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Ratnasekera A, Seng SS, Ciarmella M, Gallagher A, Poirier K, Harding ES, Haut ER, Geerts W, Murphy P. Thromboprophylaxis in hospitalized trauma patients: a systematic review and meta-analysis of implementation strategies. Trauma Surg Acute Care Open 2024; 9:e001420. [PMID: 38686174 PMCID: PMC11057278 DOI: 10.1136/tsaco-2024-001420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 03/27/2024] [Indexed: 05/02/2024] Open
Abstract
Introduction Venous thromboembolism (VTE) prophylaxis implementation strategies are well-studied in some hospitalized medical and surgical patients. Although VTE is associated with substantial mortality and morbidity in trauma patients, implementation strategies for the prevention of VTE in trauma appear to be based on limited evidence. Therefore, we conducted a systematic review and meta-analysis of published literature on active implementation strategies for VTE prophylaxis administration in hospitalized trauma patients and the impact on VTE events. Methods A systematic review and meta-analysis was performed in adult hospitalized trauma patients to assess if active VTE prevention implementation strategies change the proportion of patients who received VTE prophylaxis, VTE events, and adverse effects such as bleeding or heparin-induced thrombocytopenia as well as hospital length of stay and the cost of care. An academic medical librarian searched Medline, Scopus, and Web of Science until December 2022. Results Four studies with a total of 1723 patients in the active implementation strategy group (strategies included education, reminders, human and computer alerts, audit and feedback, preprinted orders, and/or root cause analysis) and 1324 in the no active implementation strategy group (guideline creation and dissemination) were included in the analysis. A higher proportion of patients received VTE prophylaxis with an active implementation strategy (OR=2.94, 95% CI (1.68 to 5.15), p<0.01). No significant difference was found in VTE events. Quality was deemed to be low due to bias and inconsistency of studies. Conclusions Active implementation strategies appeared to improve the proportion of major trauma patients who received VTE prophylaxis. Further implementation studies are needed in trauma to determine effective, sustainable strategies for VTE prevention and to assess secondary outcomes such as bleeding and costs. Level of evidence Systematic review/meta-analysis, level III. PROSPERO registration number CRD42023390538.
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Affiliation(s)
| | - Sirivan S Seng
- Crozer-Chester Medical Center, Upland, Pennsylvania, USA
| | - Marina Ciarmella
- Lincoln Memorial University DeBusk College of Osteopathic Medicine, Harrogate, Tennessee, USA
| | | | - Kelly Poirier
- Christiana Care Health System, Wilmington, Delaware, USA
| | - Eric Shea Harding
- Medical College of Wisconsin Todd Wehr Library, Milwaukee, Wisconsin, USA
| | | | - William Geerts
- Thromboembolism Program, University of Toronto, Toronto, Ontario, Canada
| | - Patrick Murphy
- Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Girardot K, Powers J, Morgan L, Hollister L. Evaluation of a Novel Mechanical Venous Thromboembolism Compression Device in Trauma Patients: A Pilot Study. J Trauma Nurs 2024; 31:97-103. [PMID: 38484165 DOI: 10.1097/jtn.0000000000000779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
BACKGROUND Venous thromboembolism (VTE) is the fourth most common preventable hospital-acquired complication for hospitalized trauma patients. Mechanical prophylaxis, using sequential compression or intermittent pneumatic compression (IPC) devices, is recommended alongside pharmacologic prophylaxis for VTE prevention. However, compliance with device use is a barrier that reduces the effectiveness of mechanical prophylaxis. OBJECTIVE This study aimed to determine whether using the Movement and Compressions (MAC) system compared with an IPC device impacts compliance with mechanical VTE prophylaxis in trauma patients. METHODS This study used a before-and-after design with historical control at a Level II trauma center with a convenience sample of adult trauma patients admitted to the intensive care unit or acute care floor for at least 24 h. We trialed the MAC device for 2 weeks in November and December 2022 with prospective data collection. Data collection for the historical control group occurred retrospectively using patients from a point-in-time audit of IPC device compliance from August and September of 2022. RESULTS A total of 51 patients met inclusion criteria, with 34 patients in the IPC group and 17 patients in the MAC group. The mean (SD) prophylaxis time was 17.2 h per day (4.0) in the MAC group and 7.5 h per day (8.8) in the IPC group, which was statistically significant (p < .001). CONCLUSION Our findings suggest that the MAC device can improve compliance with mechanical prophylaxis.
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Affiliation(s)
- Kellie Girardot
- Author Affiliations: Department of Trauma Services, Parkview Health, Fort Wayne, Indiana (Ms Girardot and Dr Hollister); Department of Patient Care Services, Parkview Health, Fort Wayne, Indiana (Ms Morgan and Dr Powers)
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Gao SL, Liu CQ, Han QH, Dai XR, Liu YW, Li K. Quality appraisal of clinical practice guidelines for the management of Dysphagia after acute stroke. Front Neurol 2023; 14:1310133. [PMID: 38116112 PMCID: PMC10728278 DOI: 10.3389/fneur.2023.1310133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 11/17/2023] [Indexed: 12/21/2023] Open
Abstract
Objectives Dysphagia is a common complication in stroke patients, widely affecting recovery and quality of life after stroke. The objective of this systematic review is to identify the gaps that between evidence and practice by critically assessing the quality of clinical practice guidelines (CPGs) for management of dysphagia in stroke. Methods We systematically searched academic databases and guideline repositories between January 1, 2014, and August 1, 2023. The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument was used by two authors to independently assess CPG quality. Results In a total of 14 CPGs included, we identified that three CPGs obtained a final evaluation of "high quality," nine CPGs achieved "moderate quality" and two CPGs received "low quality." The domain of "scope and purpose" achieved the highest mean score (91.1%) and the highest median (IQR) of 91.7% (86.1, 94.4%), while the domain of "applicability" received the lowest mean score (55.8%) and the lowest median (IQR) of 55.4% (43.2, 75.5%). Conclusion The CPG development group should pay more attention to improving the methodological quality according to the AGREE II instrument, especially in the domain of "applicability" and "stakeholder involvement;" and each item should be refined as much as possible.
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Affiliation(s)
- Shi-Lin Gao
- West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Chang-Qing Liu
- West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Qing-Hua Han
- Department of Critical Care Medicine, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Xiao-Rong Dai
- Department of Critical Care Medicine, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Yi-Wen Liu
- Department of Critical Care Medicine, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Ka Li
- West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
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Schaefer JK, Grant PJ. A need to refine venous thromboembolism risk assessment: the challenge of optimizing patient selection for thromboprophylaxis among hospitalized adults. Res Pract Thromb Haemost 2023; 7:102258. [PMID: 38193062 PMCID: PMC10772884 DOI: 10.1016/j.rpth.2023.102258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 10/03/2023] [Accepted: 10/04/2023] [Indexed: 01/10/2024] Open
Affiliation(s)
- Jordan K. Schaefer
- Department of Medicine, Division of Hematology/Oncology, University of Michigan, Ann Arbor, MI
| | - Paul J. Grant
- Department of Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor, MI
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Huang X, Zhou S, Ma X, Jiang S, Xu Y, You Y, Qu J, Shang H, Lu Y. Effectiveness of an artificial intelligence clinical assistant decision support system to improve the incidence of hospital-associated venous thromboembolism: a prospective, randomised controlled study. BMJ Open Qual 2023; 12:e002267. [PMID: 37832969 PMCID: PMC10582876 DOI: 10.1136/bmjoq-2023-002267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 09/16/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Thromboprophylaxis has been determined to be safe, effective and cost-effective for hospitalised patients at venous thromboembolism (VTE) risk. However, Chinese medical institutions have not yet fully used or improperly used thromboprophylaxis. The effectiveness of information technology applied to thromboprophylaxis in hospitalised patients has been proved in many retrospective studies, lacking of prospective research evidence. METHODS All hospitalised patients aged >18 years not discharged within 24 hours from 1 September 2020 to 31 May 2021 were prospectively enrolled. Patients were randomly assigned to the control (9890 patients) or intervention group (9895 patients). The control group implemented conventional VTE prevention programmes; the intervention group implemented an Artificial Intelligence Clinical Assistant Decision Support System (AI-CDSS) on the basis of conventional prevention. Intergroup demographics, disease status, hospital length of stay (LOS), VTE risk assessment and VTE prophylaxis were compared using the χ2 test, Fisher's exact test, t-test or Wilcoxon rank-sum test. Univariate and multivariate logistic regressions were used to explore the risk factor of VTE. RESULTS The control and intervention groups had similar baseline characteristics. The mean age was 58.32±15.41 years, and mean LOS was 7.82±7.07 days. In total, 5027 (25.40%) and 2707 (13.67%) patients were assessed as having intermediate-to-high VTE risk and high bleeding risk, respectively. The incidence of hospital-associated VTE (HA-VTE) was 0.38%, of which 86.84% had deep vein thrombosis. Compared with the control group, the incidence of HA-VTE decreased by 46.00%, mechanical prophylaxis rate increased by 24.00% and intensity of drug use increased by 9.72% in the intervention group. However, AI-CDSS use did not increase the number of clinical diagnostic tests, prophylaxis rate or appropriate prophylaxis rate. CONCLUSIONS Thromboprophylaxis is inadequate in hospitalised patients with VTE risk. The role of AI-CDSS in VTE risk management is unknown and needs further in-depth study. TRIAL REGISTRATION NUMBER ChiCTR2000035452.
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Affiliation(s)
- Xiaoyan Huang
- Dean's Office, RuiJin Hospital LuWan Branch, School of Medicine, Shanghai Jiaotong University, Shanghai, China
- Shanghai Venous Thromboembolism Alliance, Shanghai, China
| | - Shuai Zhou
- Division of Medical Affairs, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xudong Ma
- Department of Medical Administration, National Health Commission of the People's Republic of China, Beijing, China
| | - Songyi Jiang
- Solution Center For Quality Improvement, Beijing Huimei Cloud Technology Co. Ltd, Beijing, China
| | - Yuanyuan Xu
- General Office, Shanghai Hospital Association, Shanghai, China
| | - Yi You
- Solution Center For Quality Improvement, Beijing Huimei Cloud Technology Co. Ltd, Beijing, China
| | - Jieming Qu
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hanbing Shang
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Neurosurgery, RuiJin-HaiNan Hospital,Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yong Lu
- Shanghai Venous Thromboembolism Alliance, Shanghai, China
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Sonderman M, Wells QS. Closing the Gap in VTE Prophylaxis: The Role of Clinical Decision Support. JACC. ADVANCES 2023; 2:100601. [PMID: 38938335 PMCID: PMC11198200 DOI: 10.1016/j.jacadv.2023.100601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
- Mark Sonderman
- Division of Cardiology, Department of Medicine, University of Washington Medical Center, Seattle, Washington, USA
| | - Quinn S. Wells
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Zhou X, Dai M, Sun L, Li C, Xiang W, Lin Y, Jiang D. Ophthalmic nurses' knowledge, attitude, and practice toward venous thromboembolic prevention: a dual-center cross-sectional survey. PeerJ 2023; 11:e15947. [PMID: 37663300 PMCID: PMC10470452 DOI: 10.7717/peerj.15947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 08/01/2023] [Indexed: 09/05/2023] Open
Abstract
Background Venous thromboembolism (VTE) is a severe preventable complication among ophthalmic surgical patients. The knowledge, attitude, and practice (KAP) of nurses play a key role in effective VTE prevention. However, little is known about the KAP of ophthalmic nurses' VTE prevention. This study aimed to examine the level of KAP toward VTE prevention among Chinese ophthalmic nurses and to investigate the influencing factors of their VTE practice. Methods A total of 610 ophthalmic nurses from 17 cities in Hunan and Zhejiang Provinces, China, participated in this study. Data was collected via the Sojump online platform from March to April 2021. A self-administered VTE questionnaire was developed to assess nurses' KAP toward VTE prevention. Multiple linear regression analysis was used to analyze the influencing factors of ophthalmic nurses' VTE prevention practice. Results The scores (correct rates) of ophthalmic nurses' knowledge, attitude, and practice were 103.87 ± 20.50 (76.4%), 21.96 ± 2.72, and 48.96 ± 11.23 (81.6%), respectively. The three lowest-scored knowledge items were related to VTE complications, physical prevention, and risk assessment. The three lowest-scored attitude items were related to nurses' training, VTE risk, and patient education. The three lowest-scored practice items were related to the assessment scale, VTE assessment, and patient education. Nurses' knowledge, attitude, and practice were significantly correlated with each other. Multiple linear regression analysis showed that Hunan Province (B = 2.77, p = 0.006), general hospital (B = 2.97, p = 0.009), outpatient department (B = 3.93, p = 0.021), inpatient department (B = 2.50, p = 0.001), previous VTE prevention training (B = 3.46, p < 0.001), VTE prevention management in hospital (B = 4.93, p < 0.001), better knowledge (B = 0.04, p = 0.038), and positive attitude towards VTE prevention (B = 1.35, p < 0.001) were all significantly and positively associated with higher practice scores in VTE prevention. Conclusions Our study provided a comprehensive understanding of the ophthalmic nurses' knowledge, attitude, and practice in VTE prevention, as well as identified specific items in each dimension for improvement. In addition, our study showed multiple factors were associated with ophthalmic nurses' practice in VTE prevention, including environmental factors, training and management, knowledge and attitudes toward VTE prevention. Our findings provide important implications and guidance for future intervention programs to improve the ophthalmic nurses' knowledge, attitude, and practice in VTE prevention.
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Affiliation(s)
- Xiaoxi Zhou
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha, China
| | - Minhui Dai
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha, China
- Hunan Key Laboratory of Ophthalmology, Changsha, China
- Eye Center, Xiangya Hospital of Central South University, Changsha, China
| | - Lingyu Sun
- Hunan Key Laboratory of Ophthalmology, Changsha, China
- Eye Center, Xiangya Hospital of Central South University, Changsha, China
| | - Chunyan Li
- Hunan Key Laboratory of Ophthalmology, Changsha, China
- Eye Center, Xiangya Hospital of Central South University, Changsha, China
| | - Wendi Xiang
- Department of Operating Room, Xiangya Hospital of Central South University, Changsha, China
| | - Yaoyao Lin
- The Eye Hospital, School of Ophthalmology and Optometry, Wenzhou Medical University, Wenzhou, China
| | - Dandan Jiang
- The Eye Hospital, School of Ophthalmology and Optometry, Wenzhou Medical University, Wenzhou, China
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Shevell L, Ochs M, Schaefer J. Prophylactic Anticoagulation in Patients with Cancer: When and How? Curr Oncol Rep 2023; 25:201-209. [PMID: 36705880 DOI: 10.1007/s11912-023-01358-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2022] [Indexed: 01/28/2023]
Abstract
PURPOSE OF REVIEW Cancer-associated thrombosis is a leading cause of death among patients with cancer. Historically, thromboprophylaxis efforts have focused on the highest risk patients with cancer, including post-operative patients and hospitalized patients. This review covers not only thromboprophylaxis for these groups but also emerging data supporting prophylaxis in ambulatory medical oncology patients. RECENT FINDINGS Several leading guidelines, backed by clinical trial data, now support the use of direct oral anticoagulants for select high-risk outpatients for primary thromboprophylaxis. However, uptake of these findings remains low. Pharmacologic venous thromboembolism prophylaxis strategies continue to improve. However, it remains challenging to balance competing risks of bleeding and thrombosis. The morbidity and mortality associated with cancer associated thrombosis may be preventable. Understanding advancements in risk prediction, anticoagulant options, and implementation of existing data, is critical to provide optimal patient care.
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Affiliation(s)
- Lauren Shevell
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Madeleine Ochs
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Jordan Schaefer
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA.
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Assessment of the Effect on Thromboprophylaxis with Multifaceted Quality Improvement Intervention based on Clinical Decision Support System in Hospitalized Patients: A Pilot Study. J Clin Med 2022; 11:jcm11174997. [PMID: 36078927 PMCID: PMC9456483 DOI: 10.3390/jcm11174997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 08/20/2022] [Accepted: 08/23/2022] [Indexed: 12/02/2022] Open
Abstract
Background: To explore the feasibility and effectiveness of multifaceted quality improvement intervention based on the clinical decision support system (CDSS) in VTE prophylaxis in hospitalized patients. Methods: A randomized, department-based clinical trial was conducted in the department of respiratory and critical care medicine, orthopedic, and general surgery wards. Patients aged ≥18 years, without VTE in admission, were allocated to the intervention group and received regular care combined with multifaceted quality improvement intervention based on CDSS during hospitalization. VTE prophylaxis rate and the occurrence of hospital-associated VTE events were analyzed as primary and secondary outcomes. Results: A total of 3644 eligible residents were enrolled in this trial. With the implementation of the multifaceted quality improvement intervention based on the CDSS, the VTE prophylaxis rate of the intervention group increased from 22.93% to 34.56% (p < 0.001), and the incidence of HA-VTE events increased from 0.49% to 1.00% (p = 0.366). In the nonintervention group, the VTE prophylaxis rate increased from 24.49% to 27.90% (p = 0.091), and the incidence of HA-VTE events increased from 0.47% to 2.02% (p = 0.001). Conclusions: Multifaceted quality improvement intervention based on the CDSS strategy is feasible and expected to facilitate implementation of the recommended VTE prophylaxis strategies and reduce the incidence of HA-VTE in hospital. However, it is necessary to conduct more multicenter clinical trials in the future to provide more reliable real-world evidence.
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Zha H, Liu K, Tang T, Yin YH, Dou B, Jiang L, Yan H, Tian X, Wang R, Xie W. Acceptance of clinical decision support system to prevent venous thromboembolism among nurses: an extension of the UTAUT model. BMC Med Inform Decis Mak 2022; 22:221. [PMID: 35986284 PMCID: PMC9392358 DOI: 10.1186/s12911-022-01958-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/19/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Venous thromboembolism has been a major public health problem and caused a heavy disease burden. Venous thromboembolism clinical decision support system was proved to have a positive influence on the prevention and management of venous thromboembolism. As the direct users, nurses' acceptance of this system is of great importance to support the successful implementation of it. However, there are few relevant studies to investigate nurses' acceptance and the associated factors are still unclear.
Objective
To investigate the determinant factors of nurses' acceptance of venous thromboembolism clinical decision support system with the modified Unified Theory of Acceptance and Use of Technology.
Methods
We designed a questionnaire based on the modified Unified Theory of Acceptance and Use of Technology and then a cross-sectional survey was conducted among nurses in a tertiary hospital in Nanjing, China. Statistically, a Structural Equation Modeling -Partial Least Squares path modeling approach was applied to examine the research model.
Results
A total of 1100 valid questionnaires were recycled. The modified model explained 74.7%, 83.0% and 86% of the variance in user satisfaction, behavioral intention and user behavior, respectively. The results showed that performance expectancy (β = 0.254, p = 0.000), social influence (β = 0.136, p = 0.047), facilitating conditions (β = 0.245, p = 0.000), self-efficacy (β = 0.121, p = 0.048) and user satisfaction (β = 0.193, p = 0.001) all had significant effects on nurses' intention. Although effort expectancy (β = 0.010, p = 0.785) did not have a direct effect on nurses' intention, it could indirectly influence nurses' intention with user satisfaction as the mediator (β = 0.296, p = 0.000). User behavior was significantly predicted by facilitating conditions (β = 0.298, p = 0.000) and user intention (β = 0.654, p = 0.001).
Conclusion
The research enhances our understanding of the determinants of nurses' acceptance of venous thromboembolism clinical decision support system. Among these factors, performance expectancy was considered as the top priority. It highlights the importance of optimizing system performance to fit the users' needs. Generally, the findings in our research provide clinical technology designers and administrators with valuable information to better meet users' requirements and promote the implementation of venous thromboembolism clinical decision support system.
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Álvarez‐Troncoso J, Ramos‐Ruperto L, Fernández‐Cidón P, Trigo‐Esteban E, Tung‐Chen Y, Busca‐Arenzana C, Quintana‐Díaz M, Buño‐Soto A, Arnalich‐Fernández F, Fernández‐Capitán C. Screening Protocol and Prevalence of Venous Thromboembolic Disease in Hospitalized Patients With COVID-19. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:1689-1698. [PMID: 34694032 PMCID: PMC8661624 DOI: 10.1002/jum.15850] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 09/04/2021] [Accepted: 09/20/2021] [Indexed: 05/18/2023]
Abstract
BACKGROUND SARS-CoV-2 disease (COVID-19) induces endothelial damage and sustained hypoxia and facilitates immobilization as factors of hypercoagulability. OBJECTIVES The objective of our study was to assess the prevalence of venous thromboembolic disease (VTD) in COVID-19 patients and the usefulness of VTD screening based on age-adjusted D-dimer and point-of-care ultrasound (POCUS). PATIENTS/METHODS We conducted a single cohort, prospective observational study in 102 consecutive hospitalized patients. RESULTS A total of 102 POCUS and 39 pulmonary computed tomography angiography (PCTA) were performed diagnosing 27 VTD (26.5%): 17 deep vein thrombosis (DVT) (16.6% positive POCUS) and 18 pulmonary embolism (PE) (46.2% positive PCTA). COVID-19 patients with VTD were older (P < .030), had higher D-dimer (P < .001), higher International Society on Thrombosis and Hemostasis score (P < .001), and higher mortality (P = .025). However, there were no differences in inflammatory laboratory parameters neither in the cytokine storm syndrome (CSS) development. The ROC curve for D-dimer showed an AUC of 0.91. We have evidenced that patients with D-dimer between 2000 and 6000 ng/mL could benefit from a screening strategy with POCUS given the high sensitivity and specificity of the test. Furthermore, patients with D-dimer ≥6000 ng/mL should undergo POCUS and PCTA to rule out DVT and PE, respectively. CONCLUSIONS In our cohort, 26.5% of the patients presented VTD. Screening strategy based on age-adjusted D-dimer and POCUS proved high sensitivity and specificity. Future trials focused on screening strategies are necessary to early detect the presence of DVT and PE and determine thromboprophylaxis strategies in patients with COVID-19.
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Affiliation(s)
| | | | | | | | - Yale Tung‐Chen
- Department of Emergency MedicineHospital Universitario La PazMadridSpain
| | | | | | - Antonio Buño‐Soto
- Department of Clinical AnalysisHospital Universitario La PazMadridSpain
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Gallier S, Topham A, Nightingale P, Garrick M, Woolhouse I, Berry MA, Pankhurst T, Sapey E, Ball S. Electronic prescribing systems as tools to improve patient care: a learning health systems approach to increase guideline concordant prescribing for venous thromboembolism prevention. BMC Med Inform Decis Mak 2022; 22:121. [PMID: 35505311 PMCID: PMC9066759 DOI: 10.1186/s12911-022-01865-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) causes significant mortality and morbidity in hospitalised patients. Risk factors for VTE are well known and there are validated risk assessment tools to support the use of prophylactic therapies. In England, reporting the percentage of patients with a completed VTE risk assessment is mandated, but this does not include whether that risk assessment resulted in appropriate prescribing. Full guideline compliance, defined as an assessment which led to an appropriate action-here prescribing prophylactic low molecular weight heparin where indicated, is rarely reported. Education, audit and feedback enhance guideline compliance but electronic prescribing systems (EPS) can mandate guideline-compliant actions. We hypothesised that a systems-based EPS intervention (prescribing rules which mandate approval or rejection of a proposed prescription of prophylactic low molecular weight heparin based on the mandated VTE assessment) would increase full VTE guideline compliance more than interventions which focused on targeting individual prescribers. METHODS All admitted patients within University Hospitals Birmingham NHS Foundation Trust were included for analysis between 2011 and 2020. The proportion of patients who received a fully compliant risk assessment and action was assessed over time. Interventions included teaching sessions and face-to-face feedback based on measured performance (an approach targeting individual prescribers) and mandatory risk assessment and prescribing rules into an EPS (a systems approach). RESULTS Data from all 235,005 admissions and all 5503 prescribers were included in the analysis. Risk assessments were completed in > 90-95% of all patients at all times, but full guideline compliance was lower (70% at the start of this study). Face-to-face feedback improved full VTE guideline compliance from 70 to 77% (p ≤ 0.001). Changes to the EPS to mandate assessment with prescribing rules increased full VTE compliance to 95% (p ≤ 0.001). Further amendments to the EPS system to reduce erroneous VTE assessments slightly reduced full compliance to 92% (p < 0.001), but this was then maintained including during changes to the low molecular weight heparin used for VTE prophylaxis. DISCUSSION An EPS-systems approach was more effective in improving sustained guideline-compliant VTE prevention over time. Non-compliance remained at 8-5% despite this mandated system. Further research is needed to assess the potential reasons for this.
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Affiliation(s)
- S. Gallier
- PIONEER Health Data Research Hub in Acute Care, Department of Health Informatics, Queen Elizabeth Hospitals NHS Foundation Trust, Mindlesohn Way, Edgbaston, Birmingham, B15 2WB UK
| | - A. Topham
- PIONEER Health Data Research Hub in Acute Care, Department of Health Informatics, Queen Elizabeth Hospitals NHS Foundation Trust, Mindlesohn Way, Edgbaston, Birmingham, B15 2WB UK
| | - P. Nightingale
- NIHR Clinical Research Facility, Queen Elizabeth Hospitals NHS Foundation Trust, Mindlesohn Way, Edgbaston, Birmingham, B15 2WB UK
| | - M. Garrick
- Department of Health Informatics, Queen Elizabeth Hospitals NHS Foundation Trust, Mindlesohn Way, Edgbaston, Birmingham, B15 2WB UK
| | - I. Woolhouse
- Respiratory Medicine, Queen Elizabeth Hospitals NHS Foundation Trust, Mindlesohn Way, Edgbaston, Birmingham, B15 2WB UK
| | - M. A. Berry
- Acute Medicine, Queen Elizabeth Hospitals NHS Foundation Trust, Mindlesohn Way, Edgbaston, Birmingham, B15 2WB UK
| | - T. Pankhurst
- Digital Healthcare and Department of Renal Medicine, Queen Elizabeth Hospitals NHS Foundation Trust, Mindlesohn Way, Edgbaston, Birmingham, B15 2WB UK
| | - E. Sapey
- grid.6572.60000 0004 1936 7486PIONEER Health Data Research Hub in Acute Care, University of Birmingham, Edgbaston, Birmingham, B15 2TH UK
| | - S. Ball
- HDR-UK Midlands Site and Better Care Programme, Queen Elizabeth Hospitals NHS Foundation Trust, Mindlesohn Way, Edgbaston, Birmingham, B15 2WB UK
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13
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Trends and risk factors for omission of early thromboprophylaxis in Australian and New Zealand ICUs between 2009 and 2020. Intensive Care Med 2022; 48:590-598. [PMID: 35362763 PMCID: PMC9050753 DOI: 10.1007/s00134-022-06672-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 03/05/2022] [Indexed: 12/18/2022]
Abstract
Purpose Venous thromboembolism (VTE) prophylaxis is effective in reducing VTE events; however, it is underutilized in critically ill patients. We examined trends and risk factors for omission of early thromboprophylaxis within the first 24 h after admission in Australian and New Zealand intensive care units (ICUs) between 2009 and 2020. Methods Retrospective analysis of data from the Australian New Zealand Intensive Care Society Adult Patient Database. Data were obtained for 1,465,020 adult admissions between 2009 and 2020. Mixed effects logistic regression modeling (accounting for the random effects of the contributing ICUs) was used to identify factors associated with omission of early thromboprophylaxis. Results A total of 107,486 (7.3%) ICU patients did not receive any form of thromboprophylaxis within the first 24 h after ICU admission without obvious reasons. Omission of early thromboprophylaxis declined from 13.7% in 2009 to 4% in 2020 (by 70.8%) (P < 0.001). Younger patients were more like to miss out on VTE prophylaxis (odds ratios (OR)per 10-year increase 0.94, 95% CI 0.95–0.99). A documented process for monitoring VTE prophylaxis (ORs 0.90, 95% CI 0.87–0.93) and having a medical lead, dedicated for coordinating ICU quality (ORper 0.1 increase in full-time equivalent 0.97, 95% CI 0.93–0.99), are associated with less omission of VTE prophylaxis. Conclusion Omission of thromboprophylaxis within the first 24 h after ICU admission has declined steadily over the past decade. Documented process for monitoring VTE prophylaxis and having a medical lead for coordinating quality of ICU care could be potential targets for sustaining the improvement in VTE prophylaxis use. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-022-06672-7.
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Hu J, Geng Y, Ma J, Dong X, Fang S, Tian J. The Best Evidence for the Prevention and Management of Lower Extremity Deep Venous Thrombosis After Gynecological Malignant Tumor Surgery: A Systematic Review and Network Meta-Analysis. Front Surg 2022; 9:841275. [PMID: 35392060 PMCID: PMC8980406 DOI: 10.3389/fsurg.2022.841275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 02/22/2022] [Indexed: 11/26/2022] Open
Abstract
Background: To search and obtain the relevant evidence of prevention and management of lower extremity deep venous thrombosis (DVT) after gynecological malignant tumor operation and to summarize the relevant evidence. Methods We searched the JBI evidence summary, up to date, the national comprehensive cancer network of the United States, the guide library of the National Institute of clinical medicine of the United Kingdom, PubMed, the Chinese biomedical literature database, CNKI, Wanfang, and other relevant evidence on the prevention and management of DVT in patients with gynecological malignant tumors. It includes clinical practice guidelines, best practice information book, expert consensus, evidence summary, original research, etc. The retrieval time limit is from database establishment till August 20, 2021. Two researchers independently evaluated the literature quality, combined with professional judgment, and extracted the literature that met the standards. Results Finally, 18 literatures were included, including eight guidelines, three evidence summaries, four systematic evaluations, two expert consensuses, and one best practice information volume. A total of 26 pieces of the best evidence on the prevention and management of postoperative venous thrombosis in gynecological malignant tumors were summarized. It includes risk assessment, drug prevention, mechanical prevention, management strategy, and health education. Conclusion This study summarized the best evidence of risk, prevention, and health management of DVT in postoperative patients with gynecological malignant tumors to provide evidence-based basis for clinical nurses and to improve the nursing level.
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Affiliation(s)
- Jiaqi Hu
- College of Nursing, Chengde Medical University, Chengde, China
| | - Yidan Geng
- College of Nursing, Chengde Medical University, Chengde, China
| | - Jingyi Ma
- College of Nursing, Chengde Medical University, Chengde, China
| | - Xuefan Dong
- College of Nursing, Chengde Medical University, Chengde, China
| | - Shuqin Fang
- Department of Gynecology, Affiliated Hospital of Chengde Medical University, Chengde, China
| | - Jianli Tian
- College of Nursing, Chengde Medical University, Chengde, China
- *Correspondence: Jianli Tian
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Chong J, Curtain C, Gad F, Passam F, Soo G, Levy R, Dunkley S, Wong Doo N, Cunich M, Burke R, Chen V. Development and implementation of venous thromboembolism stewardship across a hospital network. Int J Med Inform 2021; 155:104575. [PMID: 34560489 DOI: 10.1016/j.ijmedinf.2021.104575] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 08/21/2021] [Accepted: 09/09/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a leading cause of preventable death in hospital. Ensuring all hospitalized patients are assessed for VTE risk and given appropriate prophylaxis can reduce the burden of VTE on patients and the healthcare system. This is the first study to explore the effectiveness of a VTE stewardship program using electronic clinical decision support (eCDS) to provide oversight of hospital initiatives to prevent VTE. AIM To determine if a VTE stewardship program can increase risk-appropriate VTE prophylaxis, VTE risk assessment using eCDS, any documented risk assessment and risk assessment within 24 h of admission, plus reduce the incidence of hospital acquired VTE (HA-VTE). METHODS Education, daily medication chart auditing, weekly clinician performance feedback, health promotion and gamification were deployed over 6 months by two multidisciplinary VTE stewardship teams across four hospitals. Service impact was assessed through cross-sectional audits of electronic medical records every 3 months and review of HA-VTE events pre- and post-intervention. Implementation costs were calculated. RESULTS A total of 1622 patients were audited in separate cohorts at baseline, 3, 6 and 9 months. There was significant improvement in the prescription of appropriate prophylaxis (78%, 83%, 84%, and 88%, p = 0.004), VTE risk assessment using the eCDS tool (20%, 50%, 81% and 87%, p < 0.001), any documented risk assessment (71%, 82%, 95% and 93%, p < 0.001) and any documented risk assessment within 24 h of admission (54%, 56%, 65% and 63%, p = 0.001). Use of eCDS was associated with prescription of risk-appropriate VTE prophylaxis (p < 0.001). Annual incidence of HA-VTE decreased from 7.88 to 6.99 events per 10,000 discharges pre- to post-intervention (Odds Ratio (OR) 0.89, 95 %CI 0.66-1.18, p = 0.43). The cost of implementing the program across 133,078 episodes of care during the study period was AUD$108,167 (mean cost of $0.82 per patient).
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Affiliation(s)
- Julianne Chong
- Concord Repatriation General Hospital, Pharmacy Department, Sydney, Australia.
| | - Colin Curtain
- University of Tasmania, School of Pharmacy and Pharmacology, Hobart, Australia
| | - Fady Gad
- Royal Prince Alfred Hospital, Pharmacy Department, Sydney, Australia
| | - Freda Passam
- Royal Prince Alfred Hospital, Department of Hematology, Sydney, Australia
| | - Garry Soo
- Concord Repatriation General Hospital, Pharmacy Department, Sydney, Australia
| | - Russell Levy
- Royal Prince Alfred Hospital, Pharmacy Department, Sydney, Australia
| | - Scott Dunkley
- Royal Prince Alfred Hospital, Department of Hematology, Sydney, Australia
| | - Nicole Wong Doo
- Concord Repatriation General Hospital, Department of Hematology, Sydney, Australia; University of Sydney, Concord Clinical School, Sydney, Australia
| | - Michelle Cunich
- University of Sydney, Charles Perkins Centre, Faculty of Medicine and Health (Central Clinical School), Sydney, Australia; Sydney Local Health District, Sydney Health Economics Collaborative, Sydney, Australia
| | - Rosemary Burke
- Executive Unit, Sydney Local Health District, Sydney, Australia
| | - Vivien Chen
- Concord Repatriation General Hospital, Department of Hematology, Sydney, Australia; Anzac Research Institute, Concord, Sydney, Australia; University of Sydney, Faculty of Medicine and Health, Sydney, Australia
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Jaspers T, Duisenberg-van Essenberg M, Maat B, Durian M, van den Berg R, van den Bemt P. A multifaceted clinical decision support intervention to improve adherence to thromboprophylaxis guidelines. Int J Clin Pharm 2021; 43:1327-1336. [PMID: 33709383 PMCID: PMC8460504 DOI: 10.1007/s11096-021-01254-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 02/20/2021] [Indexed: 12/04/2022]
Abstract
Background Venous thromboembolism is a potentially fatal complication of hospitalisation, affecting approximately 3% of non-surgical patients. Administration of low molecular weight heparins to the appropriate patients adequately decreases venous thromboembolism incidence, but guideline adherence is notoriously low. Objective To determine the effect of a multifaceted intervention on thromboprophylaxis guideline adherence. The secondary objective was to study the effect on guideline adherence specifically in patients with a high venous thromboembolism risk. As an exploratory objective, we determined how many venous thromboembolisms may be prevented. Setting A Dutch general teaching hospital. Method A prospective study with a pre- and post-intervention measurement was conducted. A multifaceted intervention, consisting of Clinical Decision Support software, a mobile phone application, monitoring of duplicate anticoagulants and training, was implemented. Guideline adherence was assessed by calculating the Padua prediction and Improve bleeding score for each patient. The number of preventable venous thromboembolisms was calculated using the incidences of venous thromboembolism in patients with and without adequate thromboprophylaxis and extrapolated to the annual number of admitted patients. Main outcome measure Adherence to thromboprophylaxis guidelines in pre- and post-intervention measurements. Results 170 patients were included: 85 in both control and intervention group. The intervention significantly increased guideline adherence from 49.4 to 82.4% (OR 4.78; 95%CI 2.37–9.63). Guideline adherence in the patient group with a high venous thromboembolism risk also increased significantly from 54.5 to 84.3% (OR 2.46; 95%CI 1.31–4.62), resulting in the potential prevention of ± 261 venous thromboembolisms per year. Conclusions Our multifaceted intervention significantly increased thromboprophylaxis guideline adherence.
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Affiliation(s)
- Tessa Jaspers
- Department of Hospital Pharmacy, Elisabeth TweeSteden Hospital, Dr. Deelenlaan 5, 5042 AD, Tilburg, The Netherlands.
| | | | - Barbara Maat
- Department of Hospital Pharmacy, Elisabeth TweeSteden Hospital, Dr. Deelenlaan 5, 5042 AD, Tilburg, The Netherlands
| | - Marc Durian
- Department of Oncology and Hematology, Elisabeth TweeSteden Hospital, Hilvarenbeekse Weg 60, 5022 GC, Tilburg, The Netherlands
| | - Roy van den Berg
- Intensive Care Unit, Elisabeth TweeSteden Hospital, Hilvarenbeekse Weg 60, 5022 GC, Tilburg, The Netherlands
| | - Patricia van den Bemt
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
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Wang Y, Zhu LY, Deng HB, Yang X, Wang L, Xu Y, Wang XJ, Pang D, Sun JH, Cao J, Liu G, Liu Y, Ma YF, Wu XJ. Quality appraisal of clinical guidelines for venous thromboembolism prophylaxis in patients undergoing hip and knee arthroplasty: a systematic review. BMJ Open 2020; 10:e040686. [PMID: 33303451 PMCID: PMC7733196 DOI: 10.1136/bmjopen-2020-040686] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 10/25/2020] [Accepted: 11/05/2020] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Venous thromboembolism (VTE) occurs in up to 40%-80% of patients after hip and knee arthroplasty. Clinical decision-making aided by guidelines is the most effective strategy to reduce the burden of VTE. However, the quality of guidelines is dependent on the strength of their evidence base. The objective of this article is to critically evaluate the quality of VTE prevention guidelines and the strength of their recommendations in VTE prophylaxis in patients undergoing hip and knee arthroplasty. METHODS Relevant literature up to 16 March 2020 was systematically searched. We searched databases such as Web of Science, PubMed, EMBASE, Cumulative Index of Nursing and Allied Health Literature, China National Knowledge Infrastructure and WanFang and nine guidelines repositories. The identified guidelines were appraised by two reviewers using the Appraisal of Guidelines for Research and Evaluation II and appraised the strength of their recommendations independently. Following quality assessment, a predesigned data collection form was used to extract the characteristics of the included guideline. RESULTS We finally included 15 guidelines. Ten of the included guidelines were rated as 'recommended' or 'recommended with modifications'. The standardised scores were relatively high in the domains of Clarity of Presentation, and Scope and Purpose. The lowest average standardised scores were observed in the domains of Applicability and Stakeholder Involvement. In reference to the domains of Rigour of Development and Editorial Independence, the standardised scores varied greatly between the guidelines. The agreement between the two appraisers is almost perfect (intraclass correlation coefficients higher than 0.80). A considerable proportion of the recommendations is based on low-quality or very-low-quality evidence or is even based on working group expert opinion. CONCLUSIONS In summary, the majority of the recommendations are based on low-quality evidence, and further confirmation is needed. Furthermore, guideline developers should pay more attention to methodological quality, especially in the Stakeholder Involvement domain and the Applicability domain.
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Affiliation(s)
- Yu Wang
- Department of Nursing, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Li-Yun Zhu
- Department of Nursing, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Hai-Bo Deng
- Department of Cardiac Surgery, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Xu Yang
- Department of Orthopedic Surgery, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Lei Wang
- Department of Vascular Surgery, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Yuan Xu
- Department of Orthopedic Surgery, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Xiao-Jie Wang
- Department of Breast Surgery, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Dong Pang
- School of Nursing, Peking University, Beijing, China
- Evidence-Based Nursing: A Joanna Briggs Institute Centre of Excellence, Peking University Health Science Centre, Beijing, China
| | - Jian-Hua Sun
- Intensive Care Unit, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Jing Cao
- Department of Nursing, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Ge Liu
- Department of Neurological Surgery, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Ying Liu
- Department of General Surgery, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Yu-Fen Ma
- Outpatient Department, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Xin-Juan Wu
- Department of Nursing, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
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18
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Schlick CJR, Merkow RP, Yang AD, Bentrem DJ. Post-discharge venous thromboembolism after pancreatectomy for malignancy: Predicting risk based on preoperative, intraoperative, and postoperative factors. J Surg Oncol 2020; 122:675-683. [PMID: 32531819 PMCID: PMC7755307 DOI: 10.1002/jso.26046] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 05/17/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Extended chemoprophylaxis is recommended for high-risk patients following pancreatectomy for malignancy. However, quantifying risk remains difficult. We sought to (a) identify factors associated with post-discharge venous thromboembolism (VTE) following pancreatectomy for malignancy and (b) develop a post-discharge VTE risk calculator to identify high-risk patients. METHODS Patients who underwent pancreatectomy for malignant histology from 2014 to 2018 were identified from the ACS NSQIP pancreatectomy procedure targeted dataset. Preoperative, intraoperative, and postoperative factors known at hospital discharge were evaluated for association with post-discharge VTE via multivariable logistic regression. A post-discharge VTE risk calculator was developed and validated. RESULTS Of 19 340 analyzed patients, 280 (1.5%) developed post-discharge VTE. Post-discharge VTE was associated with increasing body mass index (BMI; eg, morbidly obese BMI odds ratio [OR]: 1.99 [95% confidence interval {CI}: 1.30-3.02] vs normal BMI), procedure type (distal pancreatectomy OR: 1.47 [95% CI: 1.02-2.12] vs pancreaticoduodenectomy), pancreatic fistula (OR: 1.59 [95% CI: 1.19-2.13]) and delayed gastric emptying (OR: 1.81 [95% CI: 1.29-2.52]). Patients' predicted probability of post-discharge VTE ranged from 0.7% to 9.0%. Twenty iterations of 10-fold cross-validation demonstrated internal validity. CONCLUSIONS Preoperative, intraoperative, and postoperative factors were associated with post-discharge VTE following pancreatectomy for malignancy. This post-discharge VTE risk calculator allows for quantification of individual post-discharge VTE risk, which ranged from 0.7% to 9.0%.
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Affiliation(s)
- Cary Jo R. Schlick
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Ryan P. Merkow
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL
| | - Anthony D. Yang
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - David J. Bentrem
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Surgery Service, Jesse Brown VA Medical Center, Chicago, IL
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19
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George B, Gonzales S, Patel K, Petit S, Franck AJ, Bovio Franck J. Impact of a Clinical Decision-Support Tool on Venous Thromboembolism Prophylaxis in Acutely Ill Medical Patients. J Pharm Technol 2020; 36:141-147. [PMID: 34752541 DOI: 10.1177/8755122520930288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Adherence to guideline-based venous thromboembolism (VTE) prophylaxis recommendations is often inadequate. Effective improvement strategies are needed. Objective: The purpose of this quality improvement initiative was to increase use of the facility's preferred pharmacologic VTE prophylaxis, reduce unnecessary VTE prophylaxis use, and reduce use of pharmacologic VTE prophylaxis in high bleeding risk patients, in accordance with guideline-based recommendations. Methods: Clinical pharmacists spearheaded the development and implementation of a clinical decision-support tool (CDST) integrated within a Veterans Health Administration electronic health record (EHR). The CDST focused on VTE prophylaxis in acutely ill medical patients and guided prescribers to guideline-based recommendations. Following review and approval, the CDST underwent activation in the EHR. A subsequent intervention occurred, year 2 post-intervention, which embedded this CDST into the EHR admission process and admission menus. A drug message was added in the EHR to alert prescribers that low-molecular-weight heparin was the preferred agent. Measures were evaluated pre-intervention, year 1 post-intervention, and year 2 post-intervention. Results: After intervention, there were statistically significant increases in the proportion of patients receiving the facility's preferred pharmacologic VTE prophylaxis agent, enoxaparin, and a statistically significant decrease in the proportion of unwarranted VTE prophylaxis. The proportion of inappropriate pharmacologic VTE prophylaxis in high bleeding risk patients decreased, but this result did not reach statistical significance. Conclusion: The improvements observed suggest the beneficial role of CDSTs integrated into the EHR to increase adherence to guideline-based VTE prophylaxis recommendations.
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Affiliation(s)
- Brandon George
- Orlando Veterans Affairs Healthcare System, Orlando, FL, USA.,North Florida/South Georgia Veterans Health System, Gainesville, FL, USA
| | - Samantha Gonzales
- North Florida/South Georgia Veterans Health System, Gainesville, FL, USA.,Southern Arizona Veterans Affairs Health Care System, Tucson, AZ, USA
| | - Krishna Patel
- North Florida/South Georgia Veterans Health System, Gainesville, FL, USA.,San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Stephanie Petit
- North Florida/South Georgia Veterans Health System, Gainesville, FL, USA.,North Florida/South Georgia Veterans Health System, Jacksonville, FL, USA
| | - Andrew J Franck
- North Florida/South Georgia Veterans Health System, Gainesville, FL, USA
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20
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Dong F, Zhen K, Zhang Z, Si C, Xia J, Zhang T, Xia L, Wang W, Jia C, Shan G, Zhai Z, Wang C. Effect on thromboprophylaxis among hospitalized patients using a system-wide multifaceted quality improvement intervention: Rationale and design for a multicenter cluster randomized clinical trial in China. Am Heart J 2020; 225:44-54. [PMID: 32474204 PMCID: PMC7204686 DOI: 10.1016/j.ahj.2020.04.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/25/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a life-threatening disease that can affect each hospitalized patient. But the current in-hospital thromboprophylaxis remains suboptimal and there exists a large gap between clinical practice and guideline-recommended care in China. METHODS To facilitate implementation of guideline recommendations, we conduct a multicenter, adjudicator-blinded, cluster-randomized clinical trial, aiming to assess the effectiveness of a system-wide multifaceted quality improvement (QI) strategy on VTE prophylaxis improvement and thromboembolism reduction in clinical setting. Hospitals are randomized into intervention or control group. In intervention group, hospitals receive the concept of appropriate in-hospital thromboprophylaxis plus a multifaceted QI which encompasses four components: (1) an electronic alert combining computer-based clinical decision support system and electronic reminders, (2) appropriate prophylaxis based on dynamic VTE and bleeding risk assessments, (3) periodical audit and interactive feedback on performance, (4) strengthened training and patient education. In control, hospitals receive the concept of recommended prophylaxis alone without QI. Thromboprophylaxis will be at the discretion of hospitals and conducted as usual. With a final sample size of 5760 hospitalized patients in 32 hospitals on mainland China, this trial will examine the effect of QI on improvement in thromboprophylaxis and patient-centered outcomes. This is an open-label trial that patients and healthcare professionals will know group allocation after enrollment, but endpoint adjudicators and statisticians will be blinded. RCT# NCT04211181 CONCLUSIONS: The system-wide multifaceted QI intervention is expected to facilitate implementation of recommended VTE prophylaxis in hospital, thereafter reducing VTE incidence and relevant adverse events among hospitalized patients in China.
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Affiliation(s)
- Fen Dong
- Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Kaiyuan Zhen
- Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China; National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Zhu Zhang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China; National Clinical Research Center for Respiratory Diseases, Beijing, China; Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chaozeng Si
- Department of information management, China-Japan Friendship Hospital, Beijing, China
| | - Jiefeng Xia
- Department of information management, China-Japan Friendship Hospital, Beijing, China
| | - Tieshan Zhang
- Department of information management, China-Japan Friendship Hospital, Beijing, China
| | - Lei Xia
- Medical Affairs Department of China-Japan Friendship Hospital, Beijing, China
| | - Wei Wang
- Department of Nursing, China-Japan Friendship Hospital, Beijing, China
| | - Cunbo Jia
- China-Japan Friendship Hospital, Beijing, China
| | - Guangliang Shan
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Zhenguo Zhai
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China; National Clinical Research Center for Respiratory Diseases, Beijing, China.
| | - Chen Wang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China; National Clinical Research Center for Respiratory Diseases, Beijing, China; Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Preston H, Swan I, Davies L, Dummer S, Aravindan V, Beh YY, Lockman A. Improving VTE risk assessment and prophylaxis prescribing rate in medical patients: integrating risk assessment tool into the workflow. BMJ Open Qual 2020; 9:bmjoq-2019-000903. [PMID: 32540948 PMCID: PMC7295437 DOI: 10.1136/bmjoq-2019-000903] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 04/24/2020] [Accepted: 05/16/2020] [Indexed: 01/23/2023] Open
Abstract
Medical inpatients often have important risk factors for venous thromboembolism (VTE). In our institution, VTE prophylaxis in this group was underused. The main barriers identified were inattention to VTE prophylaxis, competing priorities and lack of confidence in the decision-making. We aimed to improve the rate of VTE prophylaxis use by introducing a paper-based risk assessment tool, with actionable management recommendations within the prescription chart. The rationale was that an assessment tool at the point of prescribing can reduce steps between decision-making and prescribing process, thus promoting confidence and acting as a reminder. A total of 552 prescription charts completed over a period of 29 weeks were examined during the baseline period. In the postintervention period, 871 charts completed over 40 weeks period were examined. The risk assessment tool was completed in 51% of the cases examined in the postintervention period. The introduction of the risk assessment tool was associated with a significant change in the pattern of VTE pharmacological prophylaxis use. The change occurred when the form was made highly visible and enclosed in the prescription chart. The pharmacological prophylaxis use was higher with a completed assessment form than without (mean (SD) 97.5% (7.6%) vs 70.1% (19.4%); p<0.0001). The rate of appropriate prophylaxis decision was 98.2% (SD 5.2%) with a completed assessment form, and 80.7% (SD 17.9%) when it was not used. The qualitative interviews revealed positive themes; many users found it useful, easy and convenient to use. Our data have shown that a paper-based VTE risk assessment tool placed within the prescription chart could substantially improve the rate of appropriate assessment and VTE prophylaxis implementation. This suggests that tool clearly needs to be a seamless integration into the workflow to capture users’ attention and mitigate the influence of time perception.
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Affiliation(s)
- Hannah Preston
- Acute and General Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Iain Swan
- Acute and General Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Lauren Davies
- Acute and General Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Simon Dummer
- Acute and General Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Yuan Ye Beh
- Acute and General Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Ann Lockman
- Acute and General Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
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Inappropriate Venous Thromboembolism Prophylaxis in a General Surgery Department: Risk Factors and Improvement with a Simple Educational Program. Indian J Surg 2020. [DOI: 10.1007/s12262-020-02148-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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23
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Castaldi M, George G, Turner P, McNelis J. NSQIP Impacts Patient Experience. J Patient Exp 2020; 7:89-95. [PMID: 32128376 PMCID: PMC7036676 DOI: 10.1177/2374373518817081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
National Quality Improvement Project (NSQIP) semiannual reports (SARs) revealed high observed to expected ratios for venous thromboembolic events (VTEs) on the surgical service. Press Ganey scores identified an area of particular weakness in shared decision-making in patient care. Patients reported little to no participation in shared decision-making. A performance improvement project was developed with a 2-fold objective: decrease the percentages of patients sustaining VTE through adequate screening and prophylaxis (VTEP) and to engage patients in shared decision-making to accept VTEP through enhanced patient-centered discussions and education on the risks and benefits of VTEP. A clinical pathway was developed to implement VTEP using a standardized risk assessment tool. Patient-centered discussion introduced VTEP and impact on perioperative safety. Results included telephone survey, NSQIP SARs, and Press Ganey patient experience survey. Using NSQIP data and a pathway developed for both VTE risk assessment and patient engagement, the authors observe immediate improvements in patient experience and decreased rates of VTE.
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Affiliation(s)
- Maria Castaldi
- Jacobi Medical Center, Bronx, NY, USA.,Westchester Medical Center, Valhalla, NY, USA
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Yu Y, Lu S, Sun J, Zhou W, Liu H. Thromboprophylactic Efficacy and Safety of Anticoagulants After Arthroscopic Knee Surgery: A Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost 2019; 25:1076029619881409. [PMID: 31617409 PMCID: PMC6900624 DOI: 10.1177/1076029619881409] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
To examine the efficacy and safety of anticoagulants after knee arthroscopy (KA),
PubMed, EMBASE, databases of Cochrane Central Register of Controlled Trials, and
Chinese National Knowledge Infrastructure were searched up to August 2019 for
randomized controlled trials (RCT). Seven RCTs including 4097 patients were
demonstrated eligible according to the inclusion and exclusion criteria. The
efficacy and safety of thromboprophylaxis were assessed and expressed using
relative risk (RR) and 95% confidence intervals (95% CIs). The analysis of
pooled data showed that anticoagulants group exhibited significant lower overall
incidence of symptomatic and asymptomatic venous thromboembolism (VTE; RR =
0.35, 95% CIs: 0.22-0.55, P < .00001), significant higher
incidence of all bleeding events (RR = 1.42, 95% CIs: 1.08-1.86,
P = .01) compared to control group. However, no significant
difference was found in terms of incidence of symptomatic VTE (RR = 0.43, 95%
CIs: 0.15-1.21, P = .11) and incidence of major bleeding events
(RR = 1.87, 95% CIs: 0.40-8.67, P = .42). The pooled number
needed to treat to prevent one symptomatic or asymptomatic VTE was 26, while the
pooled number needed to harm to cause one major bleeding event was 869. These
results show that anticoagulants can effectively reduce the overall risk of VTE
after KA; however, the increased risk of bleeding should be fully considered.
Further studies are required to address the risk–benefit calculus and
cost-effectiveness of anticoagulants after KA.
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Affiliation(s)
- Yang Yu
- Department of Orthopedics Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Shitao Lu
- Department of Orthopedics Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Jinpeng Sun
- Department of Orthopedics Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Wei Zhou
- Department of Orthopedics Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Hongjian Liu
- Department of Orthopedics Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan Province, China
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25
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Kahn SR, Diendéré G, Morrison DR, Piché A, Filion KB, Klil-Drori AJ, Douketis J, Emed J, Roussin A, Tagalakis V, Morris M, Geerts W. Effectiveness of interventions for the implementation of thromboprophylaxis in hospitalised patients at risk of venous thromboembolism: an updated abridged Cochrane systematic review and meta-analysis of randomised controlled trials. BMJ Open 2019; 9:e024444. [PMID: 31129575 PMCID: PMC6537979 DOI: 10.1136/bmjopen-2018-024444] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 01/30/2019] [Accepted: 03/04/2019] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To assess the effectiveness of system-wide interventions designed to increase the implementation of thromboprophylaxis and decrease the incidence of venous thromboembolism (VTE) in hospitalised medical and surgical patients at risk of VTE. DESIGN Systematic review and meta-analysis of randomised controlled trials (RCTs). DATA SOURCES Medline, PubMed, Embase, BIOSIS, CINAHL, Web of Science, CENTRAL, DARE, EED, LILACS and clinicaltrials.gov without language restrictions from inception to 7 January 2017, as well as the reference lists of relevant review articles. ELIGIBILITY CRITERIA FOR SELECTING STUDIES RCTs that evaluated the effectiveness of system-wide interventions such as alerts, multifaceted, education, and preprinted orders when compared with no intervention, existing policy or another intervention. RESULTS We included 13 RCTs involving 35 997 participants. Eleven RCTs had data available for meta-analysis. Compared with control, we found absolute increase in the prescription of prophylaxis associated with alerts (21% increase, 95% CI [15% to 275%]) and multifaceted interventions (4% increase, 95% CI [3% to 11%]), absolute increase in the prescription of appropriate prophylaxis associated with alerts (16% increase, 95% CI [12% to 20%]) and relative risk reductions (risk ratio 64%, 95% CI [47% to 86%]) in the incidence of symptomatic VTE associated with alerts. Computer alerts were found to be more effective than human alerts, and multifaceted interventions with an alert component appeared to be more effective than multifaceted interventions without, although comparative pooled analyses were not feasible. The quality of evidence for improvement in outcomes was judged to be low to moderate certainty. CONCLUSIONS Alerts increased the proportion of patients who received prophylaxis and appropriate prophylaxis, and decreased the incidence of symptomatic VTE. Multifaceted interventions increased the proportion of patients who received prophylaxis but were found to be less effective than alerts interventions. TRIAL REGISTRATION NUMBER CD008201.
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Affiliation(s)
- Susan R Kahn
- Medicine, McGill University, Montreal, Quebec, Canada
| | - Gisele Diendéré
- Centre of Excellence in Thrombosis and Anticoagulation Care (CETAC), Clinical Epidemiology of the Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
| | - David R Morrison
- Centre of Excellence in Thrombosis and Anticoagulation Care (CETAC), Clinical Epidemiology of the Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
| | - Alexandre Piché
- Department of Mathematics and Statistics, McGill University, Montreal, Quebec, Canada
| | | | - Adi J Klil-Drori
- Medicine, McGill University, Montreal, Quebec, Canada
- Centre of Excellence in Thrombosis and Anticoagulation Care (CETAC), Clinical Epidemiology of the Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
| | - James Douketis
- Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jessica Emed
- Nursing, Jewish General Hospital, Montreal, Quebec, Canada
| | - André Roussin
- Medicine, University of Montreal, Montreal, Quebec, Canada
- Thrombosis Canada, Whitby, Ontario, Canada
| | - Vicky Tagalakis
- Centre of Excellence in Thrombosis and Anticoagulation Care (CETAC), Clinical Epidemiology of the Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
- Internal Medicine and Medicine, McGill University, Montreal, Quebec, Canada
| | - Martin Morris
- Schulich Library of Physical Sciences, Life Sciences and Engineering, McGill University, Montreal, Quebec, Canada
| | - William Geerts
- Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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A multicentre controlled pre-post trial of an implementation science intervention to improve venous thromboembolism prophylaxis in critically ill patients. Intensive Care Med 2019; 45:211-222. [PMID: 30707246 DOI: 10.1007/s00134-019-05532-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 01/14/2019] [Indexed: 12/29/2022]
Abstract
PURPOSE To test whether a multicomponent intervention would increase the use of low molecular weight heparin (LMWH) over unfractionated heparin (UFH) for venous thromboembolism (VTE) prophylaxis in critically ill patients and change patient outcomes and healthcare utilization. METHODS Controlled pre-post trial of 12,342 adults admitted to 11 ICUs (five intervention, six control) May 1, 2015 to April 30, 2017 with no contraindication to pharmacological prophylaxis and an ICU stay longer than 24 h. Models were developed to examine temporal changes in ICU VTE prophylaxis (primary outcome), VTE, major bleeding, heparin-induced thrombocytopenia (HIT), death and hospital costs. RESULTS The use of LMWH increased from 45.9% to 78.3% of patient days in the intervention group and from 37.9% to 53.3% in the control group, an absolute increase difference of 17.0% (32.4% vs. 15.4%, p = 0.001). Changes in the administration of UFH were inversely related to those of LMWH. There were no significant differences in the adjusted odds of VTE (ratio of odds ratios [rOR] 1.13, 95% CI 0.51-2.46) or major bleeding (rOR 1.22, 95% CI 0.97-1.54) post-implementation of the intervention (compared to pre-implementation) between the intervention group and the control group. HIT was uncommon in both groups (n = 20 patients). There were no significant changes for ICU and hospital mortality, length of stay and costs. Results were similar when stratified according to reason for ICU admission, patient weight and kidney function. CONCLUSIONS A multicomponent intervention changed practice, but not clinical and economic outcomes. The benefit of implementing LMWH for VTE prophylaxis under real-world conditions is uncertain.
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