reexamined after three months. The incidence of low-limb DVT, pain, and swelling, as well as the degree of swelling, hemorheology, quality of life, and patient satisfaction were compared between the two groups.

RESULTS

The study group had less frequent low-limb DVT, pain and swelling than the control group (all P<0.05). In the study group, the degree of swelling was significantly reduced, with earlier return to normal activity and shorter hospital stay (all P<0.05). After intervention, plasma viscosity, whole blood low/high shear viscosity and erythrocyte aggregation (EA) decreased in both groups, especially in the study group (all P<0.05). Although GQOL-74 scores increased in both groups, there was a more significant increase that occurred in study group (all P<0.001). Patients in the study group were more satisfied with nursing services than those in the control group (P<0.05).

CONCLUSION

Rehabilitation nursing care contributes to the improvement of hypercoagulable states and the prevention of lower-limb DVT for surgically treated patients with spinal fractures, and it is effective in relieving pain and swelling of the lower limbs, thereby enhancing quality of life and patient satisfaction.

Acute Deep Venous Thrombosis and Pulmonary Embolism in Foot and Ankle Trauma in the National Trauma Data Bank: An Update and Reanalysis

The data regarding rates of deep venous thrombosis and pulmonary embolism after foot and ankle trauma remain sparse. In this study of the National Trauma Data Bank Data set (2007-2009 and 2010-2016), these rates were reexamined and risk factors associated with these complications were assessed. Data quality is improved in the later data set; the incidence of deep venous thrombosis and pulmonary embolism was 0.28% and 0.21%, respectively, in the 2010-2016 data. Prophylaxis, male gender, treatment in a university hospital, open reduction, chronic obstructive pulmonary disease, and hypertension were notable significant risk factors for pulmonary embolism. For deep venous thrombosis, male gender, bleeding disorder, angina, and prophylaxis were risk factors. Careful, individualized assessment of the risk factors associated with deep venous thrombosis and pulmonary embolism is important, and the merits of routine prophylaxis remain in question.