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Geerts WH, Jeong E, Robinson LR, Khosravani H. Venous Thromboembolism Prevention in Rehabilitation: A Review and Practice Suggestions. Am J Phys Med Rehabil 2024; 103:934-948. [PMID: 38917440 DOI: 10.1097/phm.0000000000002570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
ABSTRACT Venous thromboembolism is a frequent complication of acute hospital care, and this extends to inpatient rehabilitation. The timely use of appropriate thromboprophylaxis in patients who are at risk is a strong, evidence-based patient safety priority that has reduced clinically important venous thromboembolism, associated mortality and costs of care. While there has been extensive research on optimal approaches to venous thromboembolism prophylaxis in acute care, there is a paucity of high-quality evidence specific to patients in the rehabilitation setting, and there are no clinical practice guidelines that make recommendations for (or against) thromboprophylaxis across the broad spectrum of rehabilitation patients. Herein, we provide an evidence-informed review of the topic with practice suggestions. We conducted a series of literature searches to assess the risks of venous thromboembolism and its prevention related to inpatient rehabilitation as well as in major rehabilitation subgroups. Mobilization alone does not eliminate the risk of venous thromboembolism after another thrombotic insult. Low molecular weight heparins and direct oral anticoagulants are the principal current modalities of thromboprophylaxis. Based on the literature, we make suggestions for venous thromboembolism prevention and include an approach for consideration by rehabilitation units that can be aligned with local practice.
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Affiliation(s)
- William H Geerts
- From the Thromboembolism Program, Sunnybrook Health Sciences Centre (WHG); Department of Medicine, University of Toronto, Toronto, ON, Canada (WHG); Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, Canada (EJ); Sunnybrook Health Sciences Centre, Toronto, ON, Canada (LRR, HK); Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, Canada (LRR); and Division of Neurology, University of Toronto, Toronto, ON, Canada (HK)
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Capiau A, De Vleeschauwer J, De Backer T, Gevaert S, Randon C, Mehuys E, Boussery K, Somers A. Optimizing anticoagulation therapy for in-hospital patients on direct oral anticoagulants: a single-centre modified Delphi study. Br J Clin Pharmacol 2024. [PMID: 38957976 DOI: 10.1111/bcp.16159] [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: 01/25/2024] [Revised: 05/23/2024] [Accepted: 06/09/2024] [Indexed: 07/04/2024] Open
Abstract
AIMS The management of patients treated with direct oral anticoagulants (DOACs) during hospitalization is a common challenge in clinical practice. Although bridging is generally not recommended, too often DOACs are switched to parenteral therapy with low molecular weight heparins. Our objectives were to update a local guideline for perioperative DOAC management and to develop a guideline for the anticoagulation management in non-surgical patients regarding temporary DOAC discontinuation. METHODS We executed a two-step modified Delphi study in a 1000-bed university hospital in Belgium. The Delphi questionnaires were developed based on a literature review and a telephone survey of prescribers. Two expert panels were established: one dedicated to perioperative DOAC management and the other to DOAC management in non-surgical patients. Both panels completed two rounds, commencing with an individual and online round, followed by a face-to-face group session. RESULTS After the two-round Delphi process, the updated perioperative guideline on DOAC management included reasons for delaying the resumption of DOACs following surgery, such as oral intake not possible, the probability of re-intervention within 3 days, and insufficient haemostasis (e.g. active clinically significant haematoma, haemorrhagic drains or wounds). Furthermore, a guideline for non-surgical hospitalized patients was developed, outlining possible reasons for interrupting DOAC therapy. Both guidelines offer clear anticoagulation therapy strategies corresponding to the identified scenarios. CONCLUSIONS We have updated and developed guidelines for DOAC management in surgical and non-surgical patients during hospitalization, which aim to support prescribers and to enhance targeted prescription review by hospital pharmacists.
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Affiliation(s)
- Andreas Capiau
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
| | | | - Tine De Backer
- Department of Cardiology, Heart Centre, Ghent University Hospital, Ghent, Belgium
- Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Sofie Gevaert
- Department of Cardiology, Heart Centre, Ghent University Hospital, Ghent, Belgium
- Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Caren Randon
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Els Mehuys
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Koen Boussery
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Annemie Somers
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
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Joassard O, Kerveillant AL, Sellal C, Coatantiec E, Jabbour V, Desjeux G, Braithwaite B, Elias A, Fauconnier A. Evaluation of Elastic Venous Compression Device dispensation in pregnant and post-partum women using the French National Health Insurance Claims Database: The ProFIL retrospective cohort study. Eur J Obstet Gynecol Reprod Biol 2024; 296:342-348. [PMID: 38531180 DOI: 10.1016/j.ejogrb.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 02/20/2024] [Accepted: 03/11/2024] [Indexed: 03/28/2024]
Abstract
OBJECTIVES To describe the real-world use of Elastic Venous Compression Devices (EVCDs) during pregnancy and post-partum using data from a representative subset of the French National Health Insurance Claims Database (the Echantillon Généraliste des Bénéficiaires, EGB). STUDY DESIGN Women aged 15-49 who were pregnant between 1st July 2017 and 15th June 2018 were identified in the EGB using pregnancy-specific acts (certain prenatal examinations or deliveries). Subgroups were defined by age, presence of Venous Thrombo-Embolism (VTE) risk factors, history of VTE, delivery type and time period. EVCD dispensations (format, prescriber, and date) were identified among those for "standard orthotics" using their unique reimbursement tariffs. Dispensation rates were computed for all subgroups, overall and by format and were compared. RESULTS 15,528 pregnant women were included: 7,252 [46.7 %] deliveries (5,796 vaginal [79.9 %], 482 planned cesarean sections (C-sections) [6.7 %] and 974 unplanned C-Sections [13.4 %]), 2,734 (17.6 %) terminations and 5,542 (35.7 %) unknown outcomes. Overall, 4,919 (31.7 %) women were dispensed at least one EVCD. Ante-partum dispensation occurred in 43.1 % (n = 3,122) of women whose pregnancy led to a delivery. Dispensation rates were 17.3 % (n = 1,005), 46.7 % (n = 225) and 44.1 % (n = 430) after vaginal delivery, planned C-sections or unplanned C-sections, respectively. Overall, dispensation rates significantly increased with age, the presence of VTE risk factors, and a history of VTE (p < 0.01). EVCD dispensation was most frequent (17.0 %) during the 5th month of pregnancy. Among pregnant women who were dispensed at least one EVCD during ante- or post-partum, 69.0 % had one or two units of compression (27.1 % [one unit], 41.9 % [two units]). Stockings (48.6 %, n = 6,038) were dispensed significantly more frequently than socks (36.9 %, n = 4,586) and tights (14.5 %, n = 1,806) (p < 0.01). The main contributors to mechanical VTE prophylaxis were gynecologists (26.3 % of dispensations, n = 2,280), general practitioners (20.2 %, n = 1,749) and midwives (15.1 %, n = 1,314). CONCLUSIONS Low observed dispensation rates highlight a discrepancy between the French National Authority for Health (Haute Autorité de Santé, HAS), recommending EVCDs use during pregnancy and after delivery, and the real-life use of EVCD. Prescription sensitization combined with targeted information campaigns for pregnant women would be beneficial to contribute to the prevention of VTE, a health problem for pregnant women.
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Affiliation(s)
- Olivier Joassard
- Laboratoires Innothera, 22 Avenue Aristide Briand, 94110 Arcueil, France.
| | | | - Claire Sellal
- Midwife practice, 14 Rue du Chapeau Rouge, 44000 Nantes, France.
| | - Erwana Coatantiec
- Laboratoires Innothera, 22 Avenue Aristide Briand, 94110 Arcueil, France.
| | - Violaine Jabbour
- Laboratoires Innothera, 22 Avenue Aristide Briand, 94110 Arcueil, France.
| | - Guillaume Desjeux
- e-Health Services Sanoïa, 70 Impasse Allegriat, 13400 Aubagne, France.
| | - Ben Braithwaite
- e-Health Services Sanoïa, 70 Impasse Allegriat, 13400 Aubagne, France.
| | - Antoine Elias
- Department of Vascular Medicine, Hôpital Sainte Musse, Centre Hospitalier Toulon La Seyne-sur-Mer, 54 Rue Henri Sainte-Claire Deville, 83100 Toulon, France; Clinical research department, Hôpital Sainte Musse, Centre Hospitalier Toulon La Seyne-sur-Mer, 54 Rue Henri Sainte-Claire Deville, 83100 Toulon, France.
| | - Arnaud Fauconnier
- Obstetrics and Gynecology department, Centre Hospitalier Intercommunal de Poissy-Saint-Germain-en-Laye, 10 Rue du Champ Gaillard, BP 3082, 78303 Poissy CEDEX, France; Paris-Saclay university, UVSQ, research unit 7285 "Risk and safety in clinical medicine for women and perinatal health (RISCQ), 2 Avenue de la source de la Bièvre, 78180 Montigny-le-Bretonneux, France.
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Ratnasekera A, Seng SS, Ciarmella M, Gallagher A, Poirier K, Harding ES, Haut ER, Geerts W, Murphy P. Thromboprophylaxis in hospitalized trauma patients: a systematic review and meta-analysis of implementation strategies. Trauma Surg Acute Care Open 2024; 9:e001420. [PMID: 38686174 PMCID: PMC11057278 DOI: 10.1136/tsaco-2024-001420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 03/27/2024] [Indexed: 05/02/2024] Open
Abstract
Introduction Venous thromboembolism (VTE) prophylaxis implementation strategies are well-studied in some hospitalized medical and surgical patients. Although VTE is associated with substantial mortality and morbidity in trauma patients, implementation strategies for the prevention of VTE in trauma appear to be based on limited evidence. Therefore, we conducted a systematic review and meta-analysis of published literature on active implementation strategies for VTE prophylaxis administration in hospitalized trauma patients and the impact on VTE events. Methods A systematic review and meta-analysis was performed in adult hospitalized trauma patients to assess if active VTE prevention implementation strategies change the proportion of patients who received VTE prophylaxis, VTE events, and adverse effects such as bleeding or heparin-induced thrombocytopenia as well as hospital length of stay and the cost of care. An academic medical librarian searched Medline, Scopus, and Web of Science until December 2022. Results Four studies with a total of 1723 patients in the active implementation strategy group (strategies included education, reminders, human and computer alerts, audit and feedback, preprinted orders, and/or root cause analysis) and 1324 in the no active implementation strategy group (guideline creation and dissemination) were included in the analysis. A higher proportion of patients received VTE prophylaxis with an active implementation strategy (OR=2.94, 95% CI (1.68 to 5.15), p<0.01). No significant difference was found in VTE events. Quality was deemed to be low due to bias and inconsistency of studies. Conclusions Active implementation strategies appeared to improve the proportion of major trauma patients who received VTE prophylaxis. Further implementation studies are needed in trauma to determine effective, sustainable strategies for VTE prevention and to assess secondary outcomes such as bleeding and costs. Level of evidence Systematic review/meta-analysis, level III. PROSPERO registration number CRD42023390538.
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Affiliation(s)
| | - Sirivan S Seng
- Crozer-Chester Medical Center, Upland, Pennsylvania, USA
| | - Marina Ciarmella
- Lincoln Memorial University DeBusk College of Osteopathic Medicine, Harrogate, Tennessee, USA
| | | | - Kelly Poirier
- Christiana Care Health System, Wilmington, Delaware, USA
| | - Eric Shea Harding
- Medical College of Wisconsin Todd Wehr Library, Milwaukee, Wisconsin, USA
| | | | - William Geerts
- Thromboembolism Program, University of Toronto, Toronto, Ontario, Canada
| | - Patrick Murphy
- Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Wang C, Toale KM. A multifaceted quality improvement intervention on venous thromboembolism prophylaxis compliance in hospitalized medical patients at a comprehensive cancer center. J Oncol Pharm Pract 2024; 30:189-196. [PMID: 37801550 DOI: 10.1177/10781552231205779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/08/2023]
Abstract
INTRODUCTION Previous studies suggest that quality improvement initiatives focused on hospital-acquired venous thromboembolism have a positive impact on prescribing rates of venous thromboembolism prophylaxis, especially those that incorporate computerized changes. METHODS We conducted a quality improvement project to determine whether education and computerized prescriber order entry system changes affect venous thromboembolism prophylaxis compliance rates in hospitalized medical patients at a Comprehensive Cancer Center. Between 1 January 2021 and 31 January 2023, 37,739 non-surgical, adult patient encounters with a length of stay > 48 h were analyzed in our study. From 18 December 2021 to 8 March 2022, provider education was delivered to the three largest admitting services, and computerized prescriber order entry changes were implemented incorporating a mandatory requirement to either order venous thromboembolism prophylaxis or document a contraindication for all patients at moderate venous thromboembolism risk. RESULTS Monthly venous thromboembolism prophylaxis compliance rates, as defined by the Centers for Medicare and Medicaid Services VTE-1 metric, increased from a mean of 74% to 93% after the interventions. This change was driven primarily by an increased utilization of mechanical venous thromboembolism prophylaxis from 37% to 53%. CONCLUSION Our study demonstrated that a multi-faceted intervention incorporating provider education and computerized prescriber order entry system changes can significantly increase venous thromboembolism prophylaxis compliance rates in cancer patients.
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Affiliation(s)
- Christopher Wang
- Department of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Clinical Pharmacy, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Katy M Toale
- Department of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Baugh CW, Cash RE, Meguerdichian D, Dunham L, Stump T, Stevens R, Reust A, White B, Dutta S. An Electronic Medical Record Intervention to Increase Pharmacologic Prophylaxis for Venous Thromboembolism in Emergency Department Observation Patients. Ann Emerg Med 2024; 83:24-34. [PMID: 37725025 DOI: 10.1016/j.annemergmed.2023.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 08/10/2023] [Accepted: 08/14/2023] [Indexed: 09/21/2023]
Abstract
STUDY OBJECTIVE The role of venous thromboembolism (VTE) prophylaxis among patients receiving emergency department (ED) observation unit care is unclear. We investigated an electronic health record-based clinical decision support tool aimed at increasing pharmacologic VTE prophylaxis use among at-risk patients placed in ED observation units. METHODS We conducted an interrupted time-series study of an Epic-based best practice advisory implemented in May 2019 at a health care system comprising 2 academic medical centers and 4 community hospitals with dedicated ED observation units. The best practice advisory alerted staff at 24 hours to conduct a risk assessment and linked to a VTE prophylaxis order set. We used an interrupted time series, Bayesian structured time series, and a multivariable mixed-effect regression model to estimate the intervention effect. RESULTS Prior to the best practice advisory implementation, there were 8,895 ED observation unit patients with a length of stay more than or equal to 24 hours, and 0.9% received pharmacologic VTE prophylaxis. Afterward, there were 12,664 ED observation unit patients with a length of stay more than or equal to 24 hours, and 4.8% received pharmacologic VTE prophylaxis. The interrupted time series and causal impact analysis showed a statistically significant increase in VTE prophylaxis (eg, absolute percent difference 3.8%, 95% confidence interval 3.5 to 4.1). In a multivariable model, only the intervention was significantly associated with receiving VTE prophylaxis (odds ratio 4.56, 95% confidence interval 2.22 to 9.37). CONCLUSION An electronic health record-based alert helped to prompt staff caring for ED observation unit patients at risk for VTE with prolonged visits to order recommended pharmacologic prophylaxis. The best risk assessment model to use and the true incidence of VTE events in this population are unclear.
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Affiliation(s)
| | - Rebecca E Cash
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | | | - Lisette Dunham
- Clinical Informatics, Mass General Brigham Digital, Boston, MA
| | - Timothy Stump
- Clinical Informatics, Mass General Brigham Digital, Boston, MA
| | - Ronelle Stevens
- Mosaic Inpatient Applications, Boston Children's Hospital, Boston, MA
| | - Audrey Reust
- Department of Emergency Medicine, Brigham & Women's Hospital, Boston, MA
| | - Benjamin White
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Sayon Dutta
- Clinical Informatics, Mass General Brigham Digital, Boston, MA; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
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Ratnasekera A, Geerts W, Haut ER, Price M, Costantini T, Murphy P. Implementation science approaches to optimizing venous thromboembolism prevention in patients with traumatic injuries: Findings from the 2022 Consensus Conference to Implement Optimal Venous Thromboembolism Prophylaxis in Trauma. J Trauma Acute Care Surg 2023; 94:490-494. [PMID: 36729882 PMCID: PMC9974883 DOI: 10.1097/ta.0000000000003850] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
ABSTRACT Disease burden of venous thromboembolism (VTE) without pharmacologic prophylaxis is high in trauma patients. Although VTE prophylaxis guidelines exist, studies on real-world use of VTE prophylaxis in trauma shows limited uptake of guideline recommendations. Despite existing guidelines, reports indicate that VTE prophylaxis implementation across trauma centers is lagging. Implementation barriers of VTE prophylaxis in trauma are multifactorial, and VTE prescribing practices require further optimization. Implementation science methods can help standardize and improve care; well-established approaches in medical and surgical hospitalized patients and their effects on clinical outcomes such as VTE and bleeding complications must be investigated because they apply to trauma patients. Nonadministration of VTE prophylaxis medications in hospitalized patients is associated with VTE events and remains a barrier to providing optimal defect-free care. Further investigations are required for VTE prophylaxis implementation across all trauma populations.
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Affiliation(s)
- Asanthi Ratnasekera
- From the Department of Surgery (A.R.), Division of Trauma and Surgical Critical Care, Drexel College of Medicine, Philadelphia, Pennsylvania; Christianacare Health (A.R.), Newark, Delaware; Thromboembolism Program, Sunnybrook Health Sciences Centre, Department of Medicine (W.G.), University of Toronto, Toronto, Canada; Division of Acute Care Surgery, Department of Surgery (E.R.H.), Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Anesthesiology and Critical Care Medicine (E.R.H.), Johns Hopkins University School of Medicine, Baltimore, Maryland; and Department of Emergency Medicine (E.R.H.), Johns Hopkins University School of Medicine, Baltimore, Maryland, Armstrong Institute for Patient Safety and Quality (E.R.H.), Johns Hopkins Medicine Baltimore, Maryland; Department of Health Policy and Management (E.R.H.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Coalition for National Trauma Research (M.P.), San Antonio, Texas; Division of Trauma, Surgical Critical Care and Burn Surgery, Department of Surgery (T.C.), University of California San Diego, California; and Division of Trauma and Acute Care Surgery, Department of Surgery (P.M.), Medical College of Wisconsin, Milwaukee, Wisconsin
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Method of venous thromboembolism prophylaxis is not a predictor of pulmonary embolus following elective bariatric surgery: a retrospective cohort study of 135,409 patients. Surg Obes Relat Dis 2022; 18:1378-1384. [PMID: 36184276 DOI: 10.1016/j.soard.2022.08.015] [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: 03/28/2022] [Revised: 06/27/2022] [Accepted: 08/30/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Patients with obesity are at increased risk of pulmonary embolus (PE), a risk that increases perioperatively and is challenging to manage. OBJECTIVE An analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was performed to determine predictors of PE in patients undergoing elective bariatric surgery. SETTING North American accredited bariatric surgery institutions included in the MBSAQIP database from 2020-2021. METHODS We extracted data from the MBSAQIP database (2020-2021) on patients who underwent elective Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Data were extracted on patient co-morbidities, race, prior history of deep vein thrombosis (DVT), and type of DVT prophylaxis. A multivariate logistic regression model was developed to determine predictors of PE and impact of PE on 30-day serious complications and mortality. RESULTS In the MBSAQIP database, a total of 135,409 patients underwent SG or RYGB from 2020 to 2021. PE was reported in 194 patients (.14%). Prior history of DVT (odds ratio [OR] = 3.28; 95% confidence interval [CI]: 1.85-5.83; P < .0001), Black race (OR = 3.03; 95% CI: 2.22-4.13; P < .0001), gastroesophageal reflux disease (OR = 1.51; 95% CI: 1.11-2.04; P = .008), higher body mass index (OR = 1.11; 95% CI: 1.01-1.20; P = .023), male sex (OR = 1.76; 95% CI: 1.26-2.45; P = .001), and older age (OR = 1.27; 95% CI: 1.10-1.46; P = .001) were associated with increased odds of PE. Chronic obstructive pulmonary disease, sleep apnea, and hypertension were not significant predictors of PE (P > .05). Neither combined mechanical and pharmacologic DVT prophylaxis nor pharmacologic prophylaxis alone was a significant predictor of PE (P > .05). CONCLUSION Prior history of DVT is the strongest predictor of PE after bariatric surgery. African American race, male sex, and gastroesophageal reflux disease are additional risk factors. Method of venous thromboembolism prophylaxis was not identified as significant predictor of PE. Further, studies on the evaluation and optimization of venous thromboembolism prophylaxis are required.
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Richie CD, Castle JT, Davis GA, Bobadilla JL, He Q, Moore MB, Kellenbarger TA, Xenos ES. Modes of Failure in Venous Thromboembolism Prophylaxis. Angiology 2022; 73:712-715. [DOI: 10.1177/00033197221083724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Venous thromboembolism (VTE) is associated with potentially preventable in-hospital morbidity and mortality. Although evidence-based guidelines are widely available, their application in clinical practice varies markedly. VTE prophylaxis involves a multistep dynamic process that can fail at various points during hospital stay. Our aim was to identify defects in VTE prophylaxis. Upon admission, our patients undergo VTE risk stratification and orders for prophylaxis are entered. All patients that fulfill the criteria for the Patient Safety Indicator (PSI)-12, as defined by the Agency for Healthcare Research and Quality, are prospectively entered in a database. From a review of 138 PSI-12 patients, only 21 had correct risk stratification and appropriate chemoprophylaxis during their hospital stay; 70 had been incorrectly stratified, with 28 of these patients receiving incorrect prophylaxis due to incorrect stratification, thus delaying the correct administration of chemoprophylaxis for >24 h. Inadequate application of mechanical prophylaxis was noted in 114 patients. VTE prophylaxis relies on correct risk stratification, ordering appropriate pharmacomechanical measures and, finally, the delivery of this treatment throughout the hospital stay. A large percentage of patients who had a thromboembolic complication received inadequate prophylaxis. This study identifies potential areas for intervention to improve VTE prophylaxis.
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Affiliation(s)
| | - Jennifer T. Castle
- Medical Education, General Surgery Residency Program, University of Kentucky College of Medicine, Lexington, KY, USA
| | - George A. Davis
- College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Joseph L. Bobadilla
- Department of Surgery, Division of Vascular Surgery, University of Kentucky Medical Center, Lexington, KY, USA
| | - Qiang He
- Center for Value, Quality and Safety, University of Kentucky Medical Center Lexington, KY, USA
| | - Mary B. Moore
- Center for Value, Quality and Safety, University of Kentucky Medical Center Lexington, KY, USA
| | | | - Eleftherios S. Xenos
- Department of Surgery, Division of Vascular Surgery, University of Kentucky Medical Center, Lexington, KY, USA
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Karajizadeh M, Hassanipour S, Sharifian R, Tajbakhsh F, Saeidnia HR. The effect of information technology intervention on using appropriate VTE prophylaxis in non-surgical patients: A systematic review and meta-analysis. Digit Health 2022; 8:20552076221118828. [PMID: 36003314 PMCID: PMC9393686 DOI: 10.1177/20552076221118828] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 07/21/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction Clinical decision support systems (CDSSs) play an important role in summarizing the best clinical practices, thereby promoting high standards of care in specific medical fields. These systems can serve as tools for gaining knowledge and mediating between clinical guidelines and physicians thereby providing the right information to the right person at the right time. Objective This review aims to evaluate the effect of CDSSs on adherence to guidelines for venous thromboembolism (VTE) prophylaxis and VTE events compared to routine care without CDSSs in non-surgical patients. Methods In order to conduct a systematic literature review, the published studies were identified through screening EMBASE, the international clinical trials registry, OVID, Cochrane database, PubMed, ISI Web of Science, and Scopus databases, from 1982 to March 2021. The included studies were reviewed by two independent reviewers; the proportion of patients that correctly received VTE prophylaxis has been next extracted for further analysis. Additionally, patients were divided into two groups: CDSS-recommended VTE prophylaxis and routine care without using a CDSS. Results Twelve articles (three randomized controlled trials, seven prospective cohort trials, and two retrospective cohort trials) were in fine analyzed. The use of CDSSs is found to be associated with a significant increase in the rate of using the appropriate prophylaxis for VTE ( p < 0.05) and a significant decrease in the incidence of VTE ( p < 0.05). Conclusion Implementation of CDSSs can help improving the appropriate use of VTE prophylaxis in non-surgical patients. Further, evidence-based and interventional studies on the development of CDSSs can provide more in-depth knowledge on both this tool design and efficiency.
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Affiliation(s)
- Mehrdad Karajizadeh
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Soheil Hassanipour
- Department of Epidemiology, Guilan University of Medical Sciences, Rasht, Iran
| | - Roxana Sharifian
- Health Human Resources Research Center, School of Management & Medical Information Sciences, Department of Health Information Management, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fatemeh Tajbakhsh
- Health Human Resources Research Center, School of Management & Medical Information Sciences, Department of Health Information Management, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamid Reza Saeidnia
- Department of Knowledge and Information Science, Tarbiat Modares University, Tehran, Iran
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Figueiredo HCES, Corrêa Neto IJF, Mocerino J, de Oliveira MC, Robles L. The Importance of the Therapeutic Care Plan in Colorectal Surgery. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1055/s-0041-1740097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Introduction A therapeutic plan is elaborated based on the health needs of each user, allowing a multidisciplinary team to assess diagnoses, treatment options, bonds, and optimal hospitalization time.
Objectives To identify risk management tools already used and implemented in a reference teaching hospital in the city of São Paulo and to analyze their application and risk factors in medium and large colorectal surgery.
Method Observational, longitudinal, and prospective study, with 30 patients with colorectal disease hospitalized in the surgical ward of the coloproctology service and in need of surgical treatment. In the first group, the protocol was applied with the knowledge of the researcher only, and, in the second group, with the knowledge of both the researcher and the attending physicians.
Results Sixty percent of the patients were female with a mean age of 60.93 years and body mass index (BMI) of 26.07 Kg/m2.After surgery, patients in the first group who did not receive venous thromboembolism (VTE) prophylaxis in the first 24 hours had an increased risk of having the event compared with those who returned to prophylaxis (p < 0.005), thus suggesting this prophylaxis was a protective factor against thromboembolic event (p = 0.006). This group also had a higher risk of hypoglycemia when no strict control was performed (p = 0.041).
Conclusion The compliance to hospital protocols with application monitoring, notedly in teaching places with annual admission of resident physicians, is a fundamental part of the adequate care of the patient combined with the implementation of therapeutic plans.
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Affiliation(s)
- Henrique Carvalho e Silva Figueiredo
- Physician and former student of Santa Marcelina College, Department of General Surgery and Coloproctology Service, Hospital Santa Marcelina, São Paulo, SP, Brazil
| | - Isaac José Felippe Corrêa Neto
- Physician specialist in Coloproctology and professor at Santa Marcelina College, Department of General Surgery and Coloproctology Service, Hospital Santa Marcelina, São Paulo, SP, Brazil
| | - Jéssica Mocerino
- Physician and former student of Santa Marcelina College, Department of General Surgery and Coloproctology Service, Hospital Santa Marcelina, São Paulo, SP, Brazil
| | - Mariana Campello de Oliveira
- Physician and former student of Santa Marcelina College, Department of General Surgery and Coloproctology Service, Hospital Santa Marcelina, São Paulo, SP, Brazil
| | - Laercio Robles
- Physician specialist in Coloproctology, professor at Santa Marcelina College and head of the Department of General Surgery, Department of General Surgery and Coloproctology Service, Hospital Santa Marcelina, São Paulo, SP, Brazil
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12
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Abstract
The Caprini risk assessment model (RAM) is widely used to assess risk of venous thromboembolism (VTE). However, it is cumbersome with 31 variables and poses challenges with inter-rater reliability. This study aimed to determine if an abbreviated model could perform similarly in VTE risk assessment. We performed a retrospective review of trauma patients ≥ 18 years old and admitted for over 24 h at a Level I trauma center from January 1, 2018, to December 31, 2018. Demographic and clinical data were analyzed to generate Caprini scores. Using a p-value cutoff of < 0.05, the individual components of the original Caprini RAM most highly associated with VTE were identified and used to calculate an abbreviated Caprini score. Logistic regression assessed odds of inpatient VTE with the original or abbreviated Caprini RAMs. Receiver operating characteristic curves and c-statistics were generated to assess discriminatory ability. The study sample included 1279 patients. Ten risk factors were included in the abbreviated model (recent major surgery, length of surgery > 2 h, transfusion, restricted mobility > 72 h, central venous catheter, current major surgery, age, history of VTE, hip or leg fracture, and serious trauma). Compared to the original, the abbreviated model had a similar odds ratio (1.17 vs 1.07, both p-values < 0.001), c-statistic (0.747 vs 0.753), sensitivity (0.73 vs 0.76) and specificity (0.62 vs 0.61). An abbreviated Caprini RAM performs similarly to the original, may streamline workflow and allow for automation in electronic health records, potentially enhancing its use in resource limited settings.
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13
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Chong J, Curtain C, Gad F, Passam F, Soo G, Levy R, Dunkley S, Wong Doo N, Cunich M, Burke R, Chen V. Development and implementation of venous thromboembolism stewardship across a hospital network. Int J Med Inform 2021; 155:104575. [PMID: 34560489 DOI: 10.1016/j.ijmedinf.2021.104575] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 08/21/2021] [Accepted: 09/09/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a leading cause of preventable death in hospital. Ensuring all hospitalized patients are assessed for VTE risk and given appropriate prophylaxis can reduce the burden of VTE on patients and the healthcare system. This is the first study to explore the effectiveness of a VTE stewardship program using electronic clinical decision support (eCDS) to provide oversight of hospital initiatives to prevent VTE. AIM To determine if a VTE stewardship program can increase risk-appropriate VTE prophylaxis, VTE risk assessment using eCDS, any documented risk assessment and risk assessment within 24 h of admission, plus reduce the incidence of hospital acquired VTE (HA-VTE). METHODS Education, daily medication chart auditing, weekly clinician performance feedback, health promotion and gamification were deployed over 6 months by two multidisciplinary VTE stewardship teams across four hospitals. Service impact was assessed through cross-sectional audits of electronic medical records every 3 months and review of HA-VTE events pre- and post-intervention. Implementation costs were calculated. RESULTS A total of 1622 patients were audited in separate cohorts at baseline, 3, 6 and 9 months. There was significant improvement in the prescription of appropriate prophylaxis (78%, 83%, 84%, and 88%, p = 0.004), VTE risk assessment using the eCDS tool (20%, 50%, 81% and 87%, p < 0.001), any documented risk assessment (71%, 82%, 95% and 93%, p < 0.001) and any documented risk assessment within 24 h of admission (54%, 56%, 65% and 63%, p = 0.001). Use of eCDS was associated with prescription of risk-appropriate VTE prophylaxis (p < 0.001). Annual incidence of HA-VTE decreased from 7.88 to 6.99 events per 10,000 discharges pre- to post-intervention (Odds Ratio (OR) 0.89, 95 %CI 0.66-1.18, p = 0.43). The cost of implementing the program across 133,078 episodes of care during the study period was AUD$108,167 (mean cost of $0.82 per patient).
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Affiliation(s)
- Julianne Chong
- Concord Repatriation General Hospital, Pharmacy Department, Sydney, Australia.
| | - Colin Curtain
- University of Tasmania, School of Pharmacy and Pharmacology, Hobart, Australia
| | - Fady Gad
- Royal Prince Alfred Hospital, Pharmacy Department, Sydney, Australia
| | - Freda Passam
- Royal Prince Alfred Hospital, Department of Hematology, Sydney, Australia
| | - Garry Soo
- Concord Repatriation General Hospital, Pharmacy Department, Sydney, Australia
| | - Russell Levy
- Royal Prince Alfred Hospital, Pharmacy Department, Sydney, Australia
| | - Scott Dunkley
- Royal Prince Alfred Hospital, Department of Hematology, Sydney, Australia
| | - Nicole Wong Doo
- Concord Repatriation General Hospital, Department of Hematology, Sydney, Australia; University of Sydney, Concord Clinical School, Sydney, Australia
| | - Michelle Cunich
- University of Sydney, Charles Perkins Centre, Faculty of Medicine and Health (Central Clinical School), Sydney, Australia; Sydney Local Health District, Sydney Health Economics Collaborative, Sydney, Australia
| | - Rosemary Burke
- Executive Unit, Sydney Local Health District, Sydney, Australia
| | - Vivien Chen
- Concord Repatriation General Hospital, Department of Hematology, Sydney, Australia; Anzac Research Institute, Concord, Sydney, Australia; University of Sydney, Faculty of Medicine and Health, Sydney, Australia
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14
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Blitzer RR, Eisenstein S. Venous Thromboembolism and Pulmonary Embolism: Strategies for Prevention and Management. Surg Clin North Am 2021; 101:925-938. [PMID: 34537152 DOI: 10.1016/j.suc.2021.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Perioperative venous thromboembolism (VTE) is a common complication within the surgical patient population. Perioperative mechanical and chemoprophylaxis have been shown to reduce the incidence of both deep venous thrombosis and pulmonary embolism. Prophylactic regimen must be tailored to the patient's individual risk factors as well as the nature of the procedure. In the event of VTE, treatment most commonly includes long-term anticoagulation, whereas more severe cases may require lytic or mechanical interventions.
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Affiliation(s)
- Rachel R Blitzer
- Department of Surgery, UC San Diego Health System, 200 W. Arbor Drive, San Diego, CA 92103, USA
| | - Samuel Eisenstein
- Department of Surgery, UC San Diego Health System, 3855 Health Sciences Drive #0987, La Jolla, CA 92037, USA.
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15
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Heins SE, Castillo RC. Changes in Opioid Prescribing Following the Implementation of State Policies Limiting Morphine Equivalent Daily Dose in a Commercially Insured Population. Med Care 2021; 59:801-807. [PMID: 34081679 PMCID: PMC8384656 DOI: 10.1097/mlr.0000000000001587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prescription opioid mortality doubled 2002-2016 in the United States. Given the association between high-dose opioid prescribing and opioid mortality, several states have enacted morphine equivalent daily dose (MEDD) policies to limit high-dose prescribing. The study objective is to evaluate the impact of state-level MEDD policies on opioid prescribing among the privately insured. METHODS Claims data, 2010-2015 from 9 policy states and 2 control states and a comparative interrupted time series design were utilized. Primary outcomes were any monthly opioid use and average monthly MEDD. Stratified analyses evaluated theorized weaker policies (guidelines) and theorized stronger policies (passive alert systems, legislative acts, and rules/regulations) separately. Patient groups explicitly excluded from policies (eg, individuals with cancer diagnoses or receiving hospice care) were also examined separately. Analyses adjusted for covariates, state fixed effects, and time trends. RESULTS Both guideline and strong policy implementation were both associated with 15% lower odds of any opioid use, relative to control states. However, there was no statistically significant change in the use of high-dose opioids in policy states relative to control states. There was also no difference in direction and significance of the relationship among targeted patient groups. CONCLUSIONS MEDD policies were associated with decreased use of any opioids relative to control states, but no change in high-dose prescribing was observed. While the overall policy environment in treatment states may have discouraged opioid prescribing, there was no evidence of MEDD policy impact, specifically. Further research is needed to understand the mechanisms through which MEDD policies may influence prescribing behavior.
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Affiliation(s)
- Sara E. Heins
- RAND Corporation, 4570 Fifth Ave #600, Pittsburgh, PA 15213
| | - Renan C. Castillo
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205
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16
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Titi MA, Alotair HA, Fayed A, Baksh M, Alsaif FAA, Almomani Z, Atallah M, Alsharif AF, Jamal AA, Amer YS. Effects of Computerised Clinical Decision Support on Adherence to VTE Prophylaxis Clinical Practice Guidelines among Hospitalised Patients. Int J Qual Health Care 2021; 33:6153904. [PMID: 33647102 DOI: 10.1093/intqhc/mzab034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/27/2021] [Accepted: 02/26/2021] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Venous thromboembolism (VTE) is an important patient safety concern. VTE leads to significant mortality and morbidity and a burden on healthcare resources. Despite the widespread availability of evidence-based clinical practice guidelines on VTE prophylaxis, we found that only 50.9% of our patients were receiving appropriate prophylaxis. The purpose of this study was to evaluate the impact of automation of an adapted VTE prophylaxis CPG using a clinical decision support system (the VTE-CDSS) on VTE prevention among hospitalised adult patients. DESIGN AND SETTING A quasi-experimental study (pre- and post-implementation) was conducted at a large 900-bed tertiary teaching multi-specialty hospital in Riyadh, Saudi Arabia. PARTICIPANTS The 1809 adult patients in the study included 871 enrolled during the pre-implementation stage and 938 enrolled during the post-implementation stage. INTERVENTION Multi-faceted implementation interventions were utilised, including leadership engagement and support, quality and clinical champions, staff training and education and regular audit and feedback. MAIN OUTCOME MEASURE Two rate-based process measures were calculated for each admission cohort (i.e. pre- and post-implementation): the percentage of inpatients who were assessed for VTE risk on admission and the percentage of inpatients who received appropriate VTE prophylaxis. Two outcome measures were calculated: the prevalence of hospital-acquired VTE (HA-VTE) events and the in-hospital all-cause mortality. RESULTS The percentage of inpatients risk assessed for VTE on admission increased from 77.4% to 93.3% (P < 0.01). The percentage of patients who received appropriate VTE prophylaxis increased from 50.9% to 81.4% (P < 0.01). The HA-VTE events decreased by 50% from 0.33% to 0.15% (P < 0.01).All-cause in-hospital mortality did not significantly change after implementation of the VTE-CDSS compared with pre-implementation mortality (P > 0.05). CONCLUSION The VTE-CDSS improved patient safety by enhancing adherence to the VTE prophylaxis best practice and adapted CPG. The multi-faceted implementation strategies approach improved the compliance rate of risk assessment and the adherence to prophylaxis recommendations and substantially reduced the HA-VTE prevalence. A successful CDSS requires a set of critical components to ensure better user compliance and positive patient outcomes.
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Affiliation(s)
- Maher A Titi
- Research Chair of Evidence-Based Healthcare and Knowledge Translation, Deanship of Scientific Research, King Khalid University Hospital, King Saud University Medical City, King Saud University, King Khalid Road, Riyadh 11472, Saudi Arabia.,Quality Management Department, King Khalid University Hospital, King Saud University Medical City, King Saud University, King Khalid Road, Riyadh 11472, Saudi Arabia
| | - Hadil A Alotair
- Division of Pulmonary and Critical Care, King Khalid University Hospital, King Saud University Medical City, King Saud University, King Khalid Road, Riyadh 11472, Saudi Arabia
| | - Amel Fayed
- College of Medicine, Clinical Department, Princess Nora Bint Abdulrahman University, Riyadh 11671, Saudi Arabia.,High Institute of Public Health, Alexandria University, 165 El-Horeya Road, El-Ibrahimia Qebli wa El-Hadarah Bahari, Qism Bab Sharqi, Alexandria Governorate, Alexandria 165, Egypt
| | - Maram Baksh
- Quality Management Department, King Khalid University Hospital, King Saud University Medical City, King Saud University, King Khalid Road, Riyadh 11472, Saudi Arabia
| | - Faisal Abdullah Abdulaziz Alsaif
- Department of Surgery, College of Medicine, King Khalid University Hospital, King Saud University Medical City, King Saud University, King Khalid Road, Riyadh 11472, Saudi Arabia
| | - Ziad Almomani
- Quality Management Department, King Khalid University Hospital, King Saud University Medical City, King Saud University, King Khalid Road, Riyadh 11472, Saudi Arabia
| | - Mohammad Atallah
- Nursing Department, King Khalid University Hospital, King Saud University Medical City, King Saud University, King Khalid Road, Riyadh 11472, Saudi Arabia
| | - Asrar F Alsharif
- Information Technology Department, King Khalid University Hospital, King Saud University Medical City, King Saud University, King Khalid Road, Riyadh 11472, Saudi Arabia
| | - Amr A Jamal
- Research Chair of Evidence-Based Healthcare and Knowledge Translation, Deanship of Scientific Research, King Khalid University Hospital, King Saud University Medical City, King Saud University, King Khalid Road, Riyadh 11472, Saudi Arabia.,Department of Family and Community Medicine, King Khalid University Hospital, King Saud University Medical City, King Saud University, King Khalid Road, Riyadh 11472, Saudi Arabia
| | - Yasser S Amer
- Research Chair of Evidence-Based Healthcare and Knowledge Translation, Deanship of Scientific Research, King Khalid University Hospital, King Saud University Medical City, King Saud University, King Khalid Road, Riyadh 11472, Saudi Arabia.,Quality Management Department, King Khalid University Hospital, King Saud University Medical City, King Saud University, King Khalid Road, Riyadh 11472, Saudi Arabia.,Alexandria Center for Evidence-Based Clinical Practice Guidelines, New University Hospital, Alexandria University, Alexandria 21131, Egypt
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17
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Holley AB. Preventing venous thromboembolism without causing harm. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2021; 6:100066. [PMID: 34327402 PMCID: PMC8315367 DOI: 10.1016/j.lanwpc.2020.100066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 11/18/2020] [Indexed: 11/21/2022]
Affiliation(s)
- Aaron B Holley
- Pulmonary/Sleep and Critical Care Medicine, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD 20889, United States
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18
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Factors to Consider When Evaluating Rates of Pharmacologic Venous Thromboembolism Prophylaxis Administration Among Trauma Patients. J Healthc Qual 2020; 42:304-314. [DOI: 10.1097/jhq.0000000000000230] [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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19
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Schlick CJR, Yuce TK, Yang AD, McGee MF, Bentrem DJ, Bilimoria KY, Merkow RP. A postdischarge venous thromboembolism risk calculator for inflammatory bowel disease surgery. Surgery 2020; 169:240-247. [PMID: 33077197 DOI: 10.1016/j.surg.2020.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/26/2020] [Accepted: 09/04/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Guidelines recommend extended chemoprophylaxis for venous thromboembolism in high-risk patients having operations for inflammatory bowel disease. Quantifying patients' risk of venous thromboembolism, however, remains challenging. We sought (1) to identify factors associated with postdischarge venous thromboembolism in patients undergoing colorectal resection for inflammatory bowel disease and (2) to develop a postdischarge venous thromboembolism risk calculator to guide prescribing of extended chemoprophylaxis. METHODS Patients who underwent an operation for inflammatory bowel disease from 2012 to 2018 were identified from the American College of Surgeons National Surgical Quality Improvement Program for colectomy and proctectomy procedure targeted modules. Postdischarge venous thromboembolism included pulmonary embolism or deep vein thrombosis diagnosed after discharge from the index hospitalization. Multivariable logistic regression estimated the association of patient/operative factors with postdischarge venous thromboembolism. A postdischarge venous thromboembolism risk calculator was subsequently constructed. RESULTS Of 18,990 patients, 199 (1.1%) developed a postdischarge venous thromboembolism within the first 30 postoperative days. Preoperative factors associated with postdischarge venous thromboembolism included body mass index (1.9% with body mass index ≥35 vs 0.8% with body mass index 18.5-24.9; odds ratio 2.34 [95% confidence interval 1.49-3.67]), steroid use (1.3% vs 0.7%; odds ratio 1.91 [95% confidence interval 1.37-2.66]), and ulcerative colitis (1.5% vs 0.8% with Crohn's disease; odds ratio 1.76 [95% confidence interval 1.32-2.34]). Minimally invasive surgery was associated with postdischarge venous thromboembolism (1.2% vs 0.9% with open; odds ratio 1.42 [95% confidence interval 1.05-1.92]), as was anastomotic leak (2.8% vs 1.0%; odds ratio 2.24 [95% confidence interval 1.31-3.83]) and ileus (2.1% vs 0.9%; odds ratio 2.60 [95% confidence interval 1.91-3.54]). The predicted probability of postdischarge venous thromboembolism ranged from 0.2% to 14.3% based on individual risk factors. CONCLUSION Preoperative, intraoperative, and postoperative factors are associated with postdischarge venous thromboembolism after an operation for inflammatory bowel disease. A postdischarge venous thromboembolism risk calculator was developed which can be used to tailor extended venous thromboembolism chemoprophylaxis by individual risk.
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Affiliation(s)
- Cary Jo R Schlick
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Tarik K Yuce
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Anthony D Yang
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Michael F McGee
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - David J Bentrem
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; Surgery Service, Jesse Brown VA Medical Center, Chicago, IL
| | - Karl Y Bilimoria
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL
| | - Ryan P Merkow
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL.
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20
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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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21
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Rocha ATC, Pinheiro TB, de Souza PRSP, Marques MA. Venous thromboembolism prophylaxis protocols at Brazilian hospitals - PROTEV Brazil. J Vasc Bras 2020; 19:e20190119. [PMID: 34178064 PMCID: PMC8202209 DOI: 10.1590/1677-5449.190119] [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] [Indexed: 11/22/2022] Open
Abstract
Background In common with other international guidelines, the Agency for Healthcare Research
and Quality recommends implementation of venous thromboembolism (VTE) prophylaxis
programs in hospitals as a measure for patient safety. The VTE Safety Zone Program
(VTESZ) proposes a model for incorporation of systematic VTE risk-assessment into
hospital routines, with continuing institutional and multidisciplinary
participation. Objectives To evaluate implementation of VTE prophylaxis initiatives in Brazilian hospitals
that have adhered to the VTESZ Program. Methods Questionnaires were e-mailed to VTESZ Program representatives at hospitals visited
up to July 2016. Results Of the 132 invitations sent, 68 answers were obtained and 50 (73.5%) were
complete. 61.5% of participating hospitals had between 100 and 250 beds, and 65.4%
had more than 20 intensive care beds; 61.5% reported having hospital
accreditation, 86.3% had VTE prophylaxis committees, and 58% had electronic
medical records. VTE risk assessments using the Brazilian guidelines or the Padua
or Caprini scores were noted on the electronic medical record in 56.9% and were a
mandatory step in 45.1% of the cases. VTE risk reassessment was requested prior to
discharge in only 25% of hospitals and several issues were cited that negatively
affect the VTESZ implementation process. Conclusions This study provides an overview of implementation of VTESZ in Brazilian hospitals.
Systematic risk assessment is not yet conducted for most patients. Recognition of
various issues affecting the process may lead to new strategies for achieving
adequate prophylaxis and safety of hospitalized patients.
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Affiliation(s)
- Ana Thereza Cavalcanti Rocha
- Universidade Federal da Bahia - UFBA, Faculdade de Medicina da Bahia, Departamento de Saúde da Família, Salvador, BA, Brasil
| | - Thiago Brito Pinheiro
- Universidade Federal da Bahia - UFBA, Faculdade de Medicina da Bahia, Departamento de Saúde da Família, Salvador, BA, Brasil
| | | | - Marcos Arêas Marques
- Universidade do Estado do Rio de Janeiro - UERJ, Hospital Universitário Pedro Ernesto, Unidade Docente Assistencial de Angiologia, Rio de Janeiro, RJ, Brasil
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22
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The Impact of Morphine Equivalent Daily Dose Threshold Guidelines on Prescribed Dose in a Workers' Compensation Population. Med Care 2020; 58:241-247. [PMID: 32106166 DOI: 10.1097/mlr.0000000000001269] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Prescription opioid overdose has increased markedly and is of great concern among injured workers receiving workers' compensation insurance. Given the association between high daily dose of prescription opioids and negative health outcomes, state workers' compensation boards have disseminated Morphine Equivalent Daily Dose (MEDD) guidelines to discourage high-dose opioid prescribing. OBJECTIVE To evaluate the impact of MEDD guidelines among workers' compensation claimants on prescribed opioid dose. METHODS Workers' compensation claims data, 2010-2013 from 2 guideline states and 3 control states were utilized. The study design was an interrupted time series with comparison states and average monthly MEDD was the primary outcome. Policy variables were specified to allow for both instantaneous and gradual effects and additional stratified analyses examined evaluated the policies separately for individuals with and without acute pain, cancer, and high-dose baseline use to determine whether policies were being targeted as intended. RESULTS After adjusting for covariates, state fixed-effects, and time trends, policy implementation was associated with a 9.26 mg decrease in MEDD (95% confidence interval, -13.96 to -4.56). Decreases in MEDD also became more pronounced over time and were larger in groups targeted by the policies. CONCLUSIONS Passage of workers' compensation MEDD guidelines was associated with decreases in prescribed opioid dose among injured workers. Disseminating MEDD guidelines to doctors who treat workers' compensation cases may address an important risk factor for opioid-related mortality, while still allowing for autonomy in practice. Further research is needed to determine whether MEDD policies influence prescribing behavior and patient outcomes in other populations.
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Extended Venous Thromboembolism Prophylaxis in Medically Ill Patients: An NATF Anticoagulation Action Initiative. Am J Med 2020; 133 Suppl 1:1-27. [PMID: 32362349 DOI: 10.1016/j.amjmed.2019.12.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 12/09/2019] [Indexed: 12/19/2022]
Abstract
Hospitalized patients with acute medical illnesses are at risk for venous thromboembolism (VTE) during and after a hospital stay. Risk factors include physical immobilization and underlying pathophysiologic processes that activate the coagulation pathway and are still present after discharge. Strategies for optimal pharmacologic VTE thromboprophylaxis are evolving, and recommendations for VTE prophylaxis can be further refined to protect high-risk patients after hospital discharge. An early study of extended VTE prophylaxis with a parenteral agent in medically ill patients yielded inconclusive results with regard to efficacy and bleeding. In the Acute Medically Ill VTE Prevention with Extended Duration Betrixaban (APEX) trial, extended use of betrixaban halved symptomatic VTE, decreased hospital readmission, and reduced stroke and major adverse cardiovascular events compared with standard enoxaparin prophylaxis. Based on findings from APEX, the Food and Drug Administration approved betrixaban in 2017 for extended VTE prophylaxis in acute medically ill patients. In the Reducing Post-Discharge Venous Thrombo-Embolism Risk (MARINER) study, extended use of rivaroxaban halved symptomatic VTE in high-risk medical patients compared with placebo. In 2019, rivaroxaban was approved for extended thromboprophylaxis in high-risk medical patients, thus making available a new strategy for in-hospital and post-discharge VTE prevention. To address the critical unmet need for VTE prophylaxis in medically ill patients at the time of hospital discharge, the North American Thrombosis Forum (NATF) is launching the Anticoagulation Action Initiative, a comprehensive consensus document that provides practical guidance and straightforward, patient-centered recommendations for VTE prevention during hospitalization and after discharge.
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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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P Ho V, A Dicker R, Haut ER. Dissemination, implementation, and de-implementation: the trauma perspective. Trauma Surg Acute Care Open 2020; 5:e000423. [PMID: 32154382 PMCID: PMC7046940 DOI: 10.1136/tsaco-2019-000423] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 12/05/2019] [Indexed: 12/20/2022] Open
Affiliation(s)
- Vanessa P Ho
- Departments of Surgery and Population and Quantitative Health Sciences, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Rochelle A Dicker
- Department of Surgery, David Geffen School of Medicine, Los Angeles, California, USA
| | - Elliott R Haut
- Departments of Surgery, Anesthesiology and Critical Care Medicine, and Emergency Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA.,Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Heins SE, Frey KP, Alexander GC, Castillo RC. Reducing High-Dose Opioid Prescribing: State-Level Morphine Equivalent Daily Dose Policies, 2007-2017. PAIN MEDICINE (MALDEN, MASS.) 2020; 21:308-316. [PMID: 30865779 PMCID: PMC8607298 DOI: 10.1093/pm/pnz038] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To describe current state-level policies in the United States, January 1, 2007-June 1, 2017, limiting high morphine equivalent daily dose (MEDD) prescribing. METHODS State-level MEDD threshold policies were reviewed using LexisNexis and Westlaw Next for legislative acts and using Google for nonlegislative state-level policies. The websites of each state's Medicaid agency, health department, prescription drug monitoring program, workers' compensation board, medical board, and pharmacy board were reviewed to identify additional policies. The final policy list was checked against existing policy compilations and academic literature and through contact with state health agency representatives. Policies were independently double-coded on the categories: state, agency/organization, policy type, effective date, threshold level, and policy exceptions. RESULTS Currently, 22 states have at least one type of MEDD policy, most commonly guidelines (14 states), followed by prior authorizations (four states), rules/regulations (four states), legislative acts (three states), claim denials (two states), and alert systems/automatic patient reports (two states). Thresholds range widely (30-300 mg MEDD), with higher thresholds generally corresponding to more restrictive policies (e.g., claim denial) and lower thresholds corresponding to less restrictive policies (e.g., guidelines). The majority of policies exclude some groups of opioid users, most commonly patients with terminal illnesses or acute pain. CONCLUSIONS MEDD policies have gained popularity in recent years, but considerable variation in threshold levels and policy structure point to a lack of consensus. This work provides a foundation for future evaluation of MEDD policies and may inform states considering adopting such policies.
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Affiliation(s)
| | | | - G. Caleb Alexander
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Johns Hopkins School of Medicine, Baltimore, MD
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Assessment of Surgical Antibiotic Prophylaxis Compliance in Pediatrics: A Pre-post Quasi-experimental Study. Pediatr Infect Dis J 2020; 39:48-53. [PMID: 31651809 DOI: 10.1097/inf.0000000000002490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Data from rigorous evaluations of the impact of interventions on improving surgical antibiotic prophylaxis (SAP) compliance in pediatrics are lacking. Our objective was to assess the impact of a multifaceted intervention on improving pediatric SAP compliance in a hospital without an ongoing antimicrobial stewardship program. STUDY DESIGN A multidisciplinary team at the Montreal Children's Hospital performed a series of interventions designed to improve pediatric SAP compliance in June 2015. A retrospective, quasi-experimental study was performed to assess SAP compliance before and following the interventions. Our study included patients under 18 years old undergoing surgery between April and September in 2013 (preintervention) and in 2016 (postintervention). A 10-week washout period was included to rigorously assess the persistence of compliance without ongoing interventions. SAP, when indicated, was qualified as noncompliant, partially compliant (adequate agent and timing) or totally compliant (adequate agent, dose, timing, readministration, duration). RESULTS A total of 982 surgical cases requiring SAP were included in our primary analysis. The composite partial and total compliance increased from 51.4% to 55.8% [adjusted odds ratio 1.3; 95% confidence interval: 1.0-1.8; P = 0.06]. Although improvements in correct dose and readministration were significant, there was no significant improvement in correct timing, agent selection or duration. CONCLUSION Our study demonstrated that overall SAP compliance did not significantly improve following a washout period, illustrating the importance of ongoing surveillance and feedback from an antimicrobial stewardship program. Our strict approach in evaluating the timing criterion may also explain the lack of a significant impact on SAP compliance.
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Improving the adoption of an electronic clinical decision support tool and evaluating its effect on venous thromboembolism prophylaxis prescribing at a Sydney tertiary teaching hospital. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2019. [DOI: 10.1002/jppr.1562] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Golemi I, Salazar Adum JP, Diaz Quintero L, Paz LH, Fuentes HE, Schmitt N, Tafur AJ. Gaps of care in patients with venous thrombotic embolism: a qualitative study. INT ANGIOL 2019; 38:284-290. [PMID: 31203596 DOI: 10.23736/s0392-9590.19.04130-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) includes pulmonary embolism (PE) and deep vein thrombosis (DVT), and results in 100,000 deaths annually in the United States. There is low global VTE awareness, including limited data regarding difficulties patients encounter during their management. This study aims to identify a patient's perspective on VTE gaps of care. METHODS This is a qualitative study using semi-structured interviews with VTE patients, who had been previously diagnosed and treated for at least one VTE event in their lifetime. Participants were separated in five focused groups; sample size was defined by data saturation. Interviews were audio recorded, transcribed verbatim, and analyzed thematically using framework analysis based on data saturation evaluation. The study was approved by a local institutional review board. We used inductive framework analysis to interpret the data. RESULTS Twenty participants were included in the analysis. Ten participants (50%) were men. Three major themes were identified: 1) concerned about limited disease knowledge; 2) VTE awareness in healthcare system; 3) incomplete communication during transitional and follow-up care. CONCLUSIONS Findings suggest that gaps of VTE care extend in different levels of the medical system, including: the patient, physicians, and medical teams. Patients were sensitive to a lack of disease awareness among healthcare providers. There was appreciation for subspecialty care recommended for VTE. In a qualitative study, using the patient perspective, we have detected frustrations and perceived areas of improvement of the care of the patient with VTE. These gaps are anchored in perceived lack of disease awareness and difficult transitional care.
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Affiliation(s)
- Iva Golemi
- Department of Internal Medicine, NorthShore University HealthSystem, Evanston, IL, USA -
| | - Juan P Salazar Adum
- Department of Internal Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Luis Diaz Quintero
- Department of Internal Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Luis H Paz
- Department of Cardiovascular Medicine, Northshore University HealthSystem, Evanston, IL, USA
| | - Harry E Fuentes
- Department of Hematology Oncology, Mayo Clinic, Rochester, MN, USA
| | - Natalie Schmitt
- Department of Psychiatry and Behavioral Sciences, NorthShore University HealthSystem, Evanston, IL, USA
| | - Alfonso J Tafur
- Division of Cardiovascular Medicine, Department of Medicine, NorthShore University HealthSystem, Evanston, IL, USA
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Cole JL, Stark JE. A facility mandate for pharmacist assessment improves venous thromboembolism outcomes. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2019. [DOI: 10.1002/jac5.1067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Jennifer L. Cole
- Department of Pharmacy Veterans Healthcare System of the Ozarks Fayetteville Arkansas
| | - Jennifer E. Stark
- Department of Pharmacy Veterans Healthcare System of the Ozarks Fayetteville Arkansas
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Kahn SR, Diendéré G, Morrison DR, Piché A, Filion KB, Klil-Drori AJ, Douketis J, Emed J, Roussin A, Tagalakis V, Morris M, Geerts W. Effectiveness of interventions for the implementation of thromboprophylaxis in hospitalised patients at risk of venous thromboembolism: an updated abridged Cochrane systematic review and meta-analysis of randomised controlled trials. BMJ Open 2019; 9:e024444. [PMID: 31129575 PMCID: PMC6537979 DOI: 10.1136/bmjopen-2018-024444] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 01/30/2019] [Accepted: 03/04/2019] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To assess the effectiveness of system-wide interventions designed to increase the implementation of thromboprophylaxis and decrease the incidence of venous thromboembolism (VTE) in hospitalised medical and surgical patients at risk of VTE. DESIGN Systematic review and meta-analysis of randomised controlled trials (RCTs). DATA SOURCES Medline, PubMed, Embase, BIOSIS, CINAHL, Web of Science, CENTRAL, DARE, EED, LILACS and clinicaltrials.gov without language restrictions from inception to 7 January 2017, as well as the reference lists of relevant review articles. ELIGIBILITY CRITERIA FOR SELECTING STUDIES RCTs that evaluated the effectiveness of system-wide interventions such as alerts, multifaceted, education, and preprinted orders when compared with no intervention, existing policy or another intervention. RESULTS We included 13 RCTs involving 35 997 participants. Eleven RCTs had data available for meta-analysis. Compared with control, we found absolute increase in the prescription of prophylaxis associated with alerts (21% increase, 95% CI [15% to 275%]) and multifaceted interventions (4% increase, 95% CI [3% to 11%]), absolute increase in the prescription of appropriate prophylaxis associated with alerts (16% increase, 95% CI [12% to 20%]) and relative risk reductions (risk ratio 64%, 95% CI [47% to 86%]) in the incidence of symptomatic VTE associated with alerts. Computer alerts were found to be more effective than human alerts, and multifaceted interventions with an alert component appeared to be more effective than multifaceted interventions without, although comparative pooled analyses were not feasible. The quality of evidence for improvement in outcomes was judged to be low to moderate certainty. CONCLUSIONS Alerts increased the proportion of patients who received prophylaxis and appropriate prophylaxis, and decreased the incidence of symptomatic VTE. Multifaceted interventions increased the proportion of patients who received prophylaxis but were found to be less effective than alerts interventions. TRIAL REGISTRATION NUMBER CD008201.
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Affiliation(s)
- Susan R Kahn
- Medicine, McGill University, Montreal, Quebec, Canada
| | - Gisele Diendéré
- Centre of Excellence in Thrombosis and Anticoagulation Care (CETAC), Clinical Epidemiology of the Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
| | - David R Morrison
- Centre of Excellence in Thrombosis and Anticoagulation Care (CETAC), Clinical Epidemiology of the Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
| | - Alexandre Piché
- Department of Mathematics and Statistics, McGill University, Montreal, Quebec, Canada
| | | | - Adi J Klil-Drori
- Medicine, McGill University, Montreal, Quebec, Canada
- Centre of Excellence in Thrombosis and Anticoagulation Care (CETAC), Clinical Epidemiology of the Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
| | - James Douketis
- Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jessica Emed
- Nursing, Jewish General Hospital, Montreal, Quebec, Canada
| | - André Roussin
- Medicine, University of Montreal, Montreal, Quebec, Canada
- Thrombosis Canada, Whitby, Ontario, Canada
| | - Vicky Tagalakis
- Centre of Excellence in Thrombosis and Anticoagulation Care (CETAC), Clinical Epidemiology of the Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
- Internal Medicine and Medicine, McGill University, Montreal, Quebec, Canada
| | - Martin Morris
- Schulich Library of Physical Sciences, Life Sciences and Engineering, McGill University, Montreal, Quebec, Canada
| | - William Geerts
- Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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The effect of hospital-based antithrombotic stewardship on adherence to anticoagulant guidelines. Int J Clin Pharm 2019; 41:691-699. [PMID: 31020598 PMCID: PMC6554262 DOI: 10.1007/s11096-019-00834-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 04/10/2019] [Indexed: 10/27/2022]
Abstract
Background Anticoagulant therapy is associated with a high risk of complications. Adherence to anticoagulant therapy protocols may lower this risk but adherence is often suboptimal. The introduction of a multidisciplinary antithrombotic team may improve adherence to anticoagulant guidelines among physicians. Objective To determine the effect of hospital-based multidisciplinary antithrombotic stewardship on adherence to anticoagulant guidelines among prescribing physicians. Setting This prospective non-randomised before-and-after study was conducted in patients hospitalized between October 2015 and December 2017 and treated with anticoagulant therapy. Method A multidisciplinary antithrombotic team focusing on education, medication reviews, drafting of local anticoagulant therapy protocols, patient counseling and medication reconciliation at admission and discharge was implemented in two Dutch hospitals. Main outcome measure Primary outcome was the proportion of the admitted patients in which the prescribing physician did adhere to the anticoagulant guidelines. Results The study comprised 1886 patients, of which 941 patients were included in the usual care period and 945 patients in the intervention period. Multivariable logistic regression analysis indicated that adherence was observed significantly more often during the intervention period (adjusted odds ratio [ORadj] 1.58, 95% confidence interval [95% CI] 1.21-2.05). Detailed analysis identified that the significantly higher overall adherence in the intervention period was attributed to dosing of LMWHs (odds ratio [OR] 1.58, 95% CI 1.16-2.14). Conclusion This study shows that introduction of a multidisciplinary antithrombotic stewardship leads to a significantly higher overall adherence to anticoagulant guidelines among prescribing physicians, mainly based on the improvement of dosing of low-molecular-weight-heparins.
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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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Guidelines' risk assessment recommendations for venous thromboembolism prophylaxis: A comparison and implementability appraisal. Thromb Res 2018; 168:5-13. [PMID: 29864630 DOI: 10.1016/j.thromres.2018.05.028] [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: 02/24/2018] [Revised: 05/02/2018] [Accepted: 05/25/2018] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Venous thromboembolism (VTE) prophylaxis guidelines for non-surgical patients recommend VTE- and bleeding risk assessment to guide prophylactic strategies. These recommendations differ between guidelines and implementation is suboptimal. Assessing a guideline's implementability characteristics helps predicting the ease of implementation and reveals barriers. OBJECTIVES We aimed to compare guidelines' risk assessment recommendations and critically appraise the implementability characteristics. MATERIAL AND METHODS Two guidelines, one from the American College of Chest Physicians and one from the National Institute for Health and Care Excellence were selected for comparison. Risk assessment methods and subsequent prophylactic recommendations were compared. Eight experts then appraised the guideline recommendations on intrinsic implementability characteristics using the GuideLine Implementability Appraisal (GLIA) instrument. GLIA identifies barriers and facilitators for guideline implementation in nine dimensions. RESULTS Eleven out of 20 individual VTE-risk factors and 2 out of 19 individual bleeding-risk factors used, were present in both guidelines. Additionally, a high VTE- or bleeding risk was defined differently between the two guidelines. The GLIA appraisal identified implementation barriers within all recommendations analyzed. On content level, barriers were identified in recommendations addressing bleeding risk assessment, mechanical prophylaxis and critical care patients. On implementability level, barriers were identified in decidability, flexibility, effect on process of care and computability dimensions. CONCLUSION Depending on the guideline used, VTE-prophylaxis will most likely be provided to different non-surgical patient populations, primarily due to discordance in bleeding risk assessment. Revising the recommendations, taking into account the most apparent implementation barriers, should be considered. However, insufficient evidence to support the recommendations currently complicates this.
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Ferru A, Belhadj R, Chapelle G, Berrard C, Bregere JP, Varlet I, Morin C, Marouby D, Buors M, Ducrocq JL, Lechuga P. [Thrombosis and cancer: Awareness of private practitioners and patients in Poitou-Charentes, a French region]. JOURNAL DE MEDECINE VASCULAIRE 2018; 43:182-192. [PMID: 29754728 DOI: 10.1016/j.jdmv.2018.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 02/24/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE The purpose of this study was to enhance awareness among healthcare professionals about the application of guidelines relating to the management of venous thromboembolism (VTE) in cancer patients. METHODS This collective approach involved: the Regional Health Agency (ARS), the Unions of Representatives of Healthcare Professionals (URPS), the Observatory of Drugs, the Medical Devices and Therapeutic Innovation agency (OMEDIT), the regional Oncology Network and specialist physicians. Performance indicators were defined to evaluate the actions performed. RESULTS Multidisciplinary information meetings were organized. A standardized patient's folder was proposed in all healthcare institutions dealing with cancer, as a link between healthcare professionals and patients. Information brochures were prepared for healthcare professionals and patients. Web-based surveys were taken among healthcare professionals to evaluate changes in their knowledge and practices before and after the first actions taken. CONCLUSION This collective approach improved the awareness of health professionals about care practices for VTE in cancer patients.
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Affiliation(s)
- A Ferru
- Pôle régional de cancérologie, CHU de Poitiers, France.
| | - R Belhadj
- Service de médecine vasculaire, CHU de Poitiers, France
| | | | - C Berrard
- URPS médecins libéraux, conférence régionale santé & autonomie, France
| | | | - I Varlet
- URPS infirmiers libéraux, France
| | - C Morin
- Réseau régional de cancérologie onco Poitou-Charentes, France
| | - D Marouby
- Réseau régional de cancérologie onco Poitou-Charentes, France
| | - M Buors
- Relations institutionnelles territoriales LEO Pharma, France
| | - J-L Ducrocq
- Projets thrombose affaires médicales LEO Pharma, France
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Cave B, Hough A, Dobesh PP. Extended Venous Thromboembolism Prophylaxis in Medically Ill Patients. Pharmacotherapy 2018. [PMID: 29543384 DOI: 10.1002/phar.2102] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Brandon Cave
- Fort Loudoun Medical Center; Lenoir City Tennessee
| | - Augustus Hough
- West Palm Beach Veterans Affairs Medical Center; West Palm Beach Florida
| | - Paul P. Dobesh
- College of Pharmacy; University of Nebraska Medical Center; Omaha Nebraska
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Kahn SR, Morrison DR, Diendéré G, Piché A, Filion KB, Klil‐Drori AJ, Douketis JD, Emed J, Roussin A, Tagalakis V, Morris M, Geerts W. Interventions for implementation of thromboprophylaxis in hospitalized patients at risk for venous thromboembolism. Cochrane Database Syst Rev 2018; 4:CD008201. [PMID: 29687454 PMCID: PMC6747554 DOI: 10.1002/14651858.cd008201.pub3] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in hospitalized patients. While numerous randomized controlled trials (RCTs) have shown that the appropriate use of thromboprophylaxis in hospitalized patients at risk for VTE is safe, effective, and cost-effective, thromboprophylaxis remains underused or inappropriately used. Our previous review suggested that system-wide interventions, such as education, alerts, and multifaceted interventions were more effective at improving the prescribing of thromboprophylaxis than relying on individual providers' behaviors. However, 47 of the 55 included studies in our previous review were observational in design. Thus, an update to our systematic review, focused on the higher level of evidence of RCTs only, was warranted. OBJECTIVES To assess the effects of system-wide interventions designed to increase the implementation of thromboprophylaxis and decrease the incidence of VTE in hospitalized adult medical and surgical patients at risk for VTE, focusing on RCTs only. SEARCH METHODS Our research librarian conducted a systematic literature search of MEDLINE Ovid, and subsequently translated it to CENTRAL, PubMed, Embase Ovid, BIOSIS Previews Ovid, CINAHL, Web of Science, the Database of Abstracts of Reviews of Effects (DARE; in the Cochrane Library), NHS Economic Evaluation Database (EED; in the Cochrane Library), LILACS, and clinicaltrials.gov from inception to 7 January 2017. We also screened reference lists of relevant review articles. We identified 12,920 potentially relevant records. SELECTION CRITERIA We included all types of RCTs, with random or quasi-random methods of allocation of interventions, which either randomized individuals (e.g. parallel group, cross-over, or factorial design RCTs), or groups of individuals (cluster RCTs (CRTs)), which aimed to increase the use of prophylaxis or appropriate prophylaxis, or decrease the occurrence of VTE in hospitalized adult patients. We excluded observational studies, studies in which the intervention was simply distribution of published guidelines, and studies whose interventions were not clearly described. Studies could be in any language. DATA COLLECTION AND ANALYSIS We collected data on the following outcomes: the number of participants who received prophylaxis or appropriate prophylaxis (as defined by study authors), the occurrence of any VTE (symptomatic or asymptomatic), mortality, and safety outcomes, such as bleeding. We categorized the interventions into alerts (computer or human alerts), multifaceted interventions (combination of interventions that could include an alert component), educational interventions (e.g. grand rounds, courses), and preprinted orders (written predefined orders completed by the physician on paper or electronically). We meta-analyzed data across RCTs using a random-effects model. For CRTs, we pooled effect estimates (risk difference (RD) and risk ratio (RR), with 95% confidence interval (CI), adjusted for clustering, when possible. We pooled results if three or more trials were available for a particular intervention. We assessed the certainty of the evidence according to the GRADE approach. MAIN RESULTS From the 12,920 records identified by our search, we included 13 RCTs (N = 35,997 participants) in our qualitative analysis and 11 RCTs (N = 33,207 participants) in our meta-analyses. PRIMARY OUTCOME Alerts were associated with an increase in the proportion of participants who received prophylaxis (RD 21%, 95% CI 15% to 27%; three studies; 5057 participants; I² = 75%; low-certainty evidence). The substantial statistical heterogeneity may be in part explained by patient types, type of hospital, and type of alert. Subgroup analyses were not feasible due to the small number of studies included in the meta-analysis.Multifaceted interventions were associated with a small increase in the proportion of participants who received prophylaxis (cluster-adjusted RD 4%, 95% CI 2% to 6%; five studies; 9198 participants; I² = 0%; moderate-certainty evidence). Multifaceted interventions with an alert component were found to be more effective than multifaceted interventions that did not include an alert, although there were not enough studies to conduct a pooled analysis. SECONDARY OUTCOMES Alerts were associated with an increase in the proportion of participants who received appropriate prophylaxis (RD 16%, 95% CI 12% to 20%; three studies; 1820 participants; I² = 0; moderate-certainty evidence). Alerts were also associated with a reduction in the rate of symptomatic VTE at three months (RR 64%, 95% CI 47% to 86%; three studies; 5353 participants; I² = 15%; low-certainty evidence). Computer alerts were associated with a reduction in the rate of symptomatic VTE, although there were not enough studies to pool computer alerts and human alerts results separately. AUTHORS' CONCLUSIONS We reviewed RCTs that implemented a variety of system-wide strategies aimed at improving thromboprophylaxis in hospitalized patients. We found increased prescription of prophylaxis associated with alerts and multifaceted interventions, and increased prescription of appropriate prophylaxis associated with alerts. While multifaceted interventions were found to be less effective than alerts, a multifaceted intervention with an alert was more effective than one without an alert. Alerts, particularly computer alerts, were associated with a reduction in symptomatic VTE at three months, although there were not enough studies to pool computer alerts and human alerts results separately.Our analysis was underpowered to assess the effect on mortality and safety outcomes, such as bleeding.The incomplete reporting of relevant study design features did not allow complete assessment of the certainty of the evidence. However, the certainty of the evidence for improvement in outcomes was judged to be better than for our previous review (low- to moderate-certainty evidence, compared to very low-certainty evidence for most outcomes). The results of our updated review will help physicians, hospital administrators, and policy makers make practical decisions about adopting specific system-wide measures to improve prescription of thromboprophylaxis, and ultimately prevent VTE in hospitalized patients.
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Affiliation(s)
- Susan R Kahn
- McGill UniversityDepartment of Epidemiology, Biostatistics and Occupational HealthMontrealCanada
- SMBD‐Jewish General Hospital, McGill UniversityCentre for Clinical Epidemiology and Community Studies3755 Cote Ste CatherineMontrealQCCanadaH3T 1E2
- McGill UniversityDivision of Internal Medicine and Department of MedicineMontrealQCCanadaH3T 1E2
| | - David R Morrison
- SMBD‐Jewish General Hospital, McGill UniversityCentre for Clinical Epidemiology and Community Studies3755 Cote Ste CatherineMontrealQCCanadaH3T 1E2
| | - Gisèle Diendéré
- SMBD‐Jewish General Hospital, McGill UniversityCentre for Clinical Epidemiology and Community Studies3755 Cote Ste CatherineMontrealQCCanadaH3T 1E2
| | - Alexandre Piché
- McGill UniversityDepartment of Mathematics and StatisticsMontrealCanada
| | - Kristian B Filion
- SMBD‐Jewish General Hospital, McGill UniversityCentre for Clinical Epidemiology and Community Studies3755 Cote Ste CatherineMontrealQCCanadaH3T 1E2
- McGill UniversityDepartments of Medicine and of Epidemiology, Biostatistics and Occupational HealthMontrealCanada
| | - Adi J Klil‐Drori
- SMBD‐Jewish General Hospital, McGill UniversityCentre for Clinical Epidemiology and Community Studies3755 Cote Ste CatherineMontrealQCCanadaH3T 1E2
| | - James D Douketis
- McMaster University and St. Josephs HospitalDepartment of MedicineRoom F‐53850 Carlton Avenue EastHamiltonONCanadaL8N 4A6
| | - Jessica Emed
- Jewish General HospitalDepartment of Nursing3755 Cote Ste CatherineMontrealQCCanadaH3T 1E2
| | - André Roussin
- University of Montreal and Thrombosis CanadaDepartment of Medicine1851 Sherbrooke St # 601MontrealQCCanadaH2K 4LS
| | - Vicky Tagalakis
- SMBD‐Jewish General Hospital, McGill UniversityCentre for Clinical Epidemiology and Community Studies3755 Cote Ste CatherineMontrealQCCanadaH3T 1E2
- McGill UniversityDivision of Internal Medicine and Department of MedicineMontrealQCCanadaH3T 1E2
| | - Martin Morris
- McGill UniversitySchulich Library of Physical Sciences, Life Sciences and EngineeringMontrealCanada
| | - William Geerts
- Sunnybrook Health Sciences Centre, University of TorontoDepartment of MedicineRoom D674, 2075 Bayview AvenueTorontoONCanadaM4N 3M5
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Rwabihama JP, Audureau E, Laurent M, Rakotoarisoa L, Jegou M, Saddedine S, Krypciak S, Herbaud S, Benzengli H, Segaux L, Guery E, Ambime G, Rabus MT, Perilliat JG, David JP, Paillaud E. Prophylaxis of Venous Thromboembolism in Geriatric Settings: A Cluster-Randomized Multicomponent Interventional Trial. J Am Med Dir Assoc 2018; 19:497-503. [PMID: 29580885 DOI: 10.1016/j.jamda.2018.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 02/07/2018] [Accepted: 02/11/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate the efficacy of an intervention on the practice of venous thromboembolism prevention. DESIGN A multicenter, prospective, controlled, cluster-randomized, multifaceted intervention trial consisting of educational lectures, posters, and pocket cards reminding physicians of the guidelines for thromboprophylaxis use. SETTINGS Twelve geriatric departments with 1861 beds total, of which 202, 803, and 856 in acute care, post-acute care, and long-term care wards, respectively. PARTICIPANTS Patients hospitalized between January 1 and May 31, 2015, in participating departments. MEASUREMENTS The primary endpoint was the overall adequacy of thromboprophylaxis prescription at the patient level, defined as a composite endpoint consisting of indication, regimen, and duration of treatment. Geriatric departments were divided into an intervention group (6 departments) and control group (6 departments). The preintervention period was 1 month to provide baseline practice levels, the intervention period 2 months, and the postintervention period 1 month in acute care and post-acute care wards or 2 months in long-term care wards. Multivariable regression was used to analyze factors associated with the composite outcome. RESULTS We included 2962 patients (1426 preintervention and 1536 postintervention), with median age 85 [79;90] years. For the overall 18.9% rate of inadequate thromboprophylaxis, 11.1% was attributable to underuse and 7.9% overuse. Intervention effects were more apparent in post-acute and long-term care wards although not significantly [odds ratio 1.44 (95% confidence interval 0.78;2.66), P = .241; and 1.44 (0.68, 3.06), P = .345]. Adequacy rates significantly improved in the postintervention period for the intervention group overall (from 78.9% to 83.4%; P = .027) and in post-acute care (from 75.4% to 86.3%; P = .004) and long-term care (from 87.0% to 91.7%; P = .050) wards, with no significant trend observed in the control group. CONCLUSIONS/IMPLICATIONS This study failed to demonstrate improvement in prophylaxis adequacy with our intervention. However, the intervention seemed to improve practices in post-acute and long-term care but not acute care wards.
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Affiliation(s)
- Jean Paul Rwabihama
- Université Paris-Est, UPEC, DHU A-TVB, IMRB-EA 7376 CEpiA (Clinical Epidemiology and Aging Unit), Créteil, France; Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Joffre-Dupuytren, Draveil, France.
| | - Etienne Audureau
- Université Paris-Est, UPEC, DHU A-TVB, IMRB-EA 7376 CEpiA (Clinical Epidemiology and Aging Unit), Créteil, France; Assistance Publique-Hôpitaux de Paris, Service de Santé Publique, Hôpital Henri Mondor, Créteil, France
| | - Marie Laurent
- Université Paris-Est, UPEC, DHU A-TVB, IMRB-EA 7376 CEpiA (Clinical Epidemiology and Aging Unit), Créteil, France; Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Albert Chenevier-Henri Mondor, Créteil, France
| | - Lalaina Rakotoarisoa
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital George Clemenceau, Champceuil, France
| | - Marc Jegou
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Emile Roux, Limeil Brévannes, France
| | - Sofiane Saddedine
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Emile Roux, Limeil Brévannes, France
| | - Sébastien Krypciak
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Henri Mondor, Créteil, France
| | - Stéphane Herbaud
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Henri Mondor, Créteil, France
| | - Hind Benzengli
- Assistance Publique-Hôpitaux de Paris, Service de Pharmacie, Hôpital Joffre-Dupuytren, Draveil, France
| | - Lauriane Segaux
- Université Paris-Est, UPEC, DHU A-TVB, IMRB-EA 7376 CEpiA (Clinical Epidemiology and Aging Unit), Créteil, France; Assistance Publique-Hôpitaux de Paris, Service de Santé Publique, Hôpital Henri Mondor, Créteil, France
| | - Esther Guery
- Assistance Publique-Hôpitaux de Paris, Service de Santé Publique, Hôpital Henri Mondor, Créteil, France
| | - Gabin Ambime
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Joffre-Dupuytren, Draveil, France
| | - Marie-Thérèse Rabus
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Joffre-Dupuytren, Draveil, France
| | - Jean-Guy Perilliat
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Joffre-Dupuytren, Draveil, France
| | - Jean-Philippe David
- Université Paris-Est, UPEC, DHU A-TVB, IMRB-EA 7376 CEpiA (Clinical Epidemiology and Aging Unit), Créteil, France; Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Emile Roux, Limeil Brévannes, France
| | - Elena Paillaud
- Université Paris-Est, UPEC, DHU A-TVB, IMRB-EA 7376 CEpiA (Clinical Epidemiology and Aging Unit), Créteil, France; Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Henri Mondor, Créteil, France
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Zaher GF. Underutilization of pharmacological thromboprophylaxis in obstetrics and gynaecology patients in the absence of a risk assessment tool. J Taibah Univ Med Sci 2018; 13:10-15. [PMID: 31435297 PMCID: PMC6694994 DOI: 10.1016/j.jtumed.2017.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 08/18/2017] [Accepted: 08/20/2017] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE This study was conducted to determine the risk factors for developing venous thromboembolism and to evaluate adherence to thromboprophylaxis guidelines among patients hospitalized in Obstetrics and Gynaecology units. METHODS A retrospective cohort study was conducted from December 2015 to March 2016 in the haematology department of a teaching hospital. A total of 188 hospitalized female patients with a hospital length of stay greater than 1 day were included. Patient data were reviewed to assess the risk score for developing venous thromboembolism by an independent expert haematologist. Patients eligible for thromboprophylaxis were compared to patients who had already received thromboprophylaxis. RESULTS A total of 188 patients were included, with age ranging from 17 to 81 years. Of these, 61% percent (n = 116) were gynaecological patients, while the remainder were pregnant women admitted to the obstetrics ward (38%, n = 72). Based on independent expert decision, 54% of gynaecological patients and 37% of obstetrics patients were eligible for thromboprophylaxis; however, only 48% of gynaecological and 26% of obstetrics patients were given thromboprophylaxis by their treating physician. CONCLUSIONS Venous thromboembolism is associated with substantial mortality and is largely preventable. Our study reports underutilization of thromboprophylaxis in clinical practice. Different modalities are necessary to improve adherence to thromboprophylaxis, such as implementation of a risk stratification tool at the time of hospital admission.
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Affiliation(s)
- Galila F. Zaher
- Hematology Department, King Abdulaziz University, Jeddah, KSA
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Rahemi H, Chung J, Hinko V, Hoeglinger S, Martinek WA, Montero-Baker M, Mills JL, Najafi B. Pilot study evaluating the efficacy of exergaming for the prevention of deep venous thrombosis. J Vasc Surg Venous Lymphat Disord 2018; 6:146-153. [PMID: 29292118 DOI: 10.1016/j.jvsv.2017.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 08/31/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Current prophylactic protocols fail to prevent deep venous thrombosis (DVT) in a significant minority of patients, and it remains one of the leading causes of preventable death. We therefore quantified the efficacy of novel game-based exercises (exergaming) to augment femoral venous parameters relative to ankle movement and muscle flexion. METHODS Healthy volunteers were recruited to perform a series of ankle and foot exercises using a wireless foot sensor (LEGSys; BioSensics LLC, Watertown, Mass) to navigate a computer cursor sequentially on a screen to the center of 200 circular targets. A single ultrasound technician (W.A.M.) measured each patient's mean flow volume, peak flow velocity, mean flow velocity, and cross-sectional area of the right femoral vein at baseline and obtained immediate postexercise (PEX), 5-minute PEX, and 15-minute PEX measurements. Electromyography (EMG) was performed at baseline and during the exercise. Baseline demographics and medical and surgical comorbidities were also recorded. The primary end point was the difference between baseline and immediate PEX mean flow volume estimates. We secondarily explored the association of baseline characteristics and EMG measurements with femoral vein parameters. RESULTS Fifteen healthy subjects (53% male; 28.1 ± 4.6 years) completed the exergaming task within a mean of 4 minutes, 2 ± 21 seconds. Immediately after exercise, the femoral vein mean flow volume, mean velocity, and peak systolic velocity increased by 49%, 53%, and 48%, respectively (P < .02 for each). Mean flow volume and velocity remained significantly elevated 5 minutes after exercise (P < .04 for each). Plantar flexion and dorsiflexion velocities and EMG frequency and intensity were not significantly correlated with PEX mean flow volume estimates (P > .05). Subgroup analysis revealed that women (P < .01) and Hispanics (P < .01) exhibited significantly slower PEX responses. Subjects with the largest improvements in mean flow volume had lower peak plantar flexion velocities (P < .01). CONCLUSIONS Exergaming increases mean flow volume, mean flow velocity, and peak systolic velocity within the femoral vein by approximately 50% above baseline. Exergaming represents a novel and potentially attractive method of DVT prevention by augmenting femoral vein mean volume flow and capitalizing on biofeedback. Less forceful but more uniform contractions were found to be most effective at augmenting venous blood flow. Exergaming will require further validation in larger study bases, among patients at higher risk of DVT.
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Affiliation(s)
- Hadi Rahemi
- Interdisciplinary Consortium on Advanced Motion Performance, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Jayer Chung
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex.
| | - Vanessa Hinko
- Interdisciplinary Consortium on Advanced Motion Performance, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Simon Hoeglinger
- Interdisciplinary Consortium on Advanced Motion Performance, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Wendy A Martinek
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Miguel Montero-Baker
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Bijan Najafi
- Interdisciplinary Consortium on Advanced Motion Performance, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
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Bhattacharya S, Sedhom R, Mukherjee A, Anand K, Balica A. Preventing Thromboembolism in Hospitalized Patients: Improving Quality Using a Peer-to-Peer Electronic Alerting System. Am J Med Qual 2018; 33:108. [DOI: 10.1177/1062860617718621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Arcelus J, Felicissimo P, Bergqvist D. Evaluation of the duration of thromboembolic prophylaxis after high-risk orthopaedic surgery: The ETHOS observational study. Thromb Haemost 2017; 107:270-9. [DOI: 10.1160/th11-07-0463] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Accepted: 10/28/2011] [Indexed: 11/05/2022]
Abstract
SummaryReal-life data on post-discharge venous thromboembolism (VTE) prophylaxis practices and treatments are lacking. We assessed post-operative VTE prophylaxis prescribed and received in a prospective registry, compared with the 2004 American College of Chest Physicians (ACCP) guidelines in high-risk orthopaedic surgery patients. Consecutive patients undergoing total hip arthroplasty (THA), hip fracture surgery (HFS), or knee arthroplasty (KA) were enrolled at discharge from 161 centres in 17 European countries if they had received in-hospital VTE prophylaxis that was considered in accordance with the ACCP guidelines by the treating physician. Data on prescribed and actual prophylaxis were obtained from hospital charts and patient post-discharge diaries. Post-operative prophylaxis prescribed and actual prophylaxis received were considered adherent or adequate, respectively, if recommended therapies were used for ≥28 days (HFS and THA) or ≥10 days (KA). Among 4,388 patients, 69.9% were prescribed ACCP-adherent VTE prophylaxis (THA: 1,411/2,217 [63.6%]; HFS: 701/1,112 [63.0%]; KA: 955/1,059 [90.2%]). Actual prophylaxis received was described in 3,939 patients with an available diary after discharge (non-evaluability rate of 10%). Mean actual durations of pharmacological prophylaxis from surgery were: 28.4 ± 13.7 (THA), 29.3 ± 13.9 (HFS), and 28.7 ± 14.1 days (KA). ACCP-adequate VTE prophylaxis was received by 66.5% of patients (60.9% THA, 55.4% HFS, and 88.7% KA). Prophylaxis inadequacies were mainly due to inadequate prescription, non-recommended prophylaxis prescription at discharge, or too short prophylaxis prescribed. In high-risk orthopaedic surgery patients with hospital-initiated prophylaxis, there is a gap between ACCP recommendations, prescribed and actual prophylaxis received, mainly due to inadequate prescription at discharge.
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Zacharia BE, Youngerman BE, Bruce SS, Hershman DL, Neugut AI, Bruce JN, Wright JD. Quality of Postoperative Venous Thromboembolism Prophylaxis in Neuro-oncologic Surgery. Neurosurgery 2017; 80:73-81. [PMID: 27258769 DOI: 10.1227/neu.0000000000001270] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 02/28/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Given the vagaries of published guidelines and the lack of high-quality evidence on the method, timing, and dose of venous thromboembolism (VTE) prophylaxis in neurological surgery, little is known about practice patterns regarding VTE prophylaxis in the United States. OBJECTIVE To estimate the use of VTE prophylaxis in patients who underwent surgery for a cerebral neoplasm and to identify patient, physician, and hospital characteristics associated with prophylaxis. METHODS Using the Premier Perspective database, we classified patients undergoing surgery for intracranial neoplasm between 2006 and 2012 on the basis of the type of VTE prophylaxis they received (mechanical, pharmacological, or combination). Generalized estimating equations were used to analyze the effects of pretreatment patient and system variables, including hospital and surgeon volume, on prophylaxis while controlling for hospital clustering. RESULTS A total of 43 327 patients were identified. Venous thromboembolism prophylaxis was given to 70.2% of patients. Overall, 16 957 (39.2%) had only mechanical prophylaxis, 5628 (13%) received only pharmacological prophylaxis, and 7826 (18.1%) received combination prophylaxis. Patients with high-volume providers (odds ratio, 2.22; 95% confidence interval, 1.33-3.69) were more likely to receive prophylaxis. CONCLUSION Nearly one-third of patients who underwent surgery for an intracranial tumor did not receive any VTE prophylaxis. We noted that the rate of overall VTE prophylaxis did not significantly change over the course of the 7 years analyzed despite an increasing focus on complication prevention. High-volume surgeons were more likely to provide VTE prophylaxis.
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Affiliation(s)
- Brad E Zacharia
- Department of Neurosurgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Brett E Youngerman
- Department of Neurological Surgery, Herbert Irving Comprehensive Cancer Center, New York Presbyterian Hospital-Columbia University Medical Center, New York, New York
| | - Samuel S Bruce
- Department of Neurological Surgery, Herbert Irving Comprehensive Cancer Center, New York Presbyterian Hospital-Columbia University Medical Center, New York, New York
| | | | | | - Jeffrey N Bruce
- Department of Neurological Surgery, Herbert Irving Comprehensive Cancer Center, New York Presbyterian Hospital-Columbia University Medical Center, New York, New York
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY
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Diamantouros A, Kiss A, Papastavros T, U. D, Zwarenstein M, Geerts WH. The TOronto ThromboProphylaxis Patient Safety Initiative (TOPPS): A cluster randomised trial. Res Social Adm Pharm 2017; 13:997-1003. [DOI: 10.1016/j.sapharm.2017.05.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 05/02/2017] [Accepted: 05/26/2017] [Indexed: 11/25/2022]
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O'Shaughnessy F, Donnelly JC, Cooley SM, Deering M, Raman A, Gannon G, Hickey J, Holland A, Hayes N, Bennett K, Ní Áinle F, Cleary BJ. Thrombocalc: implementation and uptake of personalized postpartum venous thromboembolism risk assessment in a high-throughput obstetric environment. Acta Obstet Gynecol Scand 2017; 96:1382-1390. [PMID: 28832906 DOI: 10.1111/aogs.13206] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 08/06/2017] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Venous thromboembolism risk assessment (VTERA) is recommended in all pregnant and postpartum women. Our objective was to develop, pilot and implement a user-friendly electronic VTERA tool. MATERIAL AND METHODS We developed "Thrombocalc", an electronic VTERA tool using Microsoft EXCEL™ . Thrombocalc was designed as a score-based tool to facilitate rapid assessment of all women after childbirth. Calculation of a total score estimated risk of venous thromboembolism in line with consensus guidelines. Recommendations for thromboprophylaxis were included in the VTERA output. Implementation was phased. Uptake of the VTERA tool was assessed prospectively by monitoring the proportion of women who gave birth in our institution and had a completed risk assessment. Factors affecting completion and accuracy of risk assessments were also assessed. RESULTS Thrombocalc was used prospectively to risk-assess 8380 women between September 2014 and December 2015. Compliance with this tool increased dramatically throughout the study period; over 92% of women were risk-assessed in the last quarter of data collection. Compliance was not adversely affected if delivery took place out of working hours [adjusted odds ratio (aOR) 1.03, 95% confidence interval (CI) 0.93-1.14]. Risk assessment was less likely in the case of cesarean deliveries (aOR 0.66, 95% CI 0.60-0.73) and stillborn infants (aOR 0.48, 95% CI 0.29-0.79). Misclassification of risk factors led to approximately 207 (2.5%) inaccurate thromboprophylaxis recommendations. CONCLUSIONS Our electronic, score-based VTERA tool provides a highly effective mechanism for rapid assessment of individual postpartum venous thromboembolism risk in a high-throughput environment.
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Affiliation(s)
- Fergal O'Shaughnessy
- Pharmacy Department, Rotunda Hospital, Dublin, Ireland.,Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Jennifer C Donnelly
- Department of Obstetrics and Gynecology, Rotunda Hospital, Dublin, Ireland.,Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Sharon M Cooley
- Department of Obstetrics and Gynecology, Rotunda Hospital, Dublin, Ireland
| | - Mary Deering
- Department of Midwifery, Rotunda Hospital, Dublin, Ireland
| | - Ajita Raman
- Department of Midwifery, Rotunda Hospital, Dublin, Ireland
| | | | - Jane Hickey
- Department of Midwifery, Rotunda Hospital, Dublin, Ireland
| | - Alan Holland
- Department of Finance, Rotunda Hospital, Dublin, Ireland
| | - Niamh Hayes
- Department of Anesthesia, Rotunda Hospital, Dublin, Ireland
| | - Kathleen Bennett
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fionnuala Ní Áinle
- Department of Hamatology, Rotunda Hospital, Dublin, Ireland.,School of Medicine and SPHERE Research Group, University College Dublin, Conway Institute, Dublin, Ireland.,Department of Hematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Brian J Cleary
- Pharmacy Department, Rotunda Hospital, Dublin, Ireland.,School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland
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Effectiveness of two distinct web-based education tools for bedside nurses on medication administration practice for venous thromboembolism prevention: A randomized clinical trial. PLoS One 2017; 12:e0181664. [PMID: 28813425 PMCID: PMC5558918 DOI: 10.1371/journal.pone.0181664] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 07/01/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a common cause of preventable harm in hospitalized patients. While numerous successful interventions have been implemented to improve prescription of VTE prophylaxis, a substantial proportion of doses of prescribed preventive medications are not administered to hospitalized patients. The purpose of this trial was to evaluate the effectiveness of nurse education on medication administration practice. METHODS This was a double-blinded, cluster randomized trial in 21 medical or surgical floors of 933 nurses at The Johns Hopkins Hospital, an academic medical center, from April 1, 2014 -March 31, 2015. Nurses were cluster-randomized by hospital floor to receive either a linear static education (Static) module with voiceover or an interactive learner-centric dynamic scenario-based education (Dynamic) module. The primary and secondary outcomes were non-administration of prescribed VTE prophylaxis medication and nurse-reported satisfaction with education modules, respectively. RESULTS Overall, non-administration improved significantly following education (12.4% vs. 11.1%, conditional OR: 0.87, 95% CI: 0.80-0.95, p = 0.002) achieving our primary objective. The reduction in non-administration was greater for those randomized to the Dynamic arm (10.8% vs. 9.2%, conditional OR: 0.83, 95% CI: 0.72-0.95) versus the Static arm (14.5% vs. 13.5%, conditional OR: 0.92, 95% CI: 0.81-1.03), although the difference between arms was not statistically significant (p = 0.26). Satisfaction scores were significantly higher (p<0.05) for all survey items for nurses in the Dynamic arm. CONCLUSIONS Education for nurses significantly improves medication administration practice. Dynamic learner-centered education is more effective at engaging nurses. These findings suggest that education should be tailored to the learner. TRIAL REGISTRATION ClinicalTrials.gov NCT02301793.
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Hobson DB, Chang TY, Aboagye JK, Lau BD, Shihab HM, Fisher B, Young S, Sujeta N, Shaffer DL, Popoola VO, Kraus PS, Knorr G, Farrow NE, Streiff MB, Haut ER. Prevalence of graduated compression stocking–associated pressure injuries in surgical intensive care units. J Crit Care 2017; 40:1-6. [DOI: 10.1016/j.jcrc.2017.02.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 01/18/2017] [Accepted: 02/05/2017] [Indexed: 10/20/2022]
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Evaluation of venous thromboembolism prophylaxis in a major hospital in a developing country. Int J Clin Pharm 2017. [DOI: 10.1007/s11096-017-0494-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Individualized Performance Feedback to Surgical Residents Improves Appropriate Venous Thromboembolism Prophylaxis Prescription and Reduces Potentially Preventable VTE: A Prospective Cohort Study. Ann Surg 2017; 264:1181-1187. [PMID: 26649586 DOI: 10.1097/sla.0000000000001512] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the effect of providing personal clinical effectiveness performance feedback to general surgery residents regarding prescription of appropriate venous thromboembolism (VTE) prophylaxis. BACKGROUND Residents are frequently charged with prescribing medications for patients, including VTE prophylaxis, but rarely receive individual performance feedback regarding these practice habits. METHODS This prospective cohort study at the Johns Hopkins Hospital compared outcomes across 3 study periods: (1) baseline, (2) scorecard alone, and (3) scorecard plus coaching. All general surgery residents (n = 49) and surgical patients (n = 2420) for whom residents wrote admission orders during the first 9 months of the 2013-2014 academic year were included. Outcomes included the proportions of patients prescribed appropriate VTE prophylaxis, patients with preventable VTE, and residents prescribing appropriate VTE prophylaxis for every patient, and results from the Accreditation Council for Graduate Medical Education resident survey. RESULTS At baseline, 89.4% of patients were prescribed appropriate VTE prophylaxis and only 45% of residents prescribed appropriate prophylaxis for every patient. During the scorecard period, appropriate VTE prophylaxis prescription significantly increased to 95.4% (P < 0.001). For the scorecard plus coaching period, significantly more residents prescribed appropriate prophylaxis for every patient (78% vs 45%, P = 0.0017). Preventable VTE was eliminated in both intervention periods (0% vs 0.35%, P = 0.046). After providing feedback, significantly more residents reported receiving data about practice habits on the Accreditation Council for Graduate Medical Education resident survey (87% vs 38%, P < 0.001). CONCLUSIONS Providing personal clinical effectiveness feedback including data and peer-to-peer coaching improves resident performance, and results in a significant reduction in harm for patients.
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ACC/AHA Special Report: Clinical Practice Guideline Implementation Strategies: A Summary of Systematic Reviews by the NHLBI Implementation Science Work Group. J Am Coll Cardiol 2017; 69:1076-1092. [DOI: 10.1016/j.jacc.2016.11.004] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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