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Lau BD, Shaffer DL, Kraus PS, Owodunni OP, Kia MV, Chiochetti SJ, Streiff MB, Haut ER. Prevention of Hospital-Associated Venous Thromboembolism: A Road Map to Defect-Free Care. Qual Manag Health Care 2023; 32:281-282. [PMID: 37651594 PMCID: PMC10543538 DOI: 10.1097/qmh.0000000000000436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Affiliation(s)
- Brandyn D Lau
- Russell H. Morgan Department of Radiology and Radiological Science (Mr Lau), Division of Acute Care Surgery, Department of Surgery (Ms Shaffer and Drs Chiochetti and Haut), Division of Hematology, Department of Medicine (Dr Streiff), Department of Anesthesiology and Critical Care Medicine (Dr Haut), and Department of Emergency Medicine (Dr Haut), The Johns Hopkins University School of Medicine, Baltimore, Maryland; The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland (Mr Lau and Drs Streiff and Haut); Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Mr Lau and Dr Haut); Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland (Dr Kraus); Department of Emergency Medicine, University of New Mexico Hospital, Albuquerque (Dr Owodunni); and Dr Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Davie, Florida (Ms Kia)
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Haut ER, Owodunni OP, Wang J, Shaffer DL, Hobson DB, Yenokyan G, Kraus PS, Farrow NE, Canner JK, Florecki KL, Webster KLW, Holzmueller CG, Aboagye JK, Popoola VO, Kia MV, Pronovost PJ, Streiff MB, Lau BD. Alert-Triggered Patient Education Versus Nurse Feedback for Nonadministered Venous Thromboembolism Prophylaxis Doses: A Cluster-Randomized Controlled Trial. J Am Heart Assoc 2022; 11:e027119. [PMID: 36047732 DOI: 10.1161/jaha.122.027119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Many hospitalized patients are not administered prescribed doses of pharmacologic venous thromboembolism prophylaxis. Methods and Results In this cluster-randomized controlled trial, all adult non-intensive care units (10 medical, 6 surgical) in 1 academic hospital were randomized to either a real-time, electronic alert-triggered, patient-centered education bundle intervention or nurse feedback intervention to evaluate their effectiveness for reducing nonadministration of venous thromboembolism prophylaxis. Primary outcome was the proportion of nonadministered doses of prescribed pharmacologic prophylaxis. Secondary outcomes were proportions of nonadministered doses stratified by nonadministration reasons (patient refusal, other). To test our primary hypothesis that both interventions would reduce nonadministration, we compared outcomes pre- versus postintervention within each cohort. Secondary hypotheses were tested comparing the effectiveness between cohorts. Of 11 098 patient visits, overall dose nonadministration declined significantly after the interventions (13.4% versus 9.2%; odds ratio [OR], 0.64 [95% CI, 0.57-0.71]). Nonadministration decreased significantly (P<0.001) in both arms: patient-centered education bundle, 12.2% versus 7.4% (OR, 0.56 [95% CI, 0.48-0.66]), and nurse feedback, 14.7% versus 11.2% (OR, 0.72 [95% CI, 0.62-0.84]). Patient refusal decreased significantly in both arms: patient-centered education bundle, 7.3% versus 3.7% (OR, 0.46 [95% CI, 0.37-0.58]), and nurse feedback, 9.5% versus 7.1% (OR, 0.71 [95% CI, 0.59-0.86]). No differential effect occurred on medical versus surgical units. The patient-centered education bundle was significantly more effective in reducing all nonadministered (P=0.03) and refused doses (P=0.003) compared with nurse feedback (OR, 1.28 [95% CI, 1.0-1.61]; P=0.03 for interaction). Conclusions Information technology strategies like the alert-triggered, targeted patient-centered education bundle, and nurse-focused audit and feedback can improve venous thromboembolism prophylaxis administration. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03367364.
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Affiliation(s)
- Elliott R Haut
- Department of Surgery Johns Hopkins University School of Medicine Baltimore MD.,Department of Anesthesiology and Critical Care Medicine Johns Hopkins University School of Medicine Baltimore MD.,Department of Emergency Medicine Johns Hopkins University School of Medicine Baltimore MD.,The Johns Hopkins Surgery Center for Outcomes Research Johns Hopkins University School of Medicine Baltimore MD.,Armstrong Institute for Patient Safety and Quality Johns Hopkins Medicine Baltimore MD.,Department of Health Policy and Management Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | | | - Jiangxia Wang
- Department of Biostatistics Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Dauryne L Shaffer
- Department of Surgery Johns Hopkins University School of Medicine Baltimore MD.,Department of Nursing The Johns Hopkins Hospital Baltimore MD
| | - Deborah B Hobson
- Department of Surgery Johns Hopkins University School of Medicine Baltimore MD.,Armstrong Institute for Patient Safety and Quality Johns Hopkins Medicine Baltimore MD.,Department of Nursing The Johns Hopkins Hospital Baltimore MD
| | - Gayane Yenokyan
- Department of Biostatistics Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Peggy S Kraus
- Department of Pharmacy The Johns Hopkins Hospital Baltimore MD
| | - Norma E Farrow
- Department of Surgery Duke University Medical Center Durham NC
| | - Joseph K Canner
- The Johns Hopkins Surgery Center for Outcomes Research Johns Hopkins University School of Medicine Baltimore MD
| | | | - Kristen L W Webster
- Department of Anesthesiology and Critical Care Medicine Johns Hopkins University School of Medicine Baltimore MD
| | - Christine G Holzmueller
- Department of Surgery Johns Hopkins University School of Medicine Baltimore MD.,Armstrong Institute for Patient Safety and Quality Johns Hopkins Medicine Baltimore MD
| | - Jonathan K Aboagye
- Department of Surgery Johns Hopkins University School of Medicine Baltimore MD
| | - Victor O Popoola
- Department of Biostatistics Johns Hopkins Bloomberg School of Public Health Baltimore MD.,Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Mujan Varasteh Kia
- Department of Surgery Johns Hopkins University School of Medicine Baltimore MD
| | - Peter J Pronovost
- Department of Surgery Johns Hopkins University School of Medicine Baltimore MD.,Armstrong Institute for Patient Safety and Quality Johns Hopkins Medicine Baltimore MD.,Department of Health Policy and Management Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Michael B Streiff
- Division of Hematology, Department of Medicine Johns Hopkins University School of Medicine Baltimore MD.,Armstrong Institute for Patient Safety and Quality Johns Hopkins Medicine Baltimore MD
| | - Brandyn D Lau
- Division of Health Sciences Informatics, Russell H. Morgan Department of Radiology and Radiological Science Johns Hopkins University School of Medicine Baltimore MD.,Armstrong Institute for Patient Safety and Quality Johns Hopkins Medicine Baltimore MD.,Department of Health Policy and Management Johns Hopkins Bloomberg School of Public Health Baltimore MD
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Owodunni OP, Lau BD, Wang J, Shaffer DL, Kraus PS, Holzmueller CG, Aboagye JK, Hobson DB, Varasteh Kia M, Armocida S, Streiff MB, Haut ER. Effectiveness of a Patient Education Bundle on Venous Thromboembolism Prophylaxis Administration by Sex. J Surg Res 2022; 280:151-162. [PMID: 35969933 DOI: 10.1016/j.jss.2022.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 07/14/2022] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Venous thromboembolism (VTE) is a frequent cause of preventable harm among hospitalized patients. Many prescribed prophylaxis doses are not administered despite supporting evidence. We previously demonstrated a patient-centered education bundle improved VTE prophylaxis administration broadly; however, patient-specific factors driving nonadministration are unclear. We examine the effects of the education bundle on missed doses of VTE prophylaxis by sex. METHODS We performed a post-hoc analysis of a nonrandomized controlled trial to evaluate the differences in missed doses by sex. Pre-intervention and intervention periods for patients admitted to 16 surgical and medical floors between 10/2014-03/2015 (pre-intervention) and 04/2015-12/2015 (intervention) were compared. We examined the conditional odds of (1) overall missed doses, (2) missed doses due to patient refusal, and (3) missed doses for other reasons. RESULTS Overall, 16,865 patients were included (pre-intervention 6853, intervention 10,012), with 2350 male and 2460 female patients (intervention), and 6373 male and 5682 female patients (control). Any missed dose significantly reduced on the intervention floors among male (odds ratio OR 0.55; 95% confidence interval CI, 0.44-0.70, P < 0.001) and female (OR 0.59; 95% CI, 0.47-0.73, P < 0.001) patients. Similar significant reductions ensued for missed doses due to patient refusal (P < 0.001). Overall, there were no sex-specific differences (P-interaction >0.05). CONCLUSIONS Our intervention increased VTE prophylaxis administration for both female and male patients, driven by decreased patient refusal. Patient education should be applicable to a wide range of patient demographics representative of the target group. To improve future interventions, quality improvement efforts should be evaluated based on patient demographics and drivers of differences in care.
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Affiliation(s)
- Oluwafemi P Owodunni
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brandyn D Lau
- 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; The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medicine, Baltimore, Maryland; Department of Health Policy and Management, The Johns Hopkins University School of Public Health, Baltimore, Maryland
| | - Jiangxia Wang
- Department of Biostatistics, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Dauryne L Shaffer
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland; Department of Nursing, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Peggy S Kraus
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Christine G Holzmueller
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland; The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medicine, Baltimore, Maryland
| | - Jonathan K Aboagye
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah B Hobson
- The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medicine, Baltimore, Maryland; Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Mujan Varasteh Kia
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stephanie Armocida
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael B Streiff
- The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medicine, Baltimore, Maryland; Division of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elliott R Haut
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland; The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medicine, Baltimore, Maryland; Department of Health Policy and Management, The Johns Hopkins University School of Public Health, Baltimore, Maryland; Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland; The Johns Hopkins Surgery Center for Outcomes Research, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Aboagye JK, Haut ER, Streiff MB, Hobson DB, Kraus PS, Shaffer DL, Holzmueller CG, Lau BD. Audit and Feedback to Surgery Interns and Residents on Prescribing Risk-Appropriate Venous Thromboembolism Prophylaxis. J Surg Educ 2021; 78:2011-2019. [PMID: 33879395 DOI: 10.1016/j.jsurg.2021.03.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 03/19/2021] [Accepted: 03/20/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of feedback using an emailed scorecard and a web-based dashboard on risk-appropriate VTE prophylaxis prescribing practices among general surgery interns and residents. DESIGN Prospective cohort study. SETTING The Johns Hopkins Hospital, an urban academic medical center. PARTICIPANTS All 45 trainees (19 post-graduate year [PGY] 1 interns and 26 PGY-2 to PGY-5 residents) in our general surgery program. INTERVENTION Feedback implementation encompassed three sequential periods: (1) scorecard (July 1, 2014 through June 30, 2015); (2) no feedback/wash-in (July 1 through October 31, 2015); and (3) web-based dashboard (November 1, 2015 through June 30, 2016). No feedback served as the baseline period for the intern cohort. The scorecard was a static document showing an individual's compliance with risk-appropriate VTE prophylaxis prescription compared to compliance of their de-identified peers. The web-based dashboard included other information (e.g., patient details for suboptimal prophylaxis orders) besides individual compliance compared to their de-identified peers. Trainees could access the dashboard anytime to view current and historic performance. We sent monthly emails to all trainees for both feedback mechanisms. Main outcome was proportion of patients prescribed risk-appropriate VTE prophylaxis, and mean percentages reported. RESULTS During this study, 4088 VTE prophylaxis orders were placed. Among residents, mean prescription of risk-appropriate prophylaxis was higher in the wash-in (98.4% vs 95.6%, p < 0.001) and dashboard (98.4 vs 95.6%, p < 0.001) periods compared to the scorecard period. There was no difference in mean compliance between the wash-in and dashboard periods (98.4% vs 98.4%, p = 0.99). Among interns, mean prescription of risk-appropriate VTE prophylaxis improved between the wash-in and dashboard periods (91.5% vs 96.4%, p < 0.001). CONCLUSIONS AND RELEVANCE Using audit and individualized performance feedback to general surgery trainees through a web-based dashboard improved prescribing of appropriate VTE prophylaxis to a near-perfect performance.
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Affiliation(s)
- Jonathan K Aboagye
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elliott R Haut
- Division of Acute Care Surgery, Department of Surgery; Department of Anesthesiology and Critical Care Medicine; Department of Emergency Medicine; Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
| | - Michael B Streiff
- Division of Hematology, Department of Medicine; Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah B Hobson
- Department of Nursing, The Johns Hopkins Hospital; Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Peggy S Kraus
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Dauryne L Shaffer
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine; Department of Nursing, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Christine G Holzmueller
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brandyn D Lau
- Russell H. Morgan Department of Radiology and Radiological Science; Division of Health Sciences Informatics; Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Owodunni OP, Lau BD, Florecki KL, Webster KLW, Shaffer DL, Hobson DB, Kraus PS, Holzmueller CG, Canner JK, Streiff MB, Haut ER. Systematic Undercoding of Diagnostic Procedures in National Inpatient Sample (NIS): A Threat to Validity Due to Surveillance Bias. Qual Manag Health Care 2021; 30:226-232. [PMID: 34232138 DOI: 10.1097/qmh.0000000000000297] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Health services research often relies on readily available data, originally collected for administrative purposes and used for public reporting and pay-for-performance initiatives. We examined the prevalence of underreporting of diagnostic procedures for acute myocardial infarction (AMI), deep venous thrombosis (DVT), and pulmonary embolism (PE), used for public reporting and pay-for-performance initiatives. METHOD We retrospectively identified procedures for AMI, DVT, and PE in the National Inpatient Sample (NIS) database between 2012 and 2016. From January 1, 2012, through September 30, 2015, the NIS used the International Classification of Diseases, Ninth Revision (ICD-9) coding scheme. From October 1, 2015, through December 31, 2016, the NIS used the International Classification of Diseases, Tenth Revision (ICD-10) coding scheme. We grouped the data by ICD code definitions (ICD-9 or ICD-10) to reflect these code changes and to prevent any confounding or misclassification. In addition, we used survey weighting to examine the utilization of venous duplex ultrasound scan for DVT, electrocardiogram (ECG) for AMI, and chest computed tomography (CT) scan, pulmonary angiography, echocardiography, and nuclear medicine ventilation/perfusion () scan for PE. RESULTS In the ICD-9 period, by primary diagnosis, only 0.26% (n = 5930) of patients with reported AMI had an ECG. Just 2.13% (n = 7455) of patients with reported DVT had a peripheral vascular ultrasound scan. For patients with PE diagnosis, 1.92% (n = 12 885) had pulmonary angiography, 3.92% (n = 26 325) had CT scan, 5.31% (n = 35 645) had cardiac ultrasound scan, and 0.45% (n = 3025) had scan. In the ICD-10 period, by primary diagnosis, 0.04% (n = 345) of reported AMI events had an ECG and 0.91% (n = 920) of DVT events had a peripheral vascular ultrasound scan. For patients with PE diagnosis, 2.08% (n = 4805) had pulmonary angiography, 0.63% (n = 1460) had CT scan, 1.68% (n = 3890) had cardiac ultrasound scan, and 0.06% (n = 140) had scan. Small proportions of diagnostic procedures were observed for any diagnoses of AMI, DVT, or PE. CONCLUSIONS Our findings question the validity of using NIS and other administrative databases for health services and outcomes research that rely on certain diagnostic procedures. Unfortunately, the NIS does not provide granular data that can control for differences in diagnostic procedure use, which can lead to surveillance bias. Researchers and policy makers must understand and acknowledge the limitations inherent in these databases, when used for pay-for-performance initiatives and hospital benchmarking.
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Affiliation(s)
- Oluwafemi P Owodunni
- Division of Acute Care Surgery, Department of Surgery (Drs Owodunni, Florecki, Webster, and Haut and Ms Holzmueller), Department of Surgery (Mss Shaffer and Hobson), Department of Anesthesiology and Critical Care Medicine (Dr Haut), and Department of Emergency Medicine (Dr Haut), The Johns Hopkins Surgery Center for Outcomes Research, Baltimore, Maryland (Mr Canner); Division of Hematology, Department of Medicine (Dr Streiff), Russell H. Morgan Department of Radiology and Radiological Science (Mr Lau), and Division of Health Sciences Informatics (Mr Lau), The Johns Hopkins University School of Medicine, Baltimore, Maryland; Departments of Nursing (Mss Shaffer and Hobson) and Pharmacy (Dr Kraus), The Johns Hopkins Hospital, Baltimore, Maryland; The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland (Drs Haut and Streiff, Mss Hobson and Holzmueller, and Mr Lau); and Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Dr Haut and Mr Lau)
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Eisenson DL, Owodunni OP, Lau BD, Kia MV, Kraus PS, Holzmueller CG, Shaffer DL, Streiff MB, Haut ER. Prevalence and consequences of empiric anticoagulation for venous thromboembolism in patients hospitalized for COVID-19: a cautionary tale. J Thromb Thrombolysis 2021; 52:1056-1060. [PMID: 33939101 PMCID: PMC8091642 DOI: 10.1007/s11239-021-02471-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2021] [Indexed: 01/20/2023]
Affiliation(s)
| | | | - Brandyn D Lau
- Russell H. Morgan Department of Radiology and Radiological Science, Baltimore, MD, USA.,Division of Health Sciences Informatics, Baltimore, MD, USA.,The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Sheikh Zayed 6107C, 1800 Orleans St, Baltimore, MD, 21287, USA.,Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mujan Varasteh Kia
- Division of Acute Care Surgery, Department of Surgery, Baltimore, MD, USA
| | | | - Christine G Holzmueller
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Sheikh Zayed 6107C, 1800 Orleans St, Baltimore, MD, 21287, USA
| | - Dauryne L Shaffer
- Department of Surgery, Baltimore, MD, USA.,Department of Nursing, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Michael B Streiff
- Division of Hematology, Department of Medicine, Baltimore, MD, USA.,The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Sheikh Zayed 6107C, 1800 Orleans St, Baltimore, MD, 21287, USA
| | - Elliott R Haut
- Division of Acute Care Surgery, Department of Surgery, Baltimore, MD, USA. .,Department of Anesthesiology and Critical Care Medicine, Baltimore, MD, USA. .,Department of Emergency Medicine, Baltimore, MD, USA. .,The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Sheikh Zayed 6107C, 1800 Orleans St, Baltimore, MD, 21287, USA. .,Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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7
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Varasteh Kia M, Lau BD, Owodunni OP, Kraus PS, Holzmueller CG, Hobson DB, Shaffer DL, Streiff MB, Haut ER. Nonadministration of pharmacologic venous thromboembolism prophylaxis is less common in hospitalized patients with COVID-19. J Thromb Thrombolysis 2021; 52:471-475. [PMID: 33507453 PMCID: PMC7840619 DOI: 10.1007/s11239-021-02384-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2021] [Indexed: 12/28/2022]
Abstract
Introduction The incidence of venous thromboembolism (VTE) in patients hospitalized with COVID-19 is higher than most other hospitalized patients. Nonadministration of pharmacologic VTE prophylaxis is common and is associated with VTE events. Our objective was to determine whether nonadministration of pharmacologic VTE prophylaxis is more common in patients with COVID-19 versus other hospitalized patients. Materials and methods In this retrospective cohort analysis of all adult patients discharged from the Johns hopkins hospital between Mar 1 and May 12, 2020, we compared demographic, clinical characteristics, VTE outcomes, prescription and administration of VTE prophylaxis between COVID-19 positive, negative, and not tested groups. Results Patients tested positive for COVID-19 were significantly older, and more likely to be Hispanic, have a higher median body mass index, have longer hospital length of stay, require mechanical ventilation, develop pulmonary embolism and die (all p < 0.001). COVID-19 patients were more likely to be prescribed (aOR 1.51, 95% CI 1.38–1.66) and receive all doses of prescribed pharmacologic VTE prophylaxis (aOR 1.48, 95% CI 1.36–1.62). The number of patients who missed at least one dose of VTE prophylaxis and developed VTE was similar between the three groups (p = 0.31). Conclusions It is unlikely that high rates of VTE in COVID-19 are due to nonadministration of doses of pharmacologic prophylaxis. Hence, we should prioritize research into alternative approaches to optimizing VTE prevention in patients with COVID-19.
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Affiliation(s)
- Mujan Varasteh Kia
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Brandyn D. Lau
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD USA
- Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, MD USA
- The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Oluwafemi P. Owodunni
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Peggy S. Kraus
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD USA
| | - Christine G. Holzmueller
- The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD USA
| | - Deborah B. Hobson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD USA
- The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD USA
- Department of Nursing, The Johns Hopkins Hospital, Baltimore, MD USA
| | - Dauryne L. Shaffer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD USA
- Department of Nursing, The Johns Hopkins Hospital, Baltimore, MD USA
| | - Michael B. Streiff
- The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD USA
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Elliott R. Haut
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD USA
- The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD USA
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD USA
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD USA
- The Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Sheikh Zayed 6107C, 1800 Orleans St., Baltimore, MD 21287 USA
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8
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Owodunni OP, Lau BD, Shaffer DL, McQuigg D, Samuel D, Kantsiper M, Harris JE, Hobson DB, Kraus PS, Webster KLW, Holzmueller CG, Kia MV, Streiff MB, Haut ER. Disseminating a patient-centered education bundle to reduce missed doses of pharmacologic venous thromboembolism (VTE) prophylaxis to a community hospital. Journal of Patient Safety and Risk Management 2020. [DOI: 10.1177/2516043520969324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Venous thromboembolism (VTE) is a leading cause of preventable harm in hospitalized patients. However, many doses of prescribed pharmacologic VTE prophylaxis are frequently missed. We investigated the effect of a patient-centered education bundle on missed doses of VTE prophylaxis in a community hospital. Methods We performed a pre-post analysis examining missed doses of VTE prophylaxis in a community hospital. A real-time alert from the electronic health record system facilitated the delivery of a patient education bundle intervention. We included all patient visits on a single floor where at least 1 dose of VTE prophylaxis was prescribed during pre- (January 1, 2018, - November 31, 2018) and post- (January 1 - June 31, 2019) intervention periods. Outcomes included any missed dose (primary) and reasons for missed doses (refusal, other [secondary]) and were compared between both periods. Results 1,614 patient visits were included. The proportion of any missed dose significantly decreased (13.8% vs. 8.2% [OR, 0.56; 95% CI, 0.48, 0.64]) between the pre-post intervention periods. Patient refusal was the most frequent reason for missed doses. In the post-intervention period, patient refusal significantly decreased from 8.8% to 5.0% (OR, 0.54; 95% CI, 0.46, 0.64). Similarly, other reasons for missed doses significantly decreased from 5.0% to 3.2% (OR, 0.62; 95% CI, 0.51, 0.77). Conclusions A real-time alert-triggered patient-centered education bundle developed and tested in an academic hospital, significantly reduced missed doses of prescribed pharmacologic VTE prophylaxis when disseminated to a community hospital.
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Affiliation(s)
- Oluwafemi P Owodunni
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Brandyn D Lau
- Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, USA
- Division of Health Sciences Informatics, The Johns Hopkins University School of Medicine, Baltimore, USA
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Dauryne L Shaffer
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, USA
- Department of Nursing, The Johns Hopkins Hospital, Baltimore, USA
| | - Danielle McQuigg
- Howard County General Hospital, Johns Hopkins Medicine, Baltimore, USA
| | - Deborah Samuel
- Howard County General Hospital, Johns Hopkins Medicine, Baltimore, USA
| | - Mindy Kantsiper
- Howard County General Hospital, Johns Hopkins Medicine, Baltimore, USA
| | - James E Harris
- Howard County General Hospital, Johns Hopkins Medicine, Baltimore, USA
| | - Deborah B Hobson
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, USA
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, USA
- Department of Nursing, The Johns Hopkins Hospital, Baltimore, USA
| | - Peggy S Kraus
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, USA
| | - Kristen LW Webster
- Process Improvement Department, University of Louisville, Louisville, USA
| | - Christine G Holzmueller
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, USA
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, USA
| | - Mujan Varasteh Kia
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Michael B Streiff
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, USA
- Division of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Elliott R Haut
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, USA
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, USA
- Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, USA Baltimore, USA
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Lau BD, Murphy P, Nastasi AJ, Seal S, Kraus PS, Hobson DB, Shaffer DL, Holzmueller CG, Aboagye JK, Streiff MB, Haut ER. Effectiveness of ambulation to prevent venous thromboembolism in patients admitted to hospital: a systematic review. CMAJ Open 2020; 8:E832-E843. [PMID: 33293333 PMCID: PMC7743906 DOI: 10.9778/cmajo.20200003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Patient ambulation is frequently recommended to help prevent venous thromboembolism during hospital admission. Our objective was to synthesize the evidence for ambulation as a prophylaxis for venous thromboembolism in hospital. METHODS We conducted a systematic review. We searched MEDLINE, Embase, Scopus, Web of Science and Cochrane Central Register of Controlled Trials indexed from their inception through April 2020 for studies of adult patients admitted to hospital, in which ambulation or mobilization alone or concomitant with prophylaxis was indicated for prevention of venous thromboembolism. We searched ClinicalTrials.gov for unpublished trials. We included randomized controlled trials (RCTs) and observational studies. Two reviewers independently screened articles and assessed risk of bias using 2 validated tools. We scored studies on quality of reporting, internal and external validity and study power; combined scores determined the overall quality. RESULTS Eighteen articles met the inclusion criteria: 8 retrospective and 2 prospective cohorts, 7 RCTs and 1 secondary analysis of an RCT. The intervention (ambulation or mobilized) groups varied across studies. Five studies examined exercise as a therapeutic prophylaxis for thrombosis and 9 described an ambulation protocol. Five studies attempted to quantify amount and duration of patient ambulation and 3 reported ambulation distance. In the 5 studies rated as good or excellent statistical quality, findings were mixed. Incidence of venous thromboembolism was lowest when pharmacologic anticoagulants were added as part of the prescribed prophylaxis regimen. INTERPRETATION We did not find high-quality evidence supporting ambulation alone as an effective prophylaxis for venous thromboembolism. Ambulation should not be considered an adequate prophylaxis for venous thromboembolism, nor as an adequate reason to discontinue pharmacologic prophylaxis for venous thromboembolism during a patient's hospital admission.
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Affiliation(s)
- Brandyn D Lau
- Russell H. Morgan Department of Radiology and Radiological Science (Lau), Johns Hopkins University School of Medicine; Armstrong Institute for Patient Safety and Quality (Lau, Holzmueller, Streiff), Johns Hopkins Medicine, Baltimore, Md.; Department of Surgery (Murphy), Indiana University, Indianapolis, Ind.; Division of Acute Care Surgery, Medical College of Wisconsin, Wauwatosa, Wis.; London Health Sciences Centre, London, Ont. and Department of Surgery, Indiana University, (Murphy; during the conduct of the study); School of Medicine (Nastasi), Stanford University, Li Ka Shing Building, Stanford, Calif.; Welch Medical Library (Seal), Johns Hopkins University School of Medicine; Department of Pharmacy (Kraus), Johns Hopkins Hospital; Division of Acute Care Surgery (Hobson, Aboagye, Haut), Department of Surgery, School of Medicine, Johns Hopkins University; Department of Nursing (Hobson), Johns Hopkins Hospital; Department of Nursing (Shaffer), Johns Hopkins Hospital; Division of Hematology (Streiff), Department of Medicine, Johns Hopkins University School of Medicine; Department of Health Policy and Management (Haut), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Patrick Murphy
- Russell H. Morgan Department of Radiology and Radiological Science (Lau), Johns Hopkins University School of Medicine; Armstrong Institute for Patient Safety and Quality (Lau, Holzmueller, Streiff), Johns Hopkins Medicine, Baltimore, Md.; Department of Surgery (Murphy), Indiana University, Indianapolis, Ind.; Division of Acute Care Surgery, Medical College of Wisconsin, Wauwatosa, Wis.; London Health Sciences Centre, London, Ont. and Department of Surgery, Indiana University, (Murphy; during the conduct of the study); School of Medicine (Nastasi), Stanford University, Li Ka Shing Building, Stanford, Calif.; Welch Medical Library (Seal), Johns Hopkins University School of Medicine; Department of Pharmacy (Kraus), Johns Hopkins Hospital; Division of Acute Care Surgery (Hobson, Aboagye, Haut), Department of Surgery, School of Medicine, Johns Hopkins University; Department of Nursing (Hobson), Johns Hopkins Hospital; Department of Nursing (Shaffer), Johns Hopkins Hospital; Division of Hematology (Streiff), Department of Medicine, Johns Hopkins University School of Medicine; Department of Health Policy and Management (Haut), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Anthony J Nastasi
- Russell H. Morgan Department of Radiology and Radiological Science (Lau), Johns Hopkins University School of Medicine; Armstrong Institute for Patient Safety and Quality (Lau, Holzmueller, Streiff), Johns Hopkins Medicine, Baltimore, Md.; Department of Surgery (Murphy), Indiana University, Indianapolis, Ind.; Division of Acute Care Surgery, Medical College of Wisconsin, Wauwatosa, Wis.; London Health Sciences Centre, London, Ont. and Department of Surgery, Indiana University, (Murphy; during the conduct of the study); School of Medicine (Nastasi), Stanford University, Li Ka Shing Building, Stanford, Calif.; Welch Medical Library (Seal), Johns Hopkins University School of Medicine; Department of Pharmacy (Kraus), Johns Hopkins Hospital; Division of Acute Care Surgery (Hobson, Aboagye, Haut), Department of Surgery, School of Medicine, Johns Hopkins University; Department of Nursing (Hobson), Johns Hopkins Hospital; Department of Nursing (Shaffer), Johns Hopkins Hospital; Division of Hematology (Streiff), Department of Medicine, Johns Hopkins University School of Medicine; Department of Health Policy and Management (Haut), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Stella Seal
- Russell H. Morgan Department of Radiology and Radiological Science (Lau), Johns Hopkins University School of Medicine; Armstrong Institute for Patient Safety and Quality (Lau, Holzmueller, Streiff), Johns Hopkins Medicine, Baltimore, Md.; Department of Surgery (Murphy), Indiana University, Indianapolis, Ind.; Division of Acute Care Surgery, Medical College of Wisconsin, Wauwatosa, Wis.; London Health Sciences Centre, London, Ont. and Department of Surgery, Indiana University, (Murphy; during the conduct of the study); School of Medicine (Nastasi), Stanford University, Li Ka Shing Building, Stanford, Calif.; Welch Medical Library (Seal), Johns Hopkins University School of Medicine; Department of Pharmacy (Kraus), Johns Hopkins Hospital; Division of Acute Care Surgery (Hobson, Aboagye, Haut), Department of Surgery, School of Medicine, Johns Hopkins University; Department of Nursing (Hobson), Johns Hopkins Hospital; Department of Nursing (Shaffer), Johns Hopkins Hospital; Division of Hematology (Streiff), Department of Medicine, Johns Hopkins University School of Medicine; Department of Health Policy and Management (Haut), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Peggy S Kraus
- Russell H. Morgan Department of Radiology and Radiological Science (Lau), Johns Hopkins University School of Medicine; Armstrong Institute for Patient Safety and Quality (Lau, Holzmueller, Streiff), Johns Hopkins Medicine, Baltimore, Md.; Department of Surgery (Murphy), Indiana University, Indianapolis, Ind.; Division of Acute Care Surgery, Medical College of Wisconsin, Wauwatosa, Wis.; London Health Sciences Centre, London, Ont. and Department of Surgery, Indiana University, (Murphy; during the conduct of the study); School of Medicine (Nastasi), Stanford University, Li Ka Shing Building, Stanford, Calif.; Welch Medical Library (Seal), Johns Hopkins University School of Medicine; Department of Pharmacy (Kraus), Johns Hopkins Hospital; Division of Acute Care Surgery (Hobson, Aboagye, Haut), Department of Surgery, School of Medicine, Johns Hopkins University; Department of Nursing (Hobson), Johns Hopkins Hospital; Department of Nursing (Shaffer), Johns Hopkins Hospital; Division of Hematology (Streiff), Department of Medicine, Johns Hopkins University School of Medicine; Department of Health Policy and Management (Haut), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Deborah B Hobson
- Russell H. Morgan Department of Radiology and Radiological Science (Lau), Johns Hopkins University School of Medicine; Armstrong Institute for Patient Safety and Quality (Lau, Holzmueller, Streiff), Johns Hopkins Medicine, Baltimore, Md.; Department of Surgery (Murphy), Indiana University, Indianapolis, Ind.; Division of Acute Care Surgery, Medical College of Wisconsin, Wauwatosa, Wis.; London Health Sciences Centre, London, Ont. and Department of Surgery, Indiana University, (Murphy; during the conduct of the study); School of Medicine (Nastasi), Stanford University, Li Ka Shing Building, Stanford, Calif.; Welch Medical Library (Seal), Johns Hopkins University School of Medicine; Department of Pharmacy (Kraus), Johns Hopkins Hospital; Division of Acute Care Surgery (Hobson, Aboagye, Haut), Department of Surgery, School of Medicine, Johns Hopkins University; Department of Nursing (Hobson), Johns Hopkins Hospital; Department of Nursing (Shaffer), Johns Hopkins Hospital; Division of Hematology (Streiff), Department of Medicine, Johns Hopkins University School of Medicine; Department of Health Policy and Management (Haut), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Dauryne L Shaffer
- Russell H. Morgan Department of Radiology and Radiological Science (Lau), Johns Hopkins University School of Medicine; Armstrong Institute for Patient Safety and Quality (Lau, Holzmueller, Streiff), Johns Hopkins Medicine, Baltimore, Md.; Department of Surgery (Murphy), Indiana University, Indianapolis, Ind.; Division of Acute Care Surgery, Medical College of Wisconsin, Wauwatosa, Wis.; London Health Sciences Centre, London, Ont. and Department of Surgery, Indiana University, (Murphy; during the conduct of the study); School of Medicine (Nastasi), Stanford University, Li Ka Shing Building, Stanford, Calif.; Welch Medical Library (Seal), Johns Hopkins University School of Medicine; Department of Pharmacy (Kraus), Johns Hopkins Hospital; Division of Acute Care Surgery (Hobson, Aboagye, Haut), Department of Surgery, School of Medicine, Johns Hopkins University; Department of Nursing (Hobson), Johns Hopkins Hospital; Department of Nursing (Shaffer), Johns Hopkins Hospital; Division of Hematology (Streiff), Department of Medicine, Johns Hopkins University School of Medicine; Department of Health Policy and Management (Haut), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Christine G Holzmueller
- Russell H. Morgan Department of Radiology and Radiological Science (Lau), Johns Hopkins University School of Medicine; Armstrong Institute for Patient Safety and Quality (Lau, Holzmueller, Streiff), Johns Hopkins Medicine, Baltimore, Md.; Department of Surgery (Murphy), Indiana University, Indianapolis, Ind.; Division of Acute Care Surgery, Medical College of Wisconsin, Wauwatosa, Wis.; London Health Sciences Centre, London, Ont. and Department of Surgery, Indiana University, (Murphy; during the conduct of the study); School of Medicine (Nastasi), Stanford University, Li Ka Shing Building, Stanford, Calif.; Welch Medical Library (Seal), Johns Hopkins University School of Medicine; Department of Pharmacy (Kraus), Johns Hopkins Hospital; Division of Acute Care Surgery (Hobson, Aboagye, Haut), Department of Surgery, School of Medicine, Johns Hopkins University; Department of Nursing (Hobson), Johns Hopkins Hospital; Department of Nursing (Shaffer), Johns Hopkins Hospital; Division of Hematology (Streiff), Department of Medicine, Johns Hopkins University School of Medicine; Department of Health Policy and Management (Haut), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Jonathan K Aboagye
- Russell H. Morgan Department of Radiology and Radiological Science (Lau), Johns Hopkins University School of Medicine; Armstrong Institute for Patient Safety and Quality (Lau, Holzmueller, Streiff), Johns Hopkins Medicine, Baltimore, Md.; Department of Surgery (Murphy), Indiana University, Indianapolis, Ind.; Division of Acute Care Surgery, Medical College of Wisconsin, Wauwatosa, Wis.; London Health Sciences Centre, London, Ont. and Department of Surgery, Indiana University, (Murphy; during the conduct of the study); School of Medicine (Nastasi), Stanford University, Li Ka Shing Building, Stanford, Calif.; Welch Medical Library (Seal), Johns Hopkins University School of Medicine; Department of Pharmacy (Kraus), Johns Hopkins Hospital; Division of Acute Care Surgery (Hobson, Aboagye, Haut), Department of Surgery, School of Medicine, Johns Hopkins University; Department of Nursing (Hobson), Johns Hopkins Hospital; Department of Nursing (Shaffer), Johns Hopkins Hospital; Division of Hematology (Streiff), Department of Medicine, Johns Hopkins University School of Medicine; Department of Health Policy and Management (Haut), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Michael B Streiff
- Russell H. Morgan Department of Radiology and Radiological Science (Lau), Johns Hopkins University School of Medicine; Armstrong Institute for Patient Safety and Quality (Lau, Holzmueller, Streiff), Johns Hopkins Medicine, Baltimore, Md.; Department of Surgery (Murphy), Indiana University, Indianapolis, Ind.; Division of Acute Care Surgery, Medical College of Wisconsin, Wauwatosa, Wis.; London Health Sciences Centre, London, Ont. and Department of Surgery, Indiana University, (Murphy; during the conduct of the study); School of Medicine (Nastasi), Stanford University, Li Ka Shing Building, Stanford, Calif.; Welch Medical Library (Seal), Johns Hopkins University School of Medicine; Department of Pharmacy (Kraus), Johns Hopkins Hospital; Division of Acute Care Surgery (Hobson, Aboagye, Haut), Department of Surgery, School of Medicine, Johns Hopkins University; Department of Nursing (Hobson), Johns Hopkins Hospital; Department of Nursing (Shaffer), Johns Hopkins Hospital; Division of Hematology (Streiff), Department of Medicine, Johns Hopkins University School of Medicine; Department of Health Policy and Management (Haut), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Elliott R Haut
- Russell H. Morgan Department of Radiology and Radiological Science (Lau), Johns Hopkins University School of Medicine; Armstrong Institute for Patient Safety and Quality (Lau, Holzmueller, Streiff), Johns Hopkins Medicine, Baltimore, Md.; Department of Surgery (Murphy), Indiana University, Indianapolis, Ind.; Division of Acute Care Surgery, Medical College of Wisconsin, Wauwatosa, Wis.; London Health Sciences Centre, London, Ont. and Department of Surgery, Indiana University, (Murphy; during the conduct of the study); School of Medicine (Nastasi), Stanford University, Li Ka Shing Building, Stanford, Calif.; Welch Medical Library (Seal), Johns Hopkins University School of Medicine; Department of Pharmacy (Kraus), Johns Hopkins Hospital; Division of Acute Care Surgery (Hobson, Aboagye, Haut), Department of Surgery, School of Medicine, Johns Hopkins University; Department of Nursing (Hobson), Johns Hopkins Hospital; Department of Nursing (Shaffer), Johns Hopkins Hospital; Division of Hematology (Streiff), Department of Medicine, Johns Hopkins University School of Medicine; Department of Health Policy and Management (Haut), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md.
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10
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Owodunni OP, Haut ER, Shaffer DL, Hobson DB, Wang J, Yenokyan G, Kraus PS, Aboagye JK, Florecki KL, Webster KLW, Holzmueller CG, Streiff MB, Lau BD. Using electronic health record system triggers to target delivery of a patient-centered intervention to improve venous thromboembolism prevention for hospitalized patients: Is there a differential effect by race? PLoS One 2020; 15:e0227339. [PMID: 31945085 PMCID: PMC6964816 DOI: 10.1371/journal.pone.0227339] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 12/16/2019] [Indexed: 11/19/2022] Open
Abstract
Background Racial disparities are common in healthcare. Venous thromboembolism (VTE) is a leading cause of preventable harm, and disparities observed in prevention practices. We examined the impact of a patient-centered VTE education bundle on the non-administration of preventive prophylaxis by race. Methods A post-hoc, subset analysis (stratified by race) of a larger nonrandomized trial. Pre-post comparisons analysis were conducted on 16 inpatient units; study periods were October 2014 through March 2015 (baseline) and April through December 2015 (post-intervention). Patients on 4 intervention units received the patient-centered, nurse educator-led intervention if the electronic health record alerted a non-administered dose of VTE prophylaxis. Patients on 12 control units received no intervention. We compared the conditional odds of non-administered doses of VTE prophylaxis when patient refusal was a reason for non-administration, stratified by race. Results Of 272 patient interventions, 123 (45.2%) were white, 126 (46.3%) were black, and 23 (8.5%) were other races. A significant reduction was observed in the odds of non-administration of prophylaxis on intervention units compared to control units among patients who were black (OR 0.61; 95% CI, 0.46–0.81, p<0.001), white (OR 0.57; 95% CI, 0.44–0.75, p<0.001), and other races (OR 0.50; 95% CI, 0.29–0.88, p = 0.015). Conclusion Our finding suggests that the patient education materials, developed collaboratively with a diverse group of patients, improved patient’s understanding and the importance of VTE prevention through prophylaxis. Quality improvement interventions should examine any differential effects by patient characteristics to ensure disparities are addressed and all patients experience the same benefits.
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Affiliation(s)
- Oluwafemi P. Owodunni
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Elliott R. Haut
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, United States of America
- Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- * E-mail:
| | - Dauryne L. Shaffer
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Nursing, The Johns Hopkins Hospital, Baltimore, Maryland, United States of America
| | - Deborah B. Hobson
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, United States of America
- Department of Nursing, The Johns Hopkins Hospital, Baltimore, Maryland, United States of America
| | - Jiangxia Wang
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Gayane Yenokyan
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Peggy S. Kraus
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland, United States of America
| | - Jonathan K. Aboagye
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Katherine L. Florecki
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Kristen L. W. Webster
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Christine G. Holzmueller
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, United States of America
| | - Michael B. Streiff
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, United States of America
- Division of Hematology, Department of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, United States of America
| | - Brandyn D. Lau
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, United States of America
- Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Hospital, Baltimore, Maryland, United States of America
- Division of Health Sciences Informatics, The Johns Hopkins Hospital, Baltimore, Maryland, United States of America
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11
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Aggarwal MV, Jarrell AS, Gilmore VT, Aboagye JK, Haut ER, Hobson DB, Lau BD, Kickler T, Kraus PS, Shaffer DL, Shermock KM, Streiff MB, Zheng G, Kruer RM. Anti-Xa activity by weight in critically ill patients receiving unfractionated heparin for venous thromboembolism prophylaxis. J Crit Care 2019; 52:180-185. [PMID: 31078999 DOI: 10.1016/j.jcrc.2019.04.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 04/25/2019] [Accepted: 04/26/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE This study compared anti-Xa activity in critically ill patients receiving UFH for VTE prophylaxis between two weight groups (<100 kg vs ≥100 kg). METHODS This prospective, observational study included critically ill patients on UFH 5000 or 7500 units every 8 h. A peak and trough anti-Xa activity assay was ordered for each patient at steady state. Goal peak anti-Xa activity was 0.1-0.3 units/mL. RESULTS From March 2017 to June 2018, 75 patients were enrolled with 44 in the <100 kg group and 31 in the ≥100 kg group. There was no significant difference in the percentage of patients with peak anti-Xa activity within goal range between patients <100 kg and ≥ 100 kg (55.3% vs 35.7%, p = 0.12). The odds ratio for achieving peak anti-Xa activity within goal range as weight-based dose increased was 1.03 (95% CI 0.99-1.07). No differences were found in trough anti-Xa activity, VTE, bleeding, length of stay, or death. CONCLUSIONS Though only one-third of patients ≥100 kg had peak anti-Xa activity within goal range, no significant difference was found between the weight groups. Additional prospective studies with adequate sample sizes are warranted to further investigate appropriate weight-based dosing of UFH in critically ill patients.
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Affiliation(s)
| | | | - Vi T Gilmore
- Department of Pharmacy, The Johns Hopkins Hospital, USA
| | - Jonathan K Aboagye
- Department of Surgery, The Johns Hopkins University School of Medicine, USA
| | - Elliott R Haut
- Department of Surgery, The Johns Hopkins University School of Medicine, USA; Armstrong Institute for Patient Safety and Quality, USA; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, USA; Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, USA; Department of Emergency Medicine, The Johns Hopkins University School of Medicine, USA
| | - Deborah B Hobson
- Department of Surgery, The Johns Hopkins University School of Medicine, USA; Armstrong Institute for Patient Safety and Quality, USA
| | - Brandyn D Lau
- Armstrong Institute for Patient Safety and Quality, USA; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, USA; Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, USA; Division of Health Sciences Informatics, The Johns Hopkins University School of Medicine, USA
| | - Thomas Kickler
- Department of Pathology, The Johns Hopkins University School of Medicine, USA
| | - Peggy S Kraus
- Department of Pharmacy, The Johns Hopkins Hospital, USA
| | - Dauryne L Shaffer
- Department of Surgery, The Johns Hopkins University School of Medicine, USA
| | | | - Michael B Streiff
- Armstrong Institute for Patient Safety and Quality, USA; Division of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, USA
| | - Gang Zheng
- Department of Pathology, The Johns Hopkins University School of Medicine, USA
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12
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Popoola VO, Lau BD, Tan E, Shaffer DL, Kraus PS, Farrow NE, Hobson DB, Aboagye JK, Streiff MB, Haut ER. Nonadministration of medication doses for venous thromboembolism prophylaxis in a cohort of hospitalized patients. Am J Health Syst Pharm 2019. [PMID: 29523536 DOI: 10.2146/ajhp161057] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Results of a study to characterize patterns of nonadministration of medication doses for venous thromboembolism (VTE) prevention among hospitalized patients are presented. METHODS The electronic records of all patients admitted to 4 floors of a medical center during a 1-month period were examined to identify patients whose records indicated at least 1 nonadministered dose of medication for VTE prophylaxis. Proportions of nonadministered doses by medication type, intended route of administration, and VTE risk categorization were compared; reasons for nonadministration were evaluated. RESULTS Overall, 12.7% of all medication doses prescribed to patients in the study cohort (n = 75) during the study period (857 of 6,758 doses in total) were not administered. Nonadministration of 1 or more doses of VTE prophylaxis medication was nearly twice as likely for subcutaneous anticoagulants than for all other medication types (231 of 1,112 doses [20.8%] versus 626 of 5,646 doses [11.2%], p < 0.001). For all medications prescribed, the most common reason for nonadministration was patient refusal (559 of 857 doses [65.2%]); the refusal rate was higher for subcutaneous anticoagulants than for all other medication categories (82.7% versus 58.8%, p < 0.001). Doses of antiretrovirals, immunosuppressives, antihypertensives, psychiatric medications, analgesics, and antiepileptics were less commonly missed than doses of electrolytes, vitamins, and gastrointestinal medications. CONCLUSION Scheduled doses of subcutaneous anticoagulants for hospitalized patients were more likely to be missed than doses of all other medication types.
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Affiliation(s)
- Victor O Popoola
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Brandyn D Lau
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, MD.,Division of Health Sciences Informatics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Esther Tan
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | | | - Peggy S Kraus
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
| | - Norma E Farrow
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | | | - Jonathan K Aboagye
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD.,Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD
| | - Michael B Streiff
- Division of Hematology, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD
| | - Elliott R Haut
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD .,Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD .,Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD
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13
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Aboagye JK, Hayanga JW, Lau BD, Bush EL, Shaffer DL, Hobson DB, Kraus PS, Streiff MB, Haut ER, D’Cunha J. Venous Thromboembolism in Patients Hospitalized for Lung Transplantation. Ann Thorac Surg 2018; 105:1071-1076. [DOI: 10.1016/j.athoracsur.2017.10.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 09/05/2017] [Accepted: 10/11/2017] [Indexed: 12/01/2022]
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Farrow NE, Aboagye JK, Lau BD, Najjar P, Orgill DP, Popoola VO, Kraus PS, Hobson DB, Shaffer DL, Safar B, Gearhart S, Efron JE, Streiff MB, Haut ER. The role of extended/outpatient venous thromboembolism prophylaxis after abdominal surgery for cancer or inflammatory bowel disease. Journal of Patient Safety and Risk Management 2018. [DOI: 10.1177/1356262217753427] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Background Current guidelines recommend in-hospital venous thromboembolism prophylaxis for many patients and extended/outpatient prophylaxis in high-risk patients undergoing abdomino-pelvic surgery for cancer. Despite these guidelines, extended venous thromboembolism prophylaxis is not used uniformly at all institutions. This study aimed to evaluate the impact of postdischarge prophylaxis practices at two academic medical centers on the rate of postdischarge venous thromboembolism. Methods We retrospectively analyzed data from the Brigham and Women’s Hospital and the Johns Hopkins Hospital’s American College of Surgeons, National Surgical Quality Improvement Program registries from 1 August 2014 to 30 June 2015. Brigham and Women’s Hospital patients received four weeks supply of extended/outpatient venous thromboembolism prophylaxis, while Johns Hopkins Hospital patients did not. We determined the proportion of patients in each cohort that developed venous thromboembolism within 30 days of surgery. Results Four hundred and eighty-nine patients underwent abdominal surgery for cancer and inflammatory bowel disease; 181 (37.0%) patients from Brigham and Women’s Hospital and 308 (63.0%) patients from Johns Hopkins Hospital. Fourteen patients developed postoperative venous thromboembolism. Seven patients developed in-hospital venous thromboembolism and seven developed venous thromboembolism postdischarge. All postdischarge venous thromboembolism occurred in the Johns Hopkins group, and this difference was statistically significant (p = 0.0498). There was no difference in postdischarge bleeding rates between the groups. Conclusions Extended prophylaxis likely prevents postdischarge venous thromboembolism after major abdominal surgery without an increased risk of bleeding.
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Affiliation(s)
- Norma E Farrow
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Jonathan K Aboagye
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Brandyn D Lau
- Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Baltimore, MD
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Division of Health Sciences Informatics, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
- The Armstrong Institute for Patient Safety, Johns Hopkins Medicine, Johns Hopkins University, Baltimore, USA
| | - Peter Najjar
- Department of Surgery, Brigham and Women’s Hospital, Boston, USA
| | - Dennis P Orgill
- Department of Surgery, Brigham and Women’s Hospital, Boston, USA
| | - Victor O Popoola
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Peggy S Kraus
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Deborah B Hobson
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Dauryne L Shaffer
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Bashar Safar
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Susan Gearhart
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Jonathan E Efron
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Michael B Streiff
- The Armstrong Institute for Patient Safety, Johns Hopkins Medicine, Johns Hopkins University, Baltimore, USA
- Department of Medicine, Johns Hopkins University, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Elliott R Haut
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Division of Health Sciences Informatics, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
- The Armstrong Institute for Patient Safety, Johns Hopkins Medicine, Johns Hopkins University, Baltimore, USA
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
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16
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Aboagye JK, Hobson DB, Lau BD, Shaffer DL, Kraus PS, Streiff MB, Haut ER. Reply about letter regarding "Prevalence of graduated compression stocking-associated pressure injuries in surgical intensive care units". J Crit Care 2017; 40:287-288. [PMID: 28629868 DOI: 10.1016/j.jcrc.2017.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 06/09/2017] [Indexed: 02/04/2023]
Affiliation(s)
- Jonathan K Aboagye
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Deborah B Hobson
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States; The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, United States.
| | - Brandyn D Lau
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States; The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, United States; Division of Health Sciences Informatics, The Johns Hopkins University School of Medicine, Baltimore, MD, United States; Department of Health Policy and Management, The Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Dauryne L Shaffer
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Peggy S Kraus
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD, United States.
| | - Michael B Streiff
- The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, United States; Division of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, United States; Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Elliott R Haut
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States; The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, United States; Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, United States; Department of Anesthesiology and Critical Care Medicine (ACCM), The Johns Hopkins University School of Medicine, Baltimore, MD, United States; Department of Health Policy and Management, The Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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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] [What about the content of this article? (0)] [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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18
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Streiff MB, Lau BD, Hobson DB, Kraus PS, Shermock KM, Shaffer DL, Popoola VO, Aboagye JK, Farrow NA, Horn PJ, Shihab HM, Pronovost PJ, Haut ER. The Johns Hopkins Venous Thromboembolism Collaborative: Multidisciplinary team approach to achieve perfect prophylaxis. J Hosp Med 2016; 11 Suppl 2:S8-S14. [PMID: 27925423 DOI: 10.1002/jhm.2657] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 08/24/2016] [Accepted: 08/28/2016] [Indexed: 11/08/2022]
Abstract
Venous thromboembolism (VTE) is an important cause of preventable harm in hospitalized patients. The critical steps in delivery of optimal VTE prevention care include (1) assessment of VTE and bleeding risk for each patient, (2) prescription of risk-appropriate VTE prophylaxis, (3) administration of risk-appropriate VTE prophylaxis in a patient-centered manner, and (4) continuously monitoring outcomes to identify new opportunities for learning and performance improvement. To ensure that every hospitalized patient receives VTE prophylaxis consistent with their individual risk level and personal care preferences, we organized a multidisciplinary task force, the Johns Hopkins VTE Collaborative. To achieve the goal of perfect prophylaxis for every patient, we developed evidence-based, specialty-specific computerized clinical decision support VTE prophylaxis order sets that assist providers in ordering risk-appropriate VTE prevention. We developed novel strategies to improve provider VTE prevention ordering practices including face-to-face performance reviews, pay for performance, and provider VTE scorecards. When we discovered that prescription of risk-appropriate VTE prophylaxis does not ensure its administration, our multidisciplinary research team conducted in-depth surveys of patients, nurses, and physicians to design a multidisciplinary patient-centered educational intervention to eliminate missed doses of pharmacologic VTE prophylaxis that has been funded by the Patient Centered Outcomes Research Institute. We expect that the studies currently underway will bring us closer to the goal of perfect VTE prevention care for every patient. Our learning journey to eliminate harm from VTE can be applied to other types of harm. Journal of Hospital Medicine 2016;11:S8-S14. © 2016 Society of Hospital Medicine.
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Affiliation(s)
- Michael B Streiff
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Armstrong Institute for Patient Safety, Johns Hopkins Medicine, Baltimore, Maryland
| | - Brandyn D Lau
- Armstrong Institute for Patient Safety, Johns Hopkins Medicine, Baltimore, Maryland
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Deborah B Hobson
- Armstrong Institute for Patient Safety, Johns Hopkins Medicine, Baltimore, Maryland
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Nursing, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Peggy S Kraus
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Kenneth M Shermock
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Dauryne L Shaffer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Nursing, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Victor O Popoola
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan K Aboagye
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Norma A Farrow
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Paula J Horn
- Department of Pharmacy, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Hasan M Shihab
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Peter J Pronovost
- Armstrong Institute for Patient Safety, Johns Hopkins Medicine, Baltimore, Maryland
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins University School of Nursing, Baltimore, Maryland
| | - Elliott R Haut
- Armstrong Institute for Patient Safety, Johns Hopkins Medicine, Baltimore, Maryland
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Lau BD, Streiff MB, Hobson DB, Kraus PS, Shaffer DL, Popoola VO, Farrow NE, Efron DT, Haut ER. Beneficial "halo effects" of surgical resident performance feedback. J Surg Res 2016; 205:179-85. [PMID: 27621016 DOI: 10.1016/j.jss.2016.06.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 04/22/2016] [Accepted: 06/07/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) prevention is one of the most frequent measures of quality in hospital settings. In 2013, we began providing individualized feedback to general surgery residents about their VTE prophylaxis prescribing habits for general surgical patients. The purpose of this study was to investigate the indirect, or "halo effects" of providing individualized performance feedback to residents regarding prescription of appropriate VTE prophylaxis. MATERIALS AND METHODS This retrospective cohort study compared appropriate VTE prophylaxis prescription for all patients admitted to the adult trauma service from July 1, 2012 to May 31, 2015 at The Johns Hopkins Hospital, an academic hospital and Level 1 trauma center in Baltimore, Maryland. On October 1, 2013, we began providing monthly performance feedback to general surgery residents regarding their VTE prophylaxis prescribing habits for general surgery patients. Data were not provided about their prescription practice for trauma patients, or to any other prescribers within the hospital. RESULTS During the study period, 931 adult trauma patients were admitted to the adult trauma service. After providing individualized feedback about general surgery patients, general surgery residents' prescribing practice for writing appropriate VTE prophylaxis orders for adult trauma patients significantly improved (93.9% versus 78.1%, P < 0.001). Prescription practice significantly improved among all other prescribers although they did not receive any specific individualized feedback, (84.9% versus 75.1%, P = 0.025); however, practice was significantly better among general surgery residents versus other providers (93.9% versus 84.9%, P = 0.003). CONCLUSIONS There is a beneficial "halo effect" for patients treated by residents receiving individualized feedback about practice habits. Individualized feedback regarding practice habits for one patient type has both a direct and indirect effect on the quality of care patients receive and should be implemented for all providers.
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Affiliation(s)
- Brandyn D Lau
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, Maryland; The Armstrong Institute for Patient Safety, Johns Hopkins Medicine, Baltimore, Maryland; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
| | - Michael B Streiff
- The Armstrong Institute for Patient Safety, Johns Hopkins Medicine, Baltimore, Maryland; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah B Hobson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Peggy S Kraus
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Dauryne L Shaffer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Victor O Popoola
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Norma E Farrow
- Department of Surgery, Duke University, Durham, North Carolina
| | - David T Efron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elliott R Haut
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; The Armstrong Institute for Patient Safety, Johns Hopkins Medicine, Baltimore, Maryland; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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20
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Popoola VO, Lau BD, Shihab HM, Farrow NE, Shaffer DL, Hobson DB, Kulik SV, Zaruba PD, Shermock KM, Kraus PS, Pronovost PJ, Streiff MB, Haut ER. Patient Preferences for Receiving Education on Venous Thromboembolism Prevention - A Survey of Stakeholder Organizations. PLoS One 2016; 11:e0152084. [PMID: 27031330 PMCID: PMC4816559 DOI: 10.1371/journal.pone.0152084] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 03/08/2016] [Indexed: 11/18/2022] Open
Abstract
Importance Venous thromboembolism (VTE) is a major cause of morbidity and mortality among hospitalized patients and is largely preventable. Strategies to decrease the burden of VTE have focused on improving clinicians’ prescribing of prophylaxis with relatively less emphasis on patient education. Objective To develop a patient-centered approach to education of patients and their families on VTE: including importance, risk factors, and benefit/harm of VTE prophylaxis in hospital settings. Design, Setting and Participants The objective of this study was to develop a patient-centered approach to education of patients and their families on VTE: including importance, risk factors, and benefit/harm of VTE prophylaxis in hospital settings. We implemented a three-phase, web-based survey (SurveyMonkey) between March 2014 and September 2014 and analyzed survey data using descriptive statistics. Four hundred twenty one members of several national stakeholder organizations and a single local patient and family advisory board were invited to participate via email. We assessed participants’ preferences for VTE education topics and methods of delivery. Participants wanted to learn about VTE symptoms, risk factors, prevention, and complications in a context that emphasized harm. Although participants were willing to learn using a variety of methods, most preferred to receive education in the context of a doctor-patient encounter. The next most common preferences were for video and paper educational materials. Conclusions Patients want to learn about the harm associated with VTE through a variety of methods. Efforts to improve VTE prophylaxis and decrease preventable harm from VTE should target the entire continuum of care and a variety of stakeholders including patients and their families.
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Affiliation(s)
- Victor O. Popoola
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Brandyn D. Lau
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Division of Health Sciences Informatics, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, United States of America
- Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Hasan M. Shihab
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Norma E. Farrow
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Dauryne L. Shaffer
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Nursing, The Johns Hopkins Hospital, Baltimore, Maryland, United States of America
| | - Deborah B. Hobson
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Nursing, The Johns Hopkins Hospital, Baltimore, Maryland, United States of America
| | - Susan V. Kulik
- Department of Nursing, The Johns Hopkins Hospital, Baltimore, Maryland, United States of America
| | - Paul D. Zaruba
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Kenneth M. Shermock
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland, United States of America
- The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, United States of America
| | - Peggy S. Kraus
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland, United States of America
| | - Peter J. Pronovost
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, United States of America
- Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Michael B. Streiff
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, United States of America
| | - Elliott R. Haut
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, United States of America
- Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- * E-mail:
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