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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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Karamacoska D, Johnson T, Harrison L, Shi K, Akrawi J, D'Souza SP, Hohenberg MI, George ES, Steiner-Lim GZ. Venous thromboembolism risk screening, training and provider awareness in Australian residential aged care facilities. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:e5010-e5016. [PMID: 35855618 DOI: 10.1111/hsc.13915] [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: 08/30/2021] [Revised: 05/23/2022] [Accepted: 07/04/2022] [Indexed: 06/15/2023]
Abstract
Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in the geriatric post-surgical population, and its prevention is a public health priority. The aim of this study was to assess the use of VTE risk screening and training protocols, and VTE awareness in the Australian residential aged care sector. A cross-sectional survey was conducted that was directed at facility and policy managers of community aged care facilities with ≥10 residents in two Australian states and territories. Forty-nine of 301 (16.3%) providers responded, representing 249/871 (28.6%) aged care facilities and 20,958/66,121 (31.7%) residents. VTE risk screening protocols were used by 1.2% of facilities (3/249), and 79.5% (198/249) were unaware that VTE is an issue in this population. Only 0.8% (2/249) were aware that risk screening and prophylaxis is required to prevent VTE; none were acting upon this. No facility had specific VTE risk assessment or prevention processes in place. Most residential aged care facilities surveyed do not have VTE risk screening protocols and were unaware of the risk that may be associated with this omission. These results have implications for development and implementation of national and international VTE risk screening guidelines in community care.
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Affiliation(s)
- Diana Karamacoska
- NICM Health Research Institute, Western Sydney University, Penrith, New South Wales, Australia
| | - Tamara Johnson
- School of Medicine, Western Sydney University, Penrith, New South Wales, Australia
- Hornsby Ku-ring-gai Hospital, Northern Sydney Local Health District, Hornsby, New South Wales, Australia
| | - Lize Harrison
- School of Medicine, Western Sydney University, Penrith, New South Wales, Australia
- Hornsby Ku-ring-gai Hospital, Northern Sydney Local Health District, Hornsby, New South Wales, Australia
| | - Kate Shi
- School of Medicine, Western Sydney University, Penrith, New South Wales, Australia
| | - Joy Akrawi
- School of Medicine, Western Sydney University, Penrith, New South Wales, Australia
| | - Stephanie P D'Souza
- School of Medicine, Western Sydney University, Penrith, New South Wales, Australia
- Westmead Hospital, Western Sydney Local Health District, Westmead, New South Wales, Australia
| | - Mark I Hohenberg
- School of Medicine, Western Sydney University, Penrith, New South Wales, Australia
| | - Emma S George
- School of Health Sciences, Western Sydney University, Penrith, New South Wales, Australia
- Translational Health Research Institute (THRI), Western Sydney University, Penrith, New South Wales, Australia
| | - Genevieve Z Steiner-Lim
- NICM Health Research Institute, Western Sydney University, Penrith, New South Wales, Australia
- Translational Health Research Institute (THRI), Western Sydney University, Penrith, New South Wales, Australia
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Allaway MGR, Eslick GD, Kwok GTY, Cox MR. Improving Venous Thromboembolism Prophylaxis Administration in an Acute Surgical Unit. J Patient Saf 2021; 17:e1341-e1345. [PMID: 30028767 DOI: 10.1097/pts.0000000000000521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Venous thromboembolism (VTE) prophylaxis regimes frequently have a wide variation in application. Nepean acute surgical unit was established in 2006 as a novel model for emergency surgical care. As part of the model's rollout, there were several areas of clinical management targeted for improvement, one being VTE prophylaxis compliance. It was decided all patients older than 18 years treated for a variety of acute surgical conditions within the acute surgical unit should be administered routine VTE prophylaxis with heparin and compression stockings. A novel multifaceted intervention was implemented at the time to achieve this goal. The primary aim of this study was to determine VTE prophylaxis administration rates before and after this intervention. METHODS A before-after study conducted as a retrospective review of medical records of all patients 18 years or older, having an appendicectomy in 3 periods: Before acute surgical unit (ASU) (November 2004 to October 2006), Early ASU (November 2006 to October 2008), and Established ASU (January 2012 to December 2013). Outcomes were mechanical and pharmacological VTE prophylaxis administration rates for each group. RESULTS There were 1149 patients included in the study: Before ASU, 167; Early ASU, 375; and Established ASU, 607. There was a significant stepwise increase in parmacological VTE prophylaxis administration: Before ASU, 54.5%; Early ASU, 74.7%; and Established ASU, 96.9% (Before versus Early: odds ratio [OR], 2.46; 95% confidence interval [CI], 1.68-3.61; P < 0.001; Early versus Established: OR, 10.500; 95% CI, 6.29-17.53; P < 0.001). Mechanical VTE prophylaxis was significantly increased in the established group (Before versus Established: OR, 47.18; 95% CI, 25.61-86.91; P < 0.001). CONCLUSIONS There was a significant increase in VTE prophylaxis administration after the implementation of our multifaceted intervention. Allocating a responsible provider dedicated to VTE prophylaxis prescription and compliance checking was a key component to this intervention.
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Affiliation(s)
- Matthew G R Allaway
- From the Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | | | - Grace T Y Kwok
- From the Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
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Ruiz-Talero P, Cerón-Perdomo D, Hernández-Flórez C, Gutiérrez-gómez S, Muñoz-Velandia O. Improving compliance to clinical practice guidelines with a multifaceted quality improvement program for the prevention of venous thromboembolic disease in nonsurgical patients. Int J Qual Health Care 2020; 32:319-324. [DOI: 10.1093/intqhc/mzaa037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 03/09/2020] [Accepted: 04/02/2020] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objective
To evaluate the change in compliance to thromboprophylaxis guidelines before and after the implementation of a multifaceted patient safety program.
Design
Longitudinal before and after study.
Setting
Teaching hospital, Hospital Universitario San Ignacio, Bogotá (Colombia).
Participants
Adult nonsurgical hospitalized patients.
Intervention
A multifaceted program for the prevention of venous thromboembolic (VTE) disease among adult nonsurgical hospitalized patients. The strategies of the program included (i) update and communication of thromboprophylaxis guidelines, (ii) the implementation of risk-assessment tools in electronic medical records, (iii) nursing staff activities and (iv) education to health personnel and patients for maintenance of the program.
Main Outcome Measure
Appropriate use of thromboprophylaxis.
Results
221 and 236 patients were evaluated in the pre- and postimplementation periods, respectively. Global appropriate thromboprophylaxis prescription went from 74.66 to 82.6% (P = 0.064). Adequate thromboprophylaxis in high-risk patients did not increase significantly (77.70 vs 80.62%, P = 0.528), but a significant reduction in inappropriate thromboprophylaxis formulation in low-risk patients was found, decreasing from 20.55 to 5.26% (P = 0.005).
Conclusions
Implementing a quality improvement multifaceted program improves the formulation of adequate thromboprophylaxis. Reducing the inappropriate prescription of VTE prophylaxis in patients at low risk of thrombosis can lead to a reduction in bleeding complications and a better use of economic and human resources.
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Affiliation(s)
- Paula Ruiz-Talero
- Internal Medicine Department, Hospital Universitario San Ignacio, Cra 7 No 40-62 Piso 7, Bogotá, Colombia
- Department of Internal Medicine, Pontificia Universidad Javeriana, Cra 7 No 40-62 Piso 7, Bogotá, Colombia
| | - Daniela Cerón-Perdomo
- Internal Medicine Department, Hospital Universitario San Ignacio, Cra 7 No 40-62 Piso 7, Bogotá, Colombia
| | - Catalina Hernández-Flórez
- Internal Medicine Department, Hospital Universitario San Ignacio, Cra 7 No 40-62 Piso 7, Bogotá, Colombia
- Department of Internal Medicine, Pontificia Universidad Javeriana, Cra 7 No 40-62 Piso 7, Bogotá, Colombia
| | - Santiago Gutiérrez-gómez
- Internal Medicine Department, Hospital Universitario San Ignacio, Cra 7 No 40-62 Piso 7, Bogotá, Colombia
| | - Oscar Muñoz-Velandia
- Internal Medicine Department, Hospital Universitario San Ignacio, Cra 7 No 40-62 Piso 7, Bogotá, Colombia
- Department of Internal Medicine, Pontificia Universidad Javeriana, Cra 7 No 40-62 Piso 7, Bogotá, Colombia
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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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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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Torrejon Torres R, Saunders R, Ho KM. A comparative cost-effectiveness analysis of mechanical and pharmacological VTE prophylaxis after lower limb arthroplasty in Australia. J Orthop Surg Res 2019; 14:93. [PMID: 30940168 PMCID: PMC6444865 DOI: 10.1186/s13018-019-1124-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 03/11/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a complication following surgery. Low-molecular-weight heparin (LMWH) or direct oral anticoagulants (DOACs) are efficacious but come with inherent bleeding risk. Mechanical prophylaxis, such as intermittent pneumatic compression (IPC), does not induce bleeding but may be difficult to implement beyond the immediate post-operative period. This study compared the cost and quality-adjusted life years (QALYs) saved of commonly used VTE prophylaxis regimens after lower limb arthroplasty. METHODS A previously published cost-utility model considering major efficacy and safety endpoints was updated to estimate the 1-year cost-effectiveness of different VTE prophylaxis regimens. The VTE strategies assessed included apixaban, dabigatran, rivaroxaban, LMWH, IPC, IPC + LMWH and IPC + apixaban. Efficacy data were derived from studies in PubMed, and cost data came from the 2017 Australian AR-DRG and PBS pricing schemes. RESULTS Costs for VTE prophylaxis including treatment of its associated complications over the first year after surgery ranged from AUD $644 (IPC) to AUD $956 (rivaroxaban). Across 500 simulations, IPC was the cheapest measure in 73% of simulations. In 97% of simulations, a DOAC was associated with the highest resulting QALYs. Compared to IPC, apixaban was cost-effective in 76.4% of simulations and apixaban + IPC in 87.8% of simulations. For VTE events avoided, the DOACs and IPC were on par. LMWH and LMWH + IPC were negatively dominated. CONCLUSIONS Apixaban, IPC or a sequential/simultaneous combination of both is currently the most cost-effective VTE prophylaxis regimens. The choice between them is best guided by the relative VTE and bleeding risks of individual patients.
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Affiliation(s)
| | - Rhodri Saunders
- Coreva Scientific, Kaiser-Joseph-Strasse 198-200, 79098 Freiburg, Germany
| | - Kwok M. Ho
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia Australia
- School of Population and Global Health, University of Western Australia, Perth, Western Australia Australia
- School of Veterinary and Life Sciences, Murdoch University, Perth, Western Australia Australia
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van C, McInerney P, Cooke R. Patients' involvement in improvement initiatives: a qualitative systematic review. ACTA ACUST UNITED AC 2018; 13:232-90. [PMID: 26571293 DOI: 10.11124/jbisrir-2015-1452] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Over the last 20 years, quality improvement in health has become an important strategy in health services in many countries. With the emphasis on quality health care, there has been a shift in social paradigms towards including service users in their own health on different levels. There is growing evidence in literature on the positive impact on health outcomes where patients are active participants in their personal care. There is however less information available on the broader influence of users on improvement in systems. OBJECTIVES The objective of this review was to identify the barriers and enablers to patients being involved in quality improvement efforts directed towards their own health care. INCLUSION CRITERIA This review considered studies that included adults and children of any age experiencing any health problem.The review considered studies that explored patient or user participation in quality improvement and the factors enabling and hindering this processThe qualitative component of this review considered studies that focused on qualitative data, including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research. Other texts such as opinion papers and reports were also considered. SEARCH STRATEGY The search strategy aimed to find both published and unpublished studies. A three-step search strategy was utilized in this review. The searches using all identified keywords and index terms included the databases PubMed, PsycINFO, Medline, Scopus, EBSCOhost and CINAHL.Qualitative, text and opinion papers were considered for inclusion in this review.Closely related concepts like community involvement, family involvement, patients' involvement in their own care (for example, in the case of shared decision making), and patient centeredness in the context of a consultation were excluded. METHODOLOGICAL QUALITY Qualitative and textual papers selected for retrieval were assessed by two independent reviewers for authenticity prior to inclusion in the review using the standardized critical appraisal instruments from the Joanna Briggs Institute. DATA EXTRACTION Qualitative and textual data were extracted from papers included in the review using the standardized data extraction tool from the Joanna Briggs Institute. DATA SYNTHESIS The above findings were pooled and through the identification of categories, a final meta-synthesis was formulated. RESULTS Two synthesized findings were created from the included papers. Firstly, there are barriers to patients' participation in quality improvement in health and in spite of policy support for user involvement in quality improvement, it is a difficult strategy to implement. The second synthesized finding was that there are enablers to patients' involvement in quality improvement: when patients are involved in quality improvement efforts in health care, there are innovative, often unexpected, outcomes at different levels of the process, and sustaining these efforts is possible with ongoing individual or group support.Five categories which supported the synthesized findings were created through the meta-aggregative process. CONCLUSIONS There are enablers and barriers to involving patients in quality improvement in health care that need to be considered when planning such interventions.Relationships and roles will need to be very clear from the outset. A developmental approach needs to be considered where support and training is part of the project. Where patients are truly engaged in service improvement, unexpected innovation occurs.There are many more reports and opinion papers published regarding this topic than there are rigorous research studies. This leaves the field open to the development of good methodological studies related to quality improvement and in particular to the participation of patients.
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Affiliation(s)
- Claire van
- 1Department of Family Medicine, University of the Witwatersrand, Johannesburg, South Africa2The Witwatersrand Center for Evidence Based Practice: an Affiliate Center of the Joanna Briggs Institute3Center for Health Science Education, Faculty of Health Science Education, University of the Witwatersrand.4Center for Rural Health, University of the Witwatersrand, Johannesburg, South Africa
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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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Al-Hameed FM, Al-Dorzi HM, Qadhi AI, Shaker A, Al-Gahtani FH, Al-Jassir FF, Zahir GF, Al-Khuwaitir TS, Addar MH, Al-Hajjaj MS, Abdelaal MA, Aboelnazar EY. Thromboprophylaxis and mortality among patients who developed venous thromboembolism in seven major hospitals in Saudi Arabia. Ann Thorac Med 2017; 12:282-289. [PMID: 29118862 PMCID: PMC5656948 DOI: 10.4103/atm.atm_101_17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION Venous thromboembolism (VTE) during hospitalization is a serious and potentially fatal condition. Despite its effectiveness, evidence-based thromboprophylaxis is still underutilized in many countries including Saudi Arabia. OBJECTIVE OF THE STUDY Our objectives were to determine how often hospital-acquired VTE patients received appropriate thromboprophylaxis, VTE-associated mortality, and the percentage of patients given anticoagulant therapy and adherence to it after discharged. METHODS This study was conducted in seven major hospitals in Saudi Arabia. From July 1, 2009, till June 30, 2010, all recorded deep vein thrombosis (DVT) and pulmonary embolism (PE) cases were noted. Only patients with confirmed VTE diagnosis were included in the analysis. RESULTS A total of 1241 confirmed VTE cases occurred during the 12-month period. Most (58.3%) of them were DVT only, 21.7% were PE, and 20% were both DVT and PE. 21.4% and 78.6% of confirmed VTE occurred in surgical and medical patients, respectively. Only 40.9% of VTE cases received appropriate prophylaxis (63.2% for surgical patients and 34.8% for medical patients; P < 0.001). The mortality rate was 14.3% which represented 1.6% of total hospital deaths. Mortality was 13.5% for surgical patients and 14.5% for medical patients (P > 0.05). Appropriate thromboprophylaxis was associated with 4.11% absolute risk reduction in mortality (95% confidence interval: 0.24%-7.97%). Most (89.4%) of the survived patients received anticoagulation therapy at discharge and 71.7% of them were adherent to it on follow-up. CONCLUSION Thromboprophylaxis was underutilized in major Saudi hospitals denoting a gap between guideline and practice. This gap was more marked in medical than surgical patients. Hospital-acquired VTE was associated with significant mortality. Efforts to improve thromboprophylaxis utilization are warranted.
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Affiliation(s)
- Fahad M Al-Hameed
- Department of Intensive Care, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, National Guard Health Affairs, Jeddah, Saudi Arabia
| | - Hasan M Al-Dorzi
- Department of Intensive Care, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Abdulelah I Qadhi
- Department of Medicine, King Fahad General Hospital, MOH, Jeddah, Saudi Arabia
| | - Amira Shaker
- Department of Medicine, Prince Sultan Military Hospital, Riyadh, Saudi Arabia
| | - Farjah H Al-Gahtani
- Department of Hematology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Fawzi F Al-Jassir
- Department of Orthopedics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Galila F Zahir
- Department of Hematology, College of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | | | - Mohammed H Addar
- Department of Obstetrics and Gynecology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mohamed S Al-Hajjaj
- Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mohamed A Abdelaal
- Department of Pathology, King Abdulaziz Medical City, National Guard Health Affairs, Jeddah, Saudi Arabia
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Minami CA, Yang AD, Ju M, Culver E, Seifert K, Kreutzer L, Halverson T, O'Leary KJ, Bilimoria KY. Evaluation of an institutional project to improve venous thromboembolism prevention. J Hosp Med 2016; 11 Suppl 2:S29-S37. [PMID: 27925424 DOI: 10.1002/jhm.2663] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 08/25/2016] [Accepted: 08/28/2016] [Indexed: 11/06/2022]
Abstract
BACKGROUND Northwestern Memorial Hospital (NMH) was historically a poor performer on the venous thromboembolism (VTE) outcome measure. As this measure has been shown to be flawed by surveillance bias, NMH embraced process-of-care measures to ensure appropriate VTE prophylaxis to assess healthcare-associated VTE prevention efforts. OBJECTIVE To evaluate the impact of an institution-wide project aimed at improving hospital performance on VTE prophylaxis measures. DESIGN A retrospective observational study. SETTING NMH, an 885-bed academic medical center in Chicago, Illinois PATIENTS: Inpatients admitted to NMH from January 1, 2013 to May 1, 2013 and from October 1, 2014 to April 1, 2015 were eligible for evaluation. INTERVENTION Using the define-measure-analyze-improve-control (DMAIC) process-improvement methodology, a multidisciplinary team implemented and iteratively improved 15 data-driven interventions in 4 broad areas: (1) electronic medical record (EMR) alerts, (2) education initiatives, (3) new EMR order sets, and (4) other EMR changes. MEASUREMENTS The Joint Commission's 6 core measures and the Surgical Care Improvement Project (SCIP) SCIP-VTE-2 measure. RESULTS Based on 3103 observations (1679 from January 1, 2013 to May 1, 2013, and 1424 from October 1, 2014 to April 1, 2015), performance on the core measures improved. Performance on measure 1 (chemoprophylaxis) improved from 82.5% to 90.2% on medicine services, and from 94.4% to 97.6% on surgical services. The largest improvements were seen in measure 4 (platelet monitoring), with a performance increase from 76.7% adherence to 100%, and measure 5 (warfarin discharge instructions), with a performance increase from 27.4% to 88.8%. CONCLUSION A systematic hospital-wide DMAIC project improved VTE prophylaxis measure performance. Sustained performance has been observed, and novel control mechanisms for continued performance surveillance have been embedded in the hospital system. Journal of Hospital Medicine 2016;11:S29-S37. © 2016 Society of Hospital Medicine.
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Affiliation(s)
- Christina A Minami
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University and Northwestern Memorial Hospital, Chicago, Illinois
- Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Anthony D Yang
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University and Northwestern Memorial Hospital, Chicago, Illinois
| | - Mila Ju
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University and Northwestern Memorial Hospital, Chicago, Illinois
| | | | | | - Lindsey Kreutzer
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University and Northwestern Memorial Hospital, Chicago, Illinois
| | | | - Kevin J O'Leary
- Division of Hospital Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Karl Y Bilimoria
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University and Northwestern Memorial Hospital, Chicago, Illinois
- Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Al-Hameed FM, Al-Dorzi HM, Abdelaal MA, Alaklabi A, Bakhsh E, Alomi YA, Al Baik M, Aldahan S, Schünemann H, Brozek J, Wiercioch W, Darzi AJ, Waziry R, Akl EA. The Saudi clinical practice guideline for the prophylaxis of venous thromboembolism in medical and critically ill patients. Saudi Med J 2016; 37:1279-1293. [PMID: 27761572 PMCID: PMC5303811 DOI: 10.15537/smj.2016.11.15268] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 08/24/2016] [Indexed: 11/16/2022] Open
Abstract
Venous thromboembolism (VTE) acquired during hospitalization is common, yet preventable by the proper implementation of thromboprophylaxis which remains to be underutilized worldwide. As a result of an initiative by the Saudi Ministry of Health to improve medical practices in the country, an expert panel led by the Saudi Association for Venous Thrombo Embolism (SAVTE; a subsidiary of the Saudi Thoracic Society) with the methodological guidance of the McMaster University Guideline working group, produced this clinical practice guideline to assist healthcare providers in VTE prevention. The expert part panel issued ten recommendations addressing 10 prioritized questions in the following areas: thromboprophylaxis in acutely ill medical patients (Recommendations 1-5), thromboprophylaxis in critically ill medical patients (Recommendations 6-9), and thromboprophylaxis in chronically ill patients (Recommendation 10). The corresponding recommendations were generated following the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach.
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Affiliation(s)
- Fahad M Al-Hameed
- Department of Intensive Care, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, National Guard Health Affairs, Jeddah, Kingdom of Saudi Arabia. E-mail.
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Beutel BG, Jenkins LS. Preventing venous thromboembolism at a district hospital: a quality improvement study. S Afr Fam Pract (2004) 2015. [DOI: 10.1080/20786190.2014.977033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Shiraev TP, Omari A, Rushworth RL. Incidence of deep venous thrombosis: a comparison of two Australian hospitals. Intern Med J 2014; 44:916-20. [PMID: 25201423 DOI: 10.1111/imj.12523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Accepted: 06/12/2014] [Indexed: 11/29/2022]
Abstract
In this retrospective observational study, we observed that principal and comorbid diagnoses of deep venous thrombosis (DVT) occurred at a rate of 1.02 and 4.86 per 1000 admissions. Principal DVT diagnosis admissions were more common in the public hospital (1.29 vs 0.57 per 1000; P < 0.001), while the private hospital had nearly three times the admissions with comorbid DVT (2.99 vs 8.23 per 1000; P < 0.001). In-hospital mortality was uncommon (0.2% and 1.6% for principal and comorbid DVT diagnoses, respectively), and this did not differ significantly between the two hospitals.
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Affiliation(s)
- T P Shiraev
- Department of Surgery, St George Hospital, Sydney, New South Wales, Australia
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Al-Hameed F, Al-Dorzi HM, Aboelnazer E. The effect of a continuing medical education program on Venous thromboembolism prophylaxis utilization and mortality in a tertiary-care hospital. Thromb J 2014; 12:9. [PMID: 24891840 PMCID: PMC4041361 DOI: 10.1186/1477-9560-12-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 02/20/2014] [Indexed: 11/10/2022] Open
Abstract
Background Venous thromboembolism (VTE) prophylaxis is underutilized for hospitalized patients. The primary objective of this study was to assess the impact of a continuing medical education (CME) program on thromboprophylaxis and VTE-associated mortality in a tertiary-care hospital. Methods This was a retrospective study of all patients admitted to a tertiary-care hospital from 01/07/2009 to 30/06/2010 (after a CME program that aimed at improving VTE prophylaxis) and had confirmed VTE during stay. VTE prophylaxis utilization and associated mortality were assessed in them and compared to those of a similar cohort of patients hospitalized in the previous 12 months. Results There were 147 confirmed VTE cases in the study period (surgical: 26.5% and medical: 73.5%). Most (63.9%) VTE patients received prophylaxis after the CME program compared with 36.5% in the previous 12 months (relative risk 1.73; 95% confidence interval, 1.38-2.18; P < 0.001). More surgical (82.1%) than medical (57.4%) patients received prophylaxis (P < 0.01). VTE-associated mortality rate was 10.9% with a significant decrease after the CME program (relative risk, 0.52; 95% confidence interval, 0.30-0.90). This mortality was lower for those who received VTE prophylaxis compared to those who didn’t (4.3% and 22.6%, respectively; P < 0.01). Additionally, VTE-associated deaths represented 1.1% of total hospital mortality compared to 1.9% in the 12 months before CME program (relative risk, 0.58; 95% confidence interval, 0.32-1.04; P = 0.07). Conclusions A CME educational program to improve VTE prophylaxis in a tertiary-care hospital was associated with improvement in VTE prophylaxis utilization and VTE-associated mortality. Such programs are highly recommended.
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Affiliation(s)
- Fahad Al-Hameed
- Department of Intensive Care, King Abdul-Aziz Medical City; College of Medicine, King Saud Bin Abdul-Aziz University for Health Sciences, National Guard Health Affairs, Jeddah, Saudi Arabia ; Saudi Association for Venous Thromboembolism (SAVTE), Jeddah, Saudi Arabia
| | - Hasan M Al-Dorzi
- Department of Intensive Care, King Abdulaziz Medical City and King Saud Bin Abdulaziz University for Health Sciences, College of Medicine, Riyadh, Saudi Arabia
| | - Essam Aboelnazer
- Department of Surgery, Medical College, University of Um Al-Qura, Mekkah, Saudi Arabia
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Al-Dorzi HM, Cherfan A, Al-Harbi S, Al-Askar A, Al-Azzam S, Hroub A, Olivier J, Al-Hameed F, Al-Moamary M, Abdelaal M, Poff GA, Arabi YM. Knowledge of thromboprophylaxis guidelines pre- and post-didactic lectures during a venous thromboembolism awareness day at a tertiary-care hospital. Ann Thorac Med 2013; 8:165-9. [PMID: 23922612 PMCID: PMC3731859 DOI: 10.4103/1817-1737.114298] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 03/17/2013] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND: Didactic lectures are frequently used to improve compliance with practice guidelines. This study assessed the knowledge of health-care providers (HCPs) at a tertiary-care hospital of its evidence-based thromboprophylaxis guidelines and the impact of didactic lectures on their knowledge. METHODS: The hospital launched a multifaceted approach to improve thromboprophylaxis practices, which included posters, a pocket-size guidelines summary and didactic lectures during the annual thromboprophylaxis awareness days. A self-administered questionnaire was distributed to HCPs before and after lectures on thromboprophylaxis guidelines (June 2010). The questionnaire, formulated and validated by two physicians, two nurses and a clinical pharmacist, covered various subjects such as risk stratification, anticoagulant dosing and the choice of anticoagulants in specific clinical situations. RESULTS: Seventy-two and 63 HCPs submitted the pre- and post-test, respectively (62% physicians, 28% nurses, from different clinical disciplines). The mean scores were 7.8 ± 2.1 (median = 8.0, range = 2-12, maximum possible score = 15) for the pre-test and 8.4 ± 1.8 for the post-test, P = 0.053. There was no significant difference in the pre-test scores of nurses and physicians (7.9 ± 1.7 and 8.2 ± 2.4, respectively, P = 0.67). For the 35 HCPs who completed the pre- and post-tests, their scores were 7.7 ± 1.7 and 8.8 ± 1.6, respectively, P = 0.003. Knowledge of appropriate anticoagulant administration in specific clinical situations was frequently inadequate, with approximately two-thirds of participants failing to adjust low-molecular-weight heparin doses in patients with renal failure. CONCLUSIONS: Education via didactic lectures resulted in a modest improvement of HCPs′ knowledge of thromboprophylaxis guidelines. This supports the need for a multifaceted approach to improve the awareness and implementation of thromboprophylaxis guidelines.
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Affiliation(s)
- Hasan M Al-Dorzi
- Department of Intensive Care, King Abdulaziz Medical City-Riyadh, Saudi Arabia ; College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, City-Riyadh Saudi Arabia
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Kahn SR, Morrison DR, Cohen JM, Emed J, Tagalakis V, Roussin A, Geerts W. Interventions for implementation of thromboprophylaxis in hospitalized medical and surgical patients at risk for venous thromboembolism. Cochrane Database Syst Rev 2013:CD008201. [PMID: 23861035 DOI: 10.1002/14651858.cd008201.pub2] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in hospitalized patients. Numerous randomized controlled trials (RCTs) show that using thromboprophylaxis in hospitalized patients at risk for VTE is safe, effective and cost-effective. Despite this, prophylactic therapies for VTE are underutilized. System-wide interventions may be more effective to improve the use of VTE prophylaxis than relying on individual providers' prescribing behaviors. OBJECTIVES To assess the effects of interventions designed to increase the implementation of thromboprophylaxis in hospitalized adult medical and surgical patients at risk for venous thromboembolism (VTE), assessed in terms of: 1. Increase in the proportion of patients who receive prophylaxis and appropriate prophylaxis 2. Reduction in risk of symptomatic VTE3. Reduction in risk of asymptomatic VTE4. Safety of the intervention. SEARCH METHODS The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator (TSC) searched the Group's Specialised Register (last searched July 2010) and the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library) 2010, Issue 3. We searched the PubMed, EMBASE, and SCOPUS databases (19 April 2010) as well as the reference lists of relevant review articles. SELECTION CRITERIA We included all studies whose interventions aimed to increase the use of prophylaxis and/or appropriate prophylaxis, decrease the proportion of symptomatic VTE, or decrease the proportion of asymptomatic VTE in hospitalized adult patients. We excluded studies that simply distributed published guidelines and studies whose interventions were not clearly described. DATA COLLECTION AND ANALYSIS We collected the following outcomes: the proportion of patients who received prophylaxis (RP), the proportion of patients who received appropriate prophylaxis (RAP) (primary outcomes), and the occurrence of symptomatic VTE, asymptomatic VTE, and safety outcomes such as bleeding. We categorized interventions into education, alerts, and multifaceted interventions. We meta-analyzed RCTs and non-randomized studies (NRS) separately by random effects meta-analysis, and assessed heterogeneity using the I(2)statistic and subgroup analyses. Before analysis, we decided that results would be pooled if three or more studies were available for a particular intervention. We assessed publication bias using funnel plots and cumulative meta-analysis. MAIN RESULTS We included a total of 55 studies. One of these reported data in patient-days and could not be quantitatively analyzed with the others. The 54 remaining studies (8 RCTs and 46 NRS) eligible for inclusion in our quantitative synthesis enrolled a total of 78,343 participants. Among RCTs, there were sufficient data to pool results for one primary outcome (received prophylaxis) for the 'alert' intervention. Alerts, such as computerized reminders or stickers on patients' charts, were associated with a risk difference (RD) of 13%, signifying an increase in the proportion of patients who received prophylaxis (95% confidence interval (CI) 1% to 25%). Among NRS, there were sufficient data to pool both primary outcomes for each intervention type. Pooled risk differences for received prophylaxis ranged from 8% to 17%, and for received appropriate prophylaxis ranged from 11% to 19%. Education and alerts were associated with statistically significant increases in prescription of appropriate prophylaxis, and multifaceted interventions were associated with statistically significant increases in prescription of any prophylaxis and appropriate prophylaxis. Multifaceted interventions had the largest pooled effects. I(2) results showed substantial statistical heterogeneity which was in part explained by patient types and type of hospital. A subgroup analysis showed that multifaceted interventions which included an alert may be more effective at improving rates of prophylaxis and appropriate prophylaxis than those without an alert. Results for VTE and safety outcomes did not show substantial benefits or harms, although most studies were underpowered to assess these outcomes. AUTHORS' CONCLUSIONS We reviewed a large number of studies which implemented a variety of system-wide strategies aimed to improve thromboprophylaxis rates in many settings and patient populations. We found statistically significant improvements in prescription of prophylaxis associated with alerts (RCTs) and multifaceted interventions (RCTs and NRS), and improvements in prescription of appropriate prophylaxis in NRS with the use of education, alerts and multifaceted interventions. Multifaceted interventions with an alert component may be the most effective. Demonstrated sources of heterogeneity included patient types and type of hospital. The results of our review will help physicians, nurses, pharmacists, hospital administrators and policy makers make practical decisions about local adoption of specific system-wide measures to improve prevention of VTE, an important public health issue. We did not find a significant benefit for VTE outcomes; however, earlier RCTs assessing the efficacy of thromboprophylaxis which were powered to address these outcomes have demonstrated the benefit of prophylactic therapies and a favourable balance of benefits versus the increased risk of bleeding events.
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Affiliation(s)
- Susan R Kahn
- Division of Internal Medicine and Department of Medicine, McGill University,Montreal, Canada.
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18
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Bateman AG, Sheaff R, Child S, Boiko O, Ukoumunne OC, Nokes T, Copplestone A, Gericke CA. The implementation of NICE guidance on venous thromboembolism risk assessment and prophylaxis: a before-after observational study to assess the impact on patient safety across four hospitals in England. BMC Health Serv Res 2013; 13:203. [PMID: 23734903 PMCID: PMC3716796 DOI: 10.1186/1472-6963-13-203] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Accepted: 06/01/2013] [Indexed: 12/04/2022] Open
Abstract
Background Venous thromboembolism (VTE) is a major cause of morbidity and mortality in hospitalised patients. VTE prevention has been identified as a major health need internationally to improve patient safety. A National Institute for Health and Clinical Excellence (NICE) guideline was issued in February 2010. Its key priorities were to assess patients for risk of VTE on admission to hospital, assess patients for bleeding risk and evaluate the risks and benefits of prescribing VTE prophylaxis. The aim of this study was to evaluate the implementation of NICE guidance and its impact on patient safety. Methods A before-after observational design was used to investigate changes in VTE risk assessment documentation and inappropriate prescribing of prophylaxis between the year prior to (2009) and the year following (2010) the implementation of NICE guidance, using data from a 3-week period during each year. A total of 408 patients were sampled in each year across four hospitals in the NHS South region. Results Implementation strategies such as audit, education and training were used. The percentage of patients for whom a VTE risk assessment was documented increased from 51.5% (210/408) in 2009 to 79.2% (323/408) in 2010; difference 27.7% (95% CI: 21.4% to 33.9%; p < 0.001). There was little evidence of change in the percentage who were prescribed prophylaxis amongst patients without a risk assessment (71.7% (142/198) in 2009 and 68.2% (58/85) in 2010; difference −3.5% (95% CI: -15.2% to 8.2%; p =0.56) nor the percentage who were prescribed low molecular weight heparin amongst patients with a contraindication (14% (4/28) in 2009 and 15% (6/41) in 2010; RD = 0.3% (95% CI: -16.5% to 17.2%; p =0.97). Conclusions The documentation of risk assessment improved following the implementation of NICE guidance; it is questionable, however, whether this led to improved patient safety with respect to prescribing appropriate prophylaxis.
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Affiliation(s)
- Alice G Bateman
- PenCLAHRC, National Institute for Health Research, Plymouth University Peninsula Schools of Medicine and Dentistry, N6 ITTC Building, Tamar Science Park, Derriford, Plymouth PL6 8BX, UK.
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19
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Abstract
Background Venous thromboembolism (VTE) is a common cause of preventable harm for hospitalised patients. Over the past decade, numerous intervention types have been implemented in attempts to improve the prescription of VTE prophylaxis in hospitals, with varying degrees of success. We reviewed key articles to assess the efficacy of different types of interventions to improve prescription of VTE prophylaxis for hospitalised patients. Methods We conducted a search of MEDLINE for key studies published between 2001 and 2012 of interventions employing education, paper based tools, computerised tools, real time audit and feedback, or combinations of intervention types to improve prescription of VTE prophylaxis for patients in hospital settings. Process outcomes of interest were prescription of any VTE prophylaxis and best practice VTE prophylaxis. Clinical outcomes of interest were any VTE and potentially preventable VTE, defined as VTE occurring in patients not prescribed appropriate prophylaxis. Results 16 articles were included in this review. Two studies employed education only, four implemented paper based tools, four used computerised tools, two evaluated audit and feedback strategies, and four studies used combinations of intervention types. Individual modalities result in improved prescription of VTE prophylaxis; however, the greatest and most sustained improvements were those that combined education with computerised tools. Conclusions Many intervention types have proven effective to different degrees in improving VTE prevention. Provider education is likely a required additional component and should be combined with other intervention types. Active mandatory tools are likely more effective than passive ones. Information technology tools that are well integrated into provider workflow, such as alerts and computerised clinical decision support, can improve best practice prophylaxis use and prevent patient harm resulting from VTE.
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Affiliation(s)
- Brandyn D Lau
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, , Baltimore, Maryland, USA
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Phillips NM, Heazlewood VJ. Venous thromboembolism prophylaxis audit in two Queensland hospitals. Intern Med J 2013; 43:560-6. [DOI: 10.1111/imj.12033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2012] [Accepted: 11/19/2012] [Indexed: 01/09/2023]
Affiliation(s)
- N. M. Phillips
- Department of Medicine; University of Queensland; Brisbane Queensland Australia
| | - V. J. Heazlewood
- Department of Medicine; Caboolture Hospital; Queensland Health; Brisbane Queensland Australia
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Mirkazemi C, Bereznicki LR, Peterson GM. Thromboprophylaxis following hip and knee arthroplasty. Intern Med J 2013; 43:124-9. [DOI: 10.1111/j.1445-5994.2013.02864.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Accepted: 05/31/2012] [Indexed: 12/01/2022]
Affiliation(s)
- C. Mirkazemi
- School of Pharmacy; University of Tasmania; Hobart; Tasmania; Australia
| | - L. R. Bereznicki
- School of Pharmacy; University of Tasmania; Hobart; Tasmania; Australia
| | - G. M. Peterson
- School of Pharmacy; University of Tasmania; Hobart; Tasmania; Australia
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Mirkazemi C, Bereznicki LR, Peterson GM. Are the national orthopaedic thromboprophylaxis guidelines appropriate? ANZ J Surg 2012; 82:913-7. [DOI: 10.1111/j.1445-2197.2012.06203.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2012] [Indexed: 11/26/2022]
Affiliation(s)
- Corinne Mirkazemi
- School of Pharmacy; University of Tasmania; Hobart; Tasmania; Australia
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Janus E, Bassi A, Jackson D, Nandurkar H, Yates M. Thromboprophylaxis use in medical and surgical inpatients and the impact of an electronic risk assessment tool as part of a multi-factorial intervention. A report on behalf of the elVis study investigators. J Thromb Thrombolysis 2012; 32:279-87. [PMID: 21643821 PMCID: PMC3170471 DOI: 10.1007/s11239-011-0602-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Venous thromboembolism (VTE) is a major source of morbidity and mortality for both surgical and medical hospitalised patients. Despite the availability of guidelines, thromboprophylaxis continues to be underutilised. This study aims to assess the effectiveness of an electronic VTE risk assessment tool (elVis) on VTE prophylaxis in hospitalised patients. A national, multicentre, prospective clinical audit collected information on VTE prophylaxis and risk factors for VTE in 2,400 hospitalised patients (comprising of equal numbers of medical, surgical and orthopaedic patients). After auditing the standard care use of VTE prophylaxis in 1,200 consecutive patients (audit 1, A1), the elVis system was installed and a second audit (A2) of VTE prophylaxis was performed in a further 1,200 patients. The use of the electronic VTE risk assessment tool was low with 20.5% of patients assessed with elVis. The intervention, elVis plus accompanying education, improved the use VTE prophylaxis to guidelines by 5.0% amongst all patients and by 10.7% amongst high risk patients (adjusted odds ratio (AOR) 1.27 and 1.65 respectively). The use of elVis in A2 varied between hospitals and specialties and this resulted in marked heterogeneity. Despite this heterogeneity, patients assessed with elVis had 1.44 times higher AOR of being treated to guidelines compared to those who were not (P < 0.05). The use of elVis accompanied by staff education improved VTE prophylaxis, especially amongst high risk patients. To optimise the effectiveness and support enduring practice change electronic systems, such as elVis, need to be completely integrated within the treatment pathway.
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Affiliation(s)
- Edward Janus
- Western Hospital, 469 Great Western Highway, Pendle Hill, NSW 2145, Australia.
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Polich AL, Etherton GM, Knezevich JT, Rousek JB, Masek CM, Hallbeck MS. Can eliminating risk stratification improve medical residents' adherence to venous thromboembolism prophylaxis? ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2011; 86:1518-1524. [PMID: 22030760 DOI: 10.1097/acm.0b013e318235c3f6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
PURPOSE Hospital-acquired venous thromboembolism (VTE) is a common and preventable adverse event that most patients are at risk of developing during their hospital stay. VTE prophylactic anticoagulation (chemoprophylaxis) is the preferred pharmacological assignment for reducing risk of VTE, but it is underused in current practices involving risk stratification (RS) for VTE prevention. The purpose of this study was to determine whether a protocol that eliminates the RS step (non-RS protocol) is more likely to lead residents to evidence-based VTE assignment than the currently used RS protocol. The non-RS protocol follows a methodology that reduces complexity by assuming that the risk of VTE is present and uses contraindications to determine appropriate VTE assignment. METHOD In 2009, 41 medicine residents at the Nebraska Western Iowa Veterans Affairs clinic participated in an online comparison of two different protocols (RS and non-RS) for assigning chemoprophylaxis for VTE. Six validated, hypothetical patient scenarios were used to compare appropriate (evidence-based) VTE assignments for VTE and completion times for each protocol. RESULTS Statistical analyses found that the non-RS protocol produced significantly faster (P < .001) scenario completion times and significantly more (P < .001) appropriate VTE assignments than the RS protocol for four of the six patient scenarios. CONCLUSIONS This study used a new, streamlined protocol (non-RS), which improved VTE assignment and the use of chemoprophylaxis and simplified the process when compared with the use of a traditional RS protocol.
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Affiliation(s)
- Ann L Polich
- Nebraska Western Iowa Veterans Affairs Health Care System and Division of General Internal Medicine, Creighton University School of Medicine, Omaha, Nebraska, USA
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Gibbs H, Fletcher J, Blombery P, Collins R, Wheatley D. Venous thromboembolism prophylaxis guideline implementation is improved by nurse directed feedback and audit. Thromb J 2011; 9:7. [PMID: 21466681 PMCID: PMC3080276 DOI: 10.1186/1477-9560-9-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Accepted: 04/05/2011] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a major health and financial burden. VTE impacts health outcomes in surgical and non-surgical patients. VTE prophylaxis is underutilized, particularly amongst high risk medical patients. We conducted a multicentre clinical audit to determine the extent to which appropriate VTE prophylaxis in acutely ill hospitalized medical patients could be improved via implementation of a multifaceted nurse facilitated educational program. METHODS This multicentre clinical audit of 15 Australian hospitals was conducted in 2007-208. The program incorporated a baseline audit to determine the proportion of patients receiving appropriate VTE prophylaxis according to best practice recommendations issued by the Australian and New Zealand Working Party on the Management and Prevention of Venous Thromboembolism (ANZ-WP recommendations), followed by a 4-month education intervention program and a post intervention audit. The primary endpoint was to compare the proportion of patients being appropriately managed based on their risk profile between the two audits. RESULTS A total of 8774 patients (audit 1; 4399 and audit 2; 4375) were included in the study, most (82.2% audit 1; and 81.0% audit 2) were high risk based on ANZ-WP recommendations. At baseline 37.9% of high risk patients were receiving appropriate thromboprophylaxis. This increased to 54.1% in the post intervention audit (absolute improvement 16%; 95% confidence interval [CI] 11.7%, 20.5%). As a result of the nurse educator program, the likelihood of high risk patients being treated according to ANZ-WP recommendations increased significantly (OR 1.96; 1.62, 2.37). CONCLUSION Utilization of VTE prophylaxis amongst hospitalized medical patients can be significantly improved by implementation of a multifaceted educational program coordinated by a dedicated nurse practitioner.
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Affiliation(s)
- Harry Gibbs
- Director of Cardiology, Lismore Base Hospital, Lismore, NSW, 2480 Australia
| | - John Fletcher
- Department of Surgery, Westmead Hospital, Westmead, NSW, 2145 Australia
| | - Peter Blombery
- Honorary Cardiovascular Physician, Heart Centre, The Alfred Hospital, Melbourne, VIC, 3181 Australia
| | - Renea Collins
- Vascular Medicine Unit, Princess Alexandra Hospital, Brisbane, QLD, 4000 Australia
| | - David Wheatley
- Medical Affairs Clinical Operations, sanofi aventis australia pty ltd, Maquarie Park, NSW, 2113 Australia
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Lesselroth BJ, Yang J, McConnachie J, Brenk T, Winterbottom L. Addressing the sociotechnical drivers of quality improvement: a case study of post-operative DVT prophylaxis computerised decision support. BMJ Qual Saf 2011; 20:381-9. [PMID: 21209144 PMCID: PMC3088464 DOI: 10.1136/bmjqs.2010.042689] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Quality improvement (QI) initiatives characterised by iterative cycles of quantitative data analysis do not readily explain the organisational determinants of change. However, the integration of sociotechnical theory can inform more effective strategies. Our specific aims were to (1) describe a computerised decision support intervention intended to improve adherence with deep venous thrombosis (DVT) prophylaxis recommendations; and (2) show how sociotechnical theory expressed in ‘Fit between Individuals, Task and Technology’ framework (FITT) can identify and clarify the facilitators and barriers to QI work. Methods A multidisciplinary team developed and implemented electronic menus with DVT prophylaxis recommendations. Stakeholders were interviewed and human factors were analysed to optimise integration. Menu exposure, order placement and clinical performance were measured. Vista tool extraction and chart review were used. Performance compliance pre-implementation was 77%. Results There were 80–110 eligible cases per month. Initial menu use rate was 20%. After barriers were classified and addressed using the FITT framework, use improved 50% to 90%. Tasks, users and technology issues in the FITT model and their interfaces were identified and addressed. Workflow styles, concerns about validity of guidelines, cycle times and perceived ambiguity of risk were issues identified. Conclusions DVT prophylaxis in a surgical setting is fraught with socio-political agendas, cognitive dissonance and misaligned expectations. These must be sought and articulated if organisations are to respond to internal resistance to change. This case study demonstrates that QI teams using information technology must understand the clinical context, even in mature electronic health record environments, in order to implement sustainable systems.
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Affiliation(s)
- Blake J Lesselroth
- Portland Oregon VA Medical Center, Oregon Health and Sciences University, Portland, Oregon, USA.
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Mahan CE, Spyropoulos AC. Venous thromboembolism prevention: a systematic review of methods to improve prophylaxis and decrease events in the hospitalized patient. Hosp Pract (1995) 2010; 38:97-108. [PMID: 20469630 DOI: 10.3810/hp.2010.02.284] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Prevention of venous thromboembolism (VTE) is currently a key initiative internationally and in US hospitals, where there has been a recent focus on national quality initiatives to prevent hospital-acquired VTE. Multiple strategies exist to prevent VTE by increasing prophylaxis rates in the hospitalized setting. Active, multifaceted interventions, including provider education, an active reminder to the provider, and regular audit and feedback to medical and hospital staff, appear to be the most effective current interventions. Active intervention programs have been validated both as electronic alerts, with or without computerized clinical decision support software and, more recently, human alerts, many of which utilize in-hospital pharmacists. A passive strategy, such as guideline dissemination, should not be used as a lone method. Although inappropriate duration remains a key reason as to why at-risk patients do not receive appropriate thromboprophylaxis within the hospital (defined by type, dose, and duration of prophylaxis), few studies address duration compared with hospital length of stay. Preventable VTE is a new quality outcome measure for hospitals but is measured in few studies. Future studies should focus on comparing various multifaceted interventions to assess their effect over time, including endpoints of bleeding for safety, appropriate type, dose, and duration of prophylaxis, overall and preventable VTE, and the impact on unnecessary prophylaxis for patients not at risk.
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Affiliation(s)
- Charles E Mahan
- Cardinal Health Pharmacy Solutions, Lovelace Medical Center, Albuquerque, NM 87102, USA.
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