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Almanzar A, Dahmani SL, Shoucair S, Sun Z, Ayscue J, Bello B, Berkey S. Risk factors for post-operative VTE following colorectal surgery: Is caprini score enough? Am J Surg 2024; 235:115703. [PMID: 38462412 DOI: 10.1016/j.amjsurg.2024.02.046] [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: 11/30/2023] [Revised: 02/15/2024] [Accepted: 02/27/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Post-operative colorectal venous thromboembolism (VTE) rates range between 1 and 3%. Often, surgeons utilize risk assessment models, like the modified Caprini, to determine need for prophylaxis. However, studies reveal additional unaccounted risk factors like preoperative serum albumin level, perioperative blood transfusion, emergency surgery, and preoperative steroid use. METHODS This was a multicenter, retrospective study conducted between January 2021-December 2021. The primary endpoint was to assess the VTE rate within 30 days post-operatively. RESULTS Overall, incidence rate was 1.75%. Of these, 53% underwent urgent/emergent surgery and 60% had perioperative blood transfusions. Twelve patients had a known preoperative serum albumin level, with 66% being less than 3.5 g/dL. Only 30% of patients had a high Caprini risk score. No patient had preoperative steroid use. CONCLUSION The study suggests considering urgent/emergent surgeries, low preoperative albumin levels, and blood transfusions for enhanced VTE screening and prophylaxis in post-operative colorectal patients.
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Affiliation(s)
- Anyelin Almanzar
- Department of Colorectal Surgery, Medstar Washington Hospital Center, USA.
| | | | - Sami Shoucair
- Department of General Surgery, Medstar Franklin Square Medical Center, USA
| | - Zhifei Sun
- Department of Colorectal Surgery, Medstar Washington Hospital Center, USA
| | - Jennifer Ayscue
- Department of Colorectal Surgery, Orlando Health Regional Medical Center, USA
| | - Brian Bello
- Department of Colorectal Surgery, Medstar Washington Hospital Center, USA
| | - Sara Berkey
- Department of Colorectal Surgery, Medstar Washington Hospital Center, USA
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Wang X, Chen S, Sun L, Zhao Z, Xiong P, Lu X, Ding A. Development and validation of a nomogram for identifying venous thromboembolism following oral and maxillofacial oncological surgery with simultaneous reconstruction. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107307. [PMID: 38048726 DOI: 10.1016/j.ejso.2023.107307] [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: 07/21/2023] [Revised: 11/15/2023] [Accepted: 11/24/2023] [Indexed: 12/06/2023]
Abstract
OBJECTIVES This study aimed to establish and validate a novel predictive model for venous thromboembolism (VTE) in patients undergoing oral and maxillofacial oncological surgery with simultaneous reconstruction. MATERIAL AND METHODS A total of 372 patients were selected, and their demographic data, comorbidities, medical history, laboratory variables, postoperative Caprini scores, perioperative indicators, and procedures were recorded and analyzed to build the model. The predictive model is displayed as a nomogram. RESULTS The incidence of VTE was 20.7% (77/372). Several factors were found to be significantly associated with VTE, including age (67 vs. 56 years, P < 0.001), preoperative level of D-dimer (0.56 vs. 0.36 mg/L, P < 0.001), proportion of female patients (46.8% vs. 33.6%, P = 0.032), hypertension (33.8% vs. 21%, P = 0.019). The predictive model was composed of age, gender, and preoperative D-dimer level, with good discriminative ability, as reflected by an area under the curve (AUC) of 0.756, the 95% confidence interval (CI) was 0.696-0.816. Moreover, it showed favorable diagnostic performance compared with both the 2005 (AUC 0.646, 95% CI = 0.578-0.714) and 2010 (AUC 0.627, 95% CI = 0.559-0.694) versions of the Caprini risk assessment model. For patients with malignant tumor, neoadjuvant chemotherapy was also an independent risk factor. CONCLUSIONS This novel predictive model consists of three readily available clinical variables that show good diagnostic performance in predicting postoperative VTE.
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Affiliation(s)
- Xin Wang
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, China
| | - Shijie Chen
- Clinical Research Unit, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, China
| | - Lulu Sun
- Department of Anesthesiology and Critical Care Medicine, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, China
| | - Zhen Zhao
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, China
| | - Ping Xiong
- Department of Ultrasound, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, China.
| | - Xinwu Lu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, China.
| | - Angang Ding
- Department of Ultrasound, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, China.
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3
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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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Schnipper JL, Reyes Nieva H, Yoon C, Mallouk M, Mixon AS, Rennke S, Chu ES, Mueller SK, Smith GR, Williams MV, Wetterneck TB, Stein J, Dalal AK, Labonville S, Sridharan A, Stolldorf DP, Orav EJ, Gresham M, Goldstein J, Platt S, Nyenpan CT, Howell E, Kripalani S. What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study. BMJ Qual Saf 2023; 32:457-469. [PMID: 36948542 PMCID: PMC11046420 DOI: 10.1136/bmjqs-2022-014806] [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: 02/04/2022] [Accepted: 01/31/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND The second Multicenter Medication Reconciliation Quality Improvement Study demonstrated a marked reduction in medication discrepancies per patient. The aim of the current analysis was to determine the association of patient exposure to each system-level intervention and receipt of each patient-level intervention on these results. METHODS This study was conducted at 17 North American Hospitals, the study period was 18 months per site, and sites typically adopted interventions after 2-5 months of preintervention data collection. We conducted an on-treatment analysis (ie, an evaluation of outcomes based on patient exposure) of system-level interventions, both at the category level and at the individual component level, based on monthly surveys of implementation site leads at each site (response rate 65%). We then conducted a similar analysis of patient-level interventions, as determined by study pharmacist review of documented activities in the medical record. We analysed the association of each intervention on the adjusted number of medication discrepancies per patient in admission and discharge orders, based on a random sample of up to 22 patients per month per site, using mixed-effects Poisson regression with hospital site as a random effect. We then used a generalised linear mixed-effects model (GLMM) decision tree to determine which patient-level interventions explained the most variance in discrepancy rates. RESULTS Among 4947 patients, patient exposure to seven of the eight system-level component categories was associated with modest but significant reductions in discrepancy rates (adjusted rate ratios (ARR) 0.75-0.97), as were 15 of the 17 individual system-level intervention components, including hiring, reallocating and training personnel to take a best possible medication history (BPMH) and training personnel to perform discharge medication reconciliation and patient counselling. Receipt of five of seven patient-level interventions was independently associated with large reductions in discrepancy rates, including receipt of a BPMH in the emergency department (ED) by a trained clinician (ARR 0.40, 95% CI 0.37 to 0.43), admission medication reconciliation by a trained clinician (ARR 0.57, 95% CI 0.50 to 0.64) and discharge medication reconciliation by a trained clinician (ARR 0.64, 95% CI 0.57 to 0.73). In GLMM decision tree analyses, patients who received both a BPMH in the ED and discharge medication reconciliation by a trained clinician experienced the lowest discrepancy rates (0.08 per medication per patient). CONCLUSION AND RELEVANCE Patient-level interventions most associated with reductions in discrepancies were receipt of a BPMH of admitted patients in the ED and admission and discharge medication reconciliation by a trained clinician. System-level interventions were associated with modest reduction in discrepancies for the average patient but are likely important to support patient-level interventions and may reach more patients. These findings can be used to help hospitals and health systems prioritise interventions to improve medication safety during care transitions.
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Affiliation(s)
- Jeffrey L Schnipper
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Hospital Medicine Unit, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
| | - Harry Reyes Nieva
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Catherine Yoon
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
| | - Meghan Mallouk
- Center for Quality Improvement, Society of Hospital Medicine, Philadelphia, Pennsylvania, USA
| | - Amanda S Mixon
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stephanie Rennke
- UCSF Health and Department of Medicine, Division of Hospital Medicine, University of California San Francisco Medical Center, San Francisco, California, USA
| | - Eugene S Chu
- Parkland Health and Hospital System and Hospital Medicine Service, Department of Internal Medicine, University of Texas Southwestern School of Medicine, Dallas, Texas, USA
| | - Stephanie K Mueller
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Hospital Medicine Unit, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
| | - G Randy Smith
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Mark V Williams
- Division of Hospital Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Tosha B Wetterneck
- Department of Medicine, Center for Quality and Productivity Improvement, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison College of Engineering, Madison, Wisconsin, USA
| | - Jason Stein
- Section of Hospital Medicine, Emory University Hospital and 1Unit, Atlanta, Georgia, USA
| | - Anuj K Dalal
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Hospital Medicine Unit, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
| | - Stephanie Labonville
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anirudh Sridharan
- Department of Medicine, Howard County General Hospital, Columbia, Maryland, USA
| | - Deonni P Stolldorf
- Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
| | - Endel John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Marcus Gresham
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
| | - Jenna Goldstein
- Center for Quality Improvement, Society of Hospital Medicine, Philadelphia, Pennsylvania, USA
| | - Sara Platt
- Center for Quality Improvement, Society of Hospital Medicine, Philadelphia, Pennsylvania, USA
| | | | - Eric Howell
- Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
- Society of Hospital Medicine, Philadelphia, Pennsylvania, USA
| | - Sunil Kripalani
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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5
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Zhang Z, Wu Y, Liu Q, Dong F, Pang W, Zhe K, Wan J, Xie W, Wang W, Yang P, Sun A, Zhai Z. Patient-Completed Caprini Risk Score for Venous Thromboembolism Risk Assessment: Developed and Validated from 1,017 Medical and Surgical Patients. TH OPEN 2022; 6:e184-e193. [PMID: 36046202 PMCID: PMC9303073 DOI: 10.1055/s-0042-1749170] [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: 10/04/2021] [Accepted: 01/11/2022] [Indexed: 10/26/2022] Open
Abstract
Abstract
Background The Caprini Risk Score (CRS) is one of the most widely used risk assessment models for venous thromboembolism (VTE). A well-validated patient-completed CRS form may allow patients to self-report and simplify the evaluation by health care workers.
Methods The Chinese version of the CRS was optimized for easy understanding in a pilot study. The amended CRS form was completed by prospectively recruited patients and blinded nurses. The agreement levels of the individual questions and the total scores of patient and nurse-completed forms were compared using the Kappa value. The total scores were used for risk stratification of patients. Correlation and differences between patient and nurse-completed forms were analyzed using the Spearman correlation and Bland–Altman method, respectively.
Results We recruited 504 medical patients and 513 surgical patients, aged 52.7 ± 16.3 years, of which 443 (43.6%) were men, and 91.6% of the patients were educated beyond junior high school. The patients spent less time to complete the form compared with trained nurses. There was good question-to-question agreement between patient and nurse-completed CRS (k >0.6 for most questions, p < 0.0001). The total scores also showed good agreement (k = 0.6097, p < 0.0001), and enabled the classification of patients into different risk groups. The patient and nurse-derived scores were highly correlated (Spearman's r = 0.84), and without extreme values (p < 0.0001).
Conclusion We have created and verified a Chinese version of the patient-completed CRS, which showed good agreement and correlation with nurse-completed CRS. CRS represents a suitable tool for VTE risk assessment of hospitalized patients in China.
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Affiliation(s)
- Zhu Zhang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China
- National Center for Respiratory Medicine, Beijing, People's Republic of China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
- National Clinical Research Center for Respiratory Diseases, Beijing, People's Republic of China
| | - Yifan Wu
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China
- National Center for Respiratory Medicine, Beijing, People's Republic of China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
- National Clinical Research Center for Respiratory Diseases, Beijing, People's Republic of China
| | - Qingxia Liu
- Department of Nursing, China-Japan Friendship Hospital, Beijing, People's Republic of China
| | - Fen Dong
- Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, People's Republic of China
| | - Wenyi Pang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China
- National Center for Respiratory Medicine, Beijing, People's Republic of China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
- National Clinical Research Center for Respiratory Diseases, Beijing, People's Republic of China
| | - Kaiyuan Zhe
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China
- National Center for Respiratory Medicine, Beijing, People's Republic of China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
- National Clinical Research Center for Respiratory Diseases, Beijing, People's Republic of China
| | - Jun Wan
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China
- National Center for Respiratory Medicine, Beijing, People's Republic of China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
- National Clinical Research Center for Respiratory Diseases, Beijing, People's Republic of China
| | - Wanmu Xie
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China
- National Center for Respiratory Medicine, Beijing, People's Republic of China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
- National Clinical Research Center for Respiratory Diseases, Beijing, People's Republic of China
| | - Wei Wang
- Department of Nursing, China-Japan Friendship Hospital, Beijing, People's Republic of China
| | - Peiran Yang
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, People's Republic of China
| | - Aihua Sun
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China
- National Center for Respiratory Medicine, Beijing, People's Republic of China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
- National Clinical Research Center for Respiratory Diseases, Beijing, People's Republic of China
- Department of Nursing, China-Japan Friendship Hospital, Beijing, People's Republic of China
| | - Zhenguo Zhai
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China
- National Center for Respiratory Medicine, Beijing, People's Republic of China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
- National Clinical Research Center for Respiratory Diseases, Beijing, People's Republic of China
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6
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Schnipper JL, Reyes Nieva H, Mallouk M, Mixon A, Rennke S, Chu E, Mueller S, Smith GRR, Williams MV, Wetterneck TB, Stein J, Dalal A, Labonville S, Sridharan A, Stolldorf DP, Orav EJ, Levin B, Gresham M, Yoon C, Goldstein J, Platt S, Nyenpan CT, Howell E, Kripalani S. Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study. BMJ Qual Saf 2022; 31:278-286. [PMID: 33927025 PMCID: PMC10964422 DOI: 10.1136/bmjqs-2020-012709] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 03/26/2021] [Accepted: 04/10/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND The first Multicenter Medication Reconciliation Quality Improvement (QI) Study (MARQUIS1) demonstrated that mentored implementation of a medication reconciliation best practices toolkit decreased total unintentional medication discrepancies in five hospitals, but results varied by site. The objective of this study was to determine the effects of a refined toolkit on a larger group of hospitals. METHODS We conducted a pragmatic quality improvement study (MARQUIS2) at 18 North American hospitals or hospital systems from 2016 to 2018. Incorporating lessons learnt from MARQUIS1, we implemented a refined toolkit, offering 17 system-level and 6 patient-level interventions. One of eight physician mentors coached each site via monthly calls and performed one to two site visits. The primary outcome was number of unintentional medication discrepancies in admission or discharge orders per patient. Time series analysis used multivariable Poisson regression. RESULTS A total of 4947 patients were sampled, including 1229 patients preimplementation and 3718 patients postimplementation. Both the number of system-level interventions adopted per site and the proportion of patients receiving patient-level interventions increased over time. During the intervention, patients experienced a steady decline in their medication discrepancy rate from 2.85 discrepancies per patient to 0.98 discrepancies per patient. An interrupted time series analysis of the 17 sites with sufficient data for analysis showed the intervention was associated with a 5% relative decrease in discrepancies per month over baseline temporal trends (adjusted incidence rate ratio: 0.95, 95% CI 0.93 to 0.97, p<0.001). Receipt of patient-level interventions was associated with decreased discrepancy rates, and these associations increased over time as sites adopted more system-level interventions. CONCLUSION A multicentre medication reconciliation QI initiative using mentored implementation of a refined best practices toolkit, including patient-level and system-level interventions, was associated with a substantial decrease in unintentional medication discrepancies over time. Future efforts should focus on sustainability and spread.
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Affiliation(s)
- Jeffrey L Schnipper
- Hospital Medicine Unit, Brigham Health, Boston, MA, USA
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Harry Reyes Nieva
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Meghan Mallouk
- Center for Quality Improvement, Society of Hospital Medicine, Philadelphia, PA, USA
| | - Amanda Mixon
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research, Education, and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Stephanie Rennke
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco Medical Center, San Francisco, CA, USA
| | - Eugene Chu
- Division of Hospital Medicine, Parkland Health and Hospital System and Department of Internal Medicine, University of Texas Southwestern School of Medicine, Dallas, TX, USA
| | - Stephanie Mueller
- Hospital Medicine Unit, Brigham Health, Boston, MA, USA
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Gregory Randy R Smith
- Division of Hospital Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mark V Williams
- Division of Hospital Medicine, Department of Internal Medicine, University of Kentucky Medical Center, Lexington, KY, USA
| | - Tosha B Wetterneck
- Division of General Internal Medicine, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | | | - Anuj Dalal
- Hospital Medicine Unit, Brigham Health, Boston, MA, USA
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | | | | | - E John Orav
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA
| | - Brian Levin
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Marcus Gresham
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Cathy Yoon
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jenna Goldstein
- Center for Quality Improvement, Society of Hospital Medicine, Philadelphia, PA, USA
| | - Sara Platt
- Center for Quality Improvement, Society of Hospital Medicine, Philadelphia, PA, USA
| | | | - Eric Howell
- Society of Hospital Medicine, Philadelphia, PA, USA
- Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Sunil Kripalani
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Center for Clinical Quality and Implementation Research, Nashville, TN, USA
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7
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Zhen K, Dong F, Fang F, Gao Q, Zhang Z, Xia L, Wang W, Yang P, Jia C, Liu P, Zhai Z, Wang C. Evaluation of In-Hospital Venous Thromboembolism Prevention and Management System Using Hospital-Level Metrics: A Nationwide Cross-Sectional Survey in China. J Patient Saf 2022; 18:e626-e632. [PMID: 34569994 DOI: 10.1097/pts.0000000000000900] [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: 11/27/2022]
Abstract
BACKGROUND Countries in the world have taken actions to prevent venous thromboembolism (VTE) in hospitals. We have conducted a study in China to assess the establishment of hospital-based systems for VTE prevention and management. METHODS A nationwide hospital survey was conducted in China to collect hospital-level metrics on their system for VTE prevention between 2019 and 2020. We analyzed hospital-level metrics potentially influencing the implementation of thromboprophylaxis using a multivariable regression model. Characteristics of the hospital, organizational structure, quality control, and staff training were analyzed. RESULTS Among 435 hospitals responding to the survey, 328 (75.4%) were able to implement thromboprophylaxis. They performed VTE and bleeding risk assessments and had prophylactic interventions. Institutional VTE steering committee and unit-based working group were set up in 317 (72.9%) and 339 (77.9%) hospitals, respectively. More than 80% of the hospitals performed quality control and staff training. In contrast, digitalization of risk assessment was only accomplished in 196 (45.1%) hospitals. Proportions of the aforementioned metrics were consistently higher in tertiary hospitals than secondary hospitals (P < 0.01) except for quality control. There were geographical disparities in the establishment of VTE steering committees (P = 0.0004). In multivariable analysis, VTE steering committee was an independent factor for the implementation of thromboprophylaxis (odds ratio, 2.22, 95% confidence interval, 1.17-4.23). Working group, quality control, and training on VTE were also positively associated with the implementation of thromboprophylaxis. CONCLUSIONS In-hospital VTE prevention has been undertaken in China, but system establishment remains suboptimal. Implementation of VTE prevention programs was associated with a decrease in thrombolytic events. Hospitals with VTE steering committees performed better on implementing preventive strategies. Suboptimal adoption of information digitization was identified, and the implementation of computer supporting techniques would be expected to improve the implementation of thromoboprophylaxis.
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Affiliation(s)
| | - Fen Dong
- From the Institute of Clinical Medical Sciences
| | | | | | | | - Lei Xia
- Medical Affairs Department of China-Japan Friendship Hospital
| | - Wei Wang
- Department of Nursing, China-Japan Friendship Hospital
| | - Peiran Yang
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, Peking Union Medical College
| | | | - Peng Liu
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital
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8
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Comprehensive Initiative to Decrease Trauma Venous Thromboembolism. J Trauma Nurs 2021; 28:250-257. [PMID: 34210945 DOI: 10.1097/jtn.0000000000000593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Our trauma center was a high outlier for pulmonary embolism on a 2017 American College of Surgeons Trauma Quality Improvement Program (TQIP) report. The odds ratio for developing a pulmonary embolus was 1.76 and was in the 10th decile (worst results). Of the patients who received chemoprophylaxis, only 69% of patients received the "gold standard" low-molecular-weight heparin. OBJECTIVE The purpose of this study was to describe and evaluate a multicomponent performance improvement project to prevent pulmonary embolus incidence. METHODS This descriptive study was a before-and-after time-series analysis of adult trauma patients. Ongoing data validation, concurrent monitoring, and analysis on incidence of venous thrombolytic events identified barriers to evidence-based chemoprophylaxis administration. RESULTS There were a total of 4,711 trauma patients in the analysis. Compared with preintervention (fall 2017), the fall 2019 TQIP report indicated the pulmonary embolus odds ratio dropped to 0.56, lowering the benchmark decile from 10 (worst) to 1 (best). The proportion of patients receiving no chemoprophylaxis decreased to 23% and was lower than all hospitals (32%). The rate of low-molecular-weight heparin use increased to 80% for patients receiving chemoprophylaxis, and unfractionated heparin use plummeted to 14%. The proportion of patients with no chemoprophylaxis in the severe traumatic brain injury cohort fell to 21%. CONCLUSIONS The high pulmonary embolus rate was driven by inaccurate data, infrequent monitoring, suboptimal ordering, and administration of chemoprophylaxis. A sustained decrease in the pulmonary embolus incidence was achieved through collaboration, updated guidelines, expanded education, concurrent validation, monitoring, and frequent reporting.
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9
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Holley AB. Preventing venous thromboembolism without causing harm. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2021; 6:100066. [PMID: 34327402 PMCID: PMC8315367 DOI: 10.1016/j.lanwpc.2020.100066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 11/18/2020] [Indexed: 11/21/2022]
Affiliation(s)
- Aaron B Holley
- Pulmonary/Sleep and Critical Care Medicine, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD 20889, United States
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10
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Ruiz-Talero P, Cerón-Perdomo D, Hernández-Flórez C, Gutiérrez-gómez S, Muñoz-Velandia O. Improving compliance to clinical practice guidelines with a multifaceted quality improvement program for the prevention of venous thromboembolic disease in nonsurgical patients. Int J Qual Health Care 2020; 32:319-324. [DOI: 10.1093/intqhc/mzaa037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 03/09/2020] [Accepted: 04/02/2020] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objective
To evaluate the change in compliance to thromboprophylaxis guidelines before and after the implementation of a multifaceted patient safety program.
Design
Longitudinal before and after study.
Setting
Teaching hospital, Hospital Universitario San Ignacio, Bogotá (Colombia).
Participants
Adult nonsurgical hospitalized patients.
Intervention
A multifaceted program for the prevention of venous thromboembolic (VTE) disease among adult nonsurgical hospitalized patients. The strategies of the program included (i) update and communication of thromboprophylaxis guidelines, (ii) the implementation of risk-assessment tools in electronic medical records, (iii) nursing staff activities and (iv) education to health personnel and patients for maintenance of the program.
Main Outcome Measure
Appropriate use of thromboprophylaxis.
Results
221 and 236 patients were evaluated in the pre- and postimplementation periods, respectively. Global appropriate thromboprophylaxis prescription went from 74.66 to 82.6% (P = 0.064). Adequate thromboprophylaxis in high-risk patients did not increase significantly (77.70 vs 80.62%, P = 0.528), but a significant reduction in inappropriate thromboprophylaxis formulation in low-risk patients was found, decreasing from 20.55 to 5.26% (P = 0.005).
Conclusions
Implementing a quality improvement multifaceted program improves the formulation of adequate thromboprophylaxis. Reducing the inappropriate prescription of VTE prophylaxis in patients at low risk of thrombosis can lead to a reduction in bleeding complications and a better use of economic and human resources.
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Affiliation(s)
- Paula Ruiz-Talero
- Internal Medicine Department, Hospital Universitario San Ignacio, Cra 7 No 40-62 Piso 7, Bogotá, Colombia
- Department of Internal Medicine, Pontificia Universidad Javeriana, Cra 7 No 40-62 Piso 7, Bogotá, Colombia
| | - Daniela Cerón-Perdomo
- Internal Medicine Department, Hospital Universitario San Ignacio, Cra 7 No 40-62 Piso 7, Bogotá, Colombia
| | - Catalina Hernández-Flórez
- Internal Medicine Department, Hospital Universitario San Ignacio, Cra 7 No 40-62 Piso 7, Bogotá, Colombia
- Department of Internal Medicine, Pontificia Universidad Javeriana, Cra 7 No 40-62 Piso 7, Bogotá, Colombia
| | - Santiago Gutiérrez-gómez
- Internal Medicine Department, Hospital Universitario San Ignacio, Cra 7 No 40-62 Piso 7, Bogotá, Colombia
| | - Oscar Muñoz-Velandia
- Internal Medicine Department, Hospital Universitario San Ignacio, Cra 7 No 40-62 Piso 7, Bogotá, Colombia
- Department of Internal Medicine, Pontificia Universidad Javeriana, Cra 7 No 40-62 Piso 7, Bogotá, Colombia
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11
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Johnson AP, Koganti D, Wallace A, Stake S, Cowan SW, Cohen MJ, Marks JA. Asymptomatic Trauma Patients Screened for Venous Thromboembolism Have a Higher Risk Profile with Lower Rate of Pulmonary Embolism: A Five-Year Single-Institution Experience. Am Surg 2020. [DOI: 10.1177/000313482008600226] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Deep vein thrombosis (DVT) is linked to reimbursements and publicly reported metrics. Some hospitals discourage venous duplex ultrasound (VDUS) screening in asymptomatic trauma patients because they often find higher rates of DVT. We aim to evaluate the association between lower extremity (LE) VDUS screening and pulmonary embolism (PE) in trauma patients. Trauma patients admitted to an urban Level-1 trauma center between 2010 and 2015 were retrospectively analyzed. We characterized the association of asymptomatic LE VDUSs with PE, upper extremity DVT, proximal LE DVT, and distal LE DVT by univariate and multivariable logistic regression controlling for confounders. Of the 3959 trauma patients included in our study—after adjusting for covariates related to patient demographics, injury, and procedures—there was a significantly lower likelihood of PE in screened patients (odds ratio (OR) = 0.02, P < 0.001) and a higher rate of distal LE DVT (OR 11.1, P = 0.004). Screening was not associated with higher rates of proximal LE DVTafter adjustment for covariates (OR = 1.8, P = 0.193). PE was associated with patient transfer status, pelvis fracture, and spinal procedures in unscreened patients. After adjusting for covariates, we have shown that LE VDUS asymptomatic screening is associated with lower rates of PE in trauma patients and not associated with higher rates of proximal LE DVT. Our detailed institutional review of a large cohort of trauma patients over five years provides support for ongoing asymptomatic screening and better characterizes venous thromboembolism outcomes than similarly sized purely administrative data reviews. As a retrospective cohort study with a large sample size, no loss to follow-up, and a population with low heterogeneity, this study should be considered as level III evidence for care management.
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Affiliation(s)
- Adam P. Johnson
- From the Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Deepika Koganti
- From the Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Adam Wallace
- From the Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Seth Stake
- From the Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Scott W. Cowan
- From the Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Murray J. Cohen
- From the Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Joshua A. Marks
- From the Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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12
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Extended Venous Thromboembolism Prophylaxis in Medically Ill Patients: An NATF Anticoagulation Action Initiative. Am J Med 2020; 133 Suppl 1:1-27. [PMID: 32362349 DOI: 10.1016/j.amjmed.2019.12.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 12/09/2019] [Indexed: 12/19/2022]
Abstract
Hospitalized patients with acute medical illnesses are at risk for venous thromboembolism (VTE) during and after a hospital stay. Risk factors include physical immobilization and underlying pathophysiologic processes that activate the coagulation pathway and are still present after discharge. Strategies for optimal pharmacologic VTE thromboprophylaxis are evolving, and recommendations for VTE prophylaxis can be further refined to protect high-risk patients after hospital discharge. An early study of extended VTE prophylaxis with a parenteral agent in medically ill patients yielded inconclusive results with regard to efficacy and bleeding. In the Acute Medically Ill VTE Prevention with Extended Duration Betrixaban (APEX) trial, extended use of betrixaban halved symptomatic VTE, decreased hospital readmission, and reduced stroke and major adverse cardiovascular events compared with standard enoxaparin prophylaxis. Based on findings from APEX, the Food and Drug Administration approved betrixaban in 2017 for extended VTE prophylaxis in acute medically ill patients. In the Reducing Post-Discharge Venous Thrombo-Embolism Risk (MARINER) study, extended use of rivaroxaban halved symptomatic VTE in high-risk medical patients compared with placebo. In 2019, rivaroxaban was approved for extended thromboprophylaxis in high-risk medical patients, thus making available a new strategy for in-hospital and post-discharge VTE prevention. To address the critical unmet need for VTE prophylaxis in medically ill patients at the time of hospital discharge, the North American Thrombosis Forum (NATF) is launching the Anticoagulation Action Initiative, a comprehensive consensus document that provides practical guidance and straightforward, patient-centered recommendations for VTE prevention during hospitalization and after discharge.
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13
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Moss SR, Jenkins AM, Caldwell AK, Herbst BF, Kelleher ME, Kinnear B, Ambroggio L, Herbst LA, Chima RS, O'Toole JK. Risk Factors for the Development of Hospital-Associated Venous Thromboembolism in Adult Patients Admitted to a Children's Hospital. Hosp Pediatr 2020; 10:166-172. [PMID: 31924691 DOI: 10.1542/hpeds.2019-0052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND OBJECTIVES Hospital-associated venous thromboembolism (HA-VTE) is a leading cause of preventable in-hospital mortality in adults. Our objective was to describe HA-VTE and evaluate risk factors for its development in adults admitted to a children's hospital, which has not been previously studied. We also evaluated the performance of commonly used risk assessment tools for HA-VTE. METHODS A case-control study was performed at a freestanding children's hospital. Cases of HA-VTE in patients ≥18 years old (2013-2017) and age-matched controls were identified. We extracted patient and HA-VTE characteristics and HA-VTE risk factors on the basis of previous literature. Thrombosis risk assessment was performed retrospectively by using established prospective adult tools (Caprini and Padua scores). RESULTS Thirty-nine cases and 78 controls were identified. Upper extremities were the most common site of thrombosis (62%). Comorbid conditions were common (91.5%), and malignancy was more common among case patients than controls (P = .04). The presence of a central venous catheter (P < .01), longer length of stay (P < .01), ICU admission (P = .005), and previous admission within 30 days (P = .01) were more common among case patients when compared with controls. Median Caprini score was higher for case patients (P < .01), whereas median Padua score was similar between groups (P = .08). CONCLUSIONS HA-VTE in adults admitted to children's hospitals is an important consideration in a growing high-risk patient population. HA-VTE characteristics in our study were more similar to published data in pediatrics.
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Affiliation(s)
- Stephanie R Moss
- Divisions of Hospital Medicine and
- Pediatrics, and
- Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Department of Hospital Medicine, Medicine Institute and
- Department of Pediatric Hospital Medicine, Pediatrics Institute, Cleveland Clinic, Cleveland, Ohio; and
| | - Ashley M Jenkins
- Divisions of Hospital Medicine and
- Pediatrics, and
- Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Alicia K Caldwell
- Divisions of Hospital Medicine and
- Pediatrics, and
- Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Brian F Herbst
- Divisions of Hospital Medicine and
- Pediatrics, and
- Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Matthew E Kelleher
- Divisions of Hospital Medicine and
- Pediatrics, and
- Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Benjamin Kinnear
- Divisions of Hospital Medicine and
- Pediatrics, and
- Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Lilliam Ambroggio
- Divisions of Hospital Medicine and
- Pediatrics, and
- Sections of Emergency Medicine and Hospital Medicine, Department of Pediatrics, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado
| | - Lori A Herbst
- Divisions of Hospital Medicine and
- Pediatrics, and
- Divisions of Geriatrics and Palliative Care, Departments of Family and Community Medicine
| | - Ranjit S Chima
- Pediatrics, and
- Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jennifer K O'Toole
- Divisions of Hospital Medicine and
- Pediatrics, and
- Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio
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14
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Rezaei Dezaki Z, Bagheri R, Pourgheysari B. Association between fibrinogen receptor (Glycoprotein IIb) polymorphism and the risk of venous thromboembolism: a systematic review. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2019. [DOI: 10.1186/s43042-019-0042-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The fibrinogen receptor is an integrin on the platelet surface and is shaped from two types of glycoprotein (GP) subunits, GPIIb and GPIIIa. Membrane glycoprotein IIb/IIIa plays an important role in platelet function. The gene encoding the glycoprotein IIIa shows a common polymorphism, PLA2 that increases the binding of the receptor to fibrinogen and enhances the platelet aggregation. The clinical impact of PLA2 polymorphism has been studied in some diseases, but the definition of its exact role on venous thromboembolism complications has been challenging. The present systematic review aimed to clarify the association of PLA2 polymorphism and venous thromboembolism.
Main text
In this study, Electronic databases including PubMed, Embase, Scopus, Web of Science, and Cochrane Library were searched. All the assessed studies focused on the relationship between PLA2 polymorphism and venous thromboembolism. Five studies were eligible for systematic review. One study revealed a significant correlation between PLA2 polymorphism and venous thromboembolism. PLA2 polymorphism was associated with deep vein thrombosis in one study and pulmonary thromboembolism in another one.
Conclusion
The published data supported the hypothesis that having the PLA2 polymorphism of GPIIIa may be a risk factor for venous thromboembolism, but the association cannot be concluded; it needs more clinical investigation.
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15
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Cronin M, Dengler N, Krauss ES, Segal A, Wei N, Daly M, Mota F, Caprini JA. Completion of the Updated Caprini Risk Assessment Model (2013 Version). Clin Appl Thromb Hemost 2019; 25:1076029619838052. [PMID: 30939900 PMCID: PMC6714938 DOI: 10.1177/1076029619838052] [Citation(s) in RCA: 119] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The Caprini risk assessment model (RAM) has been validated in over 250 000 patients in
more than 100 clinical trials worldwide. Ultimately, appropriate treatment options are
dependent on precise completion of the Caprini RAM. As the numerical score increases, the
clinical venous thromboembolism rate rises exponentially in every patient group where it
has been properly tested. The 2013 Caprini RAM was completed by specially trained medical
students via review of the presurgical assessment history, medical clearances, and medical
consults. The Caprini RAM was completed for every participant both preoperatively and
predischarge to ensure that any changes in the patient’s postoperative course were
captured by the tool. This process led to the development of completion guidelines to
ensure consistency and accuracy of scoring. The 2013 Caprini scoring system provides a
consistent, thorough, and efficacious method for risk stratification and selection of
prophylaxis for the prevention of venous thrombosis.
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Affiliation(s)
- MaryAnne Cronin
- 1 Department of Orthopaedic Surgery, Syosset Hospital, Syosset, NY, USA
| | - Nancy Dengler
- 1 Department of Orthopaedic Surgery, Syosset Hospital, Syosset, NY, USA
| | - Eugene S Krauss
- 1 Department of Orthopaedic Surgery, Syosset Hospital, Syosset, NY, USA
| | - Ayal Segal
- 1 Department of Orthopaedic Surgery, Syosset Hospital, Syosset, NY, USA
| | - Nicole Wei
- 1 Department of Orthopaedic Surgery, Syosset Hospital, Syosset, NY, USA
| | - Madison Daly
- 1 Department of Orthopaedic Surgery, Syosset Hospital, Syosset, NY, USA
| | - Frank Mota
- 1 Department of Orthopaedic Surgery, Syosset Hospital, Syosset, NY, USA
| | - Joseph A Caprini
- 2 Emeritus, NorthShore University HealthSystem, Evanston, IL, USA.,3 University of Chicago Pritzker School of Medicine, Chicago, IL, USA
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16
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Montgomery D, Friedman AM. Optimizing obstetric venous thromboembolism protocol adherence: The experience of a hospital system. Semin Perinatol 2019; 43:234-237. [PMID: 30935755 DOI: 10.1053/j.semperi.2019.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The purpose of this review is to explore the role of hospital systems in reliably providing high quality obstetric venous thromboembolism (VTE) prophylaxis focusing on the example of the Kaiser Permanente Southern California hospital system. While providers ultimately administer thromboprophylaxis on a patient-by-patient basis, hospital-level protocols, practices, and resources may be the most important determinants of whether a patient receives appropriate care. In comparison to the complex maternal and fetal emergencies that obstetricians are routinely called on to manage, VTE prophylaxis can often be simplified and integrated into the workflow, making decision-making time efficient and straightforward for the provider. Not having protocols (i.e. the provider being on their own) is associated with desired management occurring in only 40% of cases. Enhanced VTE protocols with complementary strategies to encourage use and identification of oversights addressed in real time can result in appropriate care in >90% of cases.
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Affiliation(s)
- Douglas Montgomery
- California Maternal Quality Care Collaborative Maternal Venous Thromboembolism Task Force, Kaiser Permanente Riverside Medical Center, Riverside, CA, USA
| | - Alexander M Friedman
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, 622 West 168th Street, PH 16-66, New York, NY 10032, USA.
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17
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Al-Qurayshi Z, Walsh J, Rodrigo B, Kandil E. Venous thromboembolism in head and neck surgery: Risk, outcome, and burden at the national level. Head Neck 2018; 41:411-422. [PMID: 30536494 DOI: 10.1002/hed.25409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 07/07/2018] [Accepted: 09/06/2018] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) can complicate major surgeries. This study examines the risk and outcomes of VTE in patients who underwent head and neck surgeries. METHODS Retrospective cross-sectional analysis utilizing the Nationwide Readmissions Database (2010-2014). Study population included adults (≥18 year) patients who underwent head and neck surgeries. RESULTS A total 386 VTE patients and 116 450 controls included. VTE risk was 0.37%, postoperative mortality was 4.87%. Of VTE, 57.02% identified within the initial admission for surgery, while the rest required readmission within 90 days. VTE high-risk surgeries included: major ear/skull base surgeries, major nose/paranasal sinuses surgeries, major mouth/tonsil surgeries, major salivary glands/ducts surgeries, major maxillofacial bones/mandible surgeries, and major and nonmajor pharynx and larynx surgeries (P < .05). Those same surgeries were also associated with a high risk of readmission (P < .05). CONCLUSIONS VTE is associated with a significant mortality risk. Surgeries that involve the pharynx and larynx have the highest risk of VTE and readmission.
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Affiliation(s)
- Zaid Al-Qurayshi
- Department of Otolaryngology - Head & Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Jarrett Walsh
- Department of Otolaryngology - Head & Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Bayon Rodrigo
- Department of Otolaryngology - Head & Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Emad Kandil
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
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18
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Schnipper JL, Mixon A, Stein J, Wetterneck TB, Kaboli PJ, Mueller S, Labonville S, Minahan JA, Burdick E, Orav EJ, Goldstein J, Nolido NV, Kripalani S. Effects of a multifaceted medication reconciliation quality improvement intervention on patient safety: final results of the MARQUIS study. BMJ Qual Saf 2018; 27:954-964. [PMID: 30126891 DOI: 10.1136/bmjqs-2018-008233] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 07/09/2018] [Accepted: 07/17/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND Unintentional discrepancies across care settings are a common form of medication error and can contribute to patient harm. Medication reconciliation can reduce discrepancies; however, effective implementation in real-world settings is challenging. METHODS We conducted a pragmatic quality improvement (QI) study at five US hospitals, two of which included concurrent controls. The intervention consisted of local implementation of medication reconciliation best practices, utilising an evidence-based toolkit with 11 intervention components. Trained QI mentors conducted monthly site phone calls and two site visits during the intervention, which lasted from December 2011 through June 2014. The primary outcome was number of potentially harmful unintentional medication discrepancies per patient; secondary outcome was total discrepancies regardless of potential for harm. Time series analysis used multivariable Poisson regression. RESULTS Across five sites, 1648 patients were sampled: 613 during baseline and 1035 during the implementation period. Overall, potentially harmful discrepancies did not decrease over time beyond baseline temporal trends, adjusted incidence rate ratio (IRR) 0.97 per month (95% CI 0.86 to 1.08), p=0.53. The intervention was associated with a reduction in total medication discrepancies, IRR 0.92 per month (95% CI 0.87 to 0.97), p=0.002. Of the four sites that implemented interventions, three had reductions in potentially harmful discrepancies. The fourth site, which implemented interventions and installed a new electronic health record (EHR), saw an increase in discrepancies, as did the fifth site, which did not implement any interventions but also installed a new EHR. CONCLUSIONS Mentored implementation of a multifaceted medication reconciliation QI initiative was associated with a reduction in total, but not potentially harmful, medication discrepancies. The effect of EHR implementation on medication discrepancies warrants further study. TRIAL REGISTRATION NUMBER NCT01337063.
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Affiliation(s)
- Jeffrey L Schnipper
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Amanda Mixon
- Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Geriatric Research, Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Jason Stein
- Internal Medicine, Emory University Hospital, Atlanta, Georgia, USA
| | - Tosha B Wetterneck
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Peter J Kaboli
- Internal Medicine, Iowa City VAMC and University of Iowa, Iowa City, Iowa, USA
| | - Stephanie Mueller
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Stephanie Labonville
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jacquelyn A Minahan
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Elisabeth Burdick
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Endel John Orav
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Jenna Goldstein
- Center for Quality Improvement, Society of Hospital Medicine, Philadelphia, Pennsylvania, USA
| | - Nyryan V Nolido
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sunil Kripalani
- Department of Medicine and Center for Clinical Quality and Implementation Research, Vanderbilt University, Nashville, Tennessee, USA
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19
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Woller SC, Stevens SM, Evans RS, Wray D, Christensen J, Aston VT, Wayne M, Lloyd JF, Wilson EL, Elliott CG. Electronic alerts, comparative practitioner metrics, and education improve thromboprophylaxis and reduce venous thrombosis in community hospitals. Res Pract Thromb Haemost 2018; 2:481-489. [PMID: 30046752 PMCID: PMC6046588 DOI: 10.1002/rth2.12119] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 04/23/2018] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Venous thromboembolism prophylaxis remains underutilized in hospitalized medical patients at high risk for venous thromboembolism. We previously reported that a multifaceted intervention was associated with a sustained increase in appropriate thromboprophylaxis and reduced symptomatic venous thromboembolism among medical patients hospitalized in two urban teaching hospitals. The effectiveness of this intervention in community hospitals is unknown. METHODS We performed a prospective multicenter cohort study in three community hospitals. All medical patients admitted from February 1, 2011 to January 31, 2014 were eligible. Consecutive eligible patients were enrolled into the 12-month "control," 12-month "intervention," or 12-month "maintenance" group. We provided electronic alerts, physician performance feedback, and targeted medical education for the intervention group. Only the alert component of the intervention continued in the maintenance group. The primary outcome was the rate of appropriate thromboprophylaxis among patients at high risk for venous thromboembolism defined as the prescription of guideline recommended chemoprophylaxis, or identification of a chemoprophylaxis contraindication. Secondary outcomes included rates of symptomatic venous thromboembolism, major bleeding, all-cause mortality, heparin-induced thrombocytopenia, physician satisfaction, and alert fatigue. RESULTS Appropriate thromboprophylaxis when compared to the control group rate of 67% was higher for the intervention group (85%) and for the maintenance group (77%; P < .001 for each comparison). A reduction of 90-day symptomatic venous thromboembolism accompanied the intervention (control 4.5%, intervention 3.4%, maintenance 3.0%, P = .04). CONCLUSIONS This multifaceted intervention was associated with an overall increase in appropriate thromboprophylaxis of medical patients compared with the control period. Hospital-associated venous thrombosis rates decreased.
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Affiliation(s)
- Scott C. Woller
- Department of MedicineIntermountain Medical CenterMurrayUTUSA
- Department of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUTUSA
| | - Scott M. Stevens
- Department of MedicineIntermountain Medical CenterMurrayUTUSA
- Department of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUTUSA
| | - R. Scott Evans
- Department of Medical InformaticsIntermountain HealthcareMurrayUTUSA
- Department of Biomedical InformaticsUniversity of UtahSalt Lake CityUTUSA
| | - Daniel Wray
- Twine Clinical Consulting, LLCPark CityUTUSA
| | - John Christensen
- Department of MedicineIntermountain Medical CenterMurrayUTUSA
- Department of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUTUSA
| | | | | | - James F. Lloyd
- Department of Medical InformaticsIntermountain HealthcareMurrayUTUSA
| | - Emily L. Wilson
- Department of MedicineIntermountain Medical CenterMurrayUTUSA
| | - C. Gregory Elliott
- Department of MedicineIntermountain Medical CenterMurrayUTUSA
- Department of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUTUSA
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Jenkins I, O'Bryan T, Holdych J, Maynard G. Impact of a Multicenter, Mentored Quality Collaborative on Hospital-Associated Venous Thromboembolism. J Hosp Med 2018; 13:462-469. [PMID: 29455231 DOI: 10.12788/jhm.2942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Reliable prophylaxis of hospitalassociated venous thromboembolism (HA-VTE) is not achieved in many hospitals. Efforts to improve prophylaxis have had uneven results. OBJECTIVE To reduce HA-VTE with a scalable quality improvement collaborative. DESIGN A prospective, unblinded, open-intervention study with historical controls. PARTICIPANTS AND SETTING All adult inpatients at 35 community hospitals in California, Arizona, and Nevada. INTERVENTIONS A centrally supported collaborative implementing standardized VTE risk assessment and prophylaxis. Protocols were developed with 9 "pilot" sites, which received individualized mentoring. Finished protocols were disseminated to 26 "spread" sites, which received improvement webinars without mentoring. Active surveillance for real-time correction of suboptimal prophylaxis was funded in pilot sites and encouraged in spread sites. Planning and minimal improvement work began in 2011; most implementation occurred in 2012 and 2013. MEASUREMENTS Rates of per-protocol prophylaxis (at pilot sites), and compliance with The Joint Commission VTE measures (all sites), were monitored starting in January 2012. The International Classification of Diseases, 9th Edition-Clinical Modification codes were used to determine the rates of HA-VTE within 30 days of discharge, heparininduced thrombocytopenia, and anticoagulation adverse events; preimplementation (2011) rates were compared with postimplementation (2014) rates. RESULTS Protocol-appropriate prophylaxis rates and The Joint Commission measure compliance both reached 97% in 2014, up from 70% to 89% in 2012 and 2013. Five thousand three hundred and seventy HA-VTEs occurred during 1.16 million admissions. Four hundred twenty-eight fewer HA-VTEs occurred in 2014 than in 2011 (relative risk 0.78; 95% confidence interval, 0.73-0.85). HA-VTEs fell more in pilot sites than spread sites (26% vs 20%). The rates of adverse events were reduced or unchanged. CONCLUSIONS Collaborative efforts were associated with improved prophylaxis rates and fewer HA-VTEs.
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Affiliation(s)
- Ian Jenkins
- Department of Medicine, University of California San Diego Health System, San Diego, California, USA
| | | | | | - Gregory Maynard
- University of California Davis Medical Center, Sacramento, California, USA
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Chendrasekhar A, Aleti S. Venous thromboembolism risk assessments on trauma patients has suboptimal interobserver reliability among inexperienced clinicians (fourth-year medical students). Int J Gen Med 2018; 11:225-231. [PMID: 29950883 PMCID: PMC6012549 DOI: 10.2147/ijgm.s162025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Venous thromboembolic disease is a major cause of morbidity and mortality in hospitalized patients worldwide. The objective of this study is to compare interobserver reliability for qualitative and quantitative venous thromboembolism (VTE) risk assessments in hospitalized trauma patients. Methods We conducted a retrospective medical record review of 40 randomly selected trauma patients admitted to a 448-bed urban level-I trauma center from January 2013 to January 2014. Interclass correlation coefficient (ICC) was calculated based on a two-way mixed model. The sample was equally distributed between patients admitted to the floor and the intensive care unit (ICU). Eight fourth-year medical students performed the risk assessments by the medical record. Two forms for risk assessment were used: a qualitative screening and a quantitative screening. The composite of intraobserver and interobserver variabilities was determined. Results The ICC for qualitative VTE risk assessments was 0.845 and for quantitative VTE risk assessment was 0.628. Conclusion To optimize accuracy of VTE risk stratification and appropriate prophylaxis, medical students and first-year residents should be formally trained to perform quantitative assessments.
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Affiliation(s)
- Akella Chendrasekhar
- State University of New York Downstate, Brooklyn, NY, USA.,Department of Surgery, Richmond University Medical Center, Staten Island, NY, USA
| | - Sireesha Aleti
- Department of Surgery, Richmond University Medical Center, Staten Island, NY, USA
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Guidelines' risk assessment recommendations for venous thromboembolism prophylaxis: A comparison and implementability appraisal. Thromb Res 2018; 168:5-13. [PMID: 29864630 DOI: 10.1016/j.thromres.2018.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 05/02/2018] [Accepted: 05/25/2018] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Venous thromboembolism (VTE) prophylaxis guidelines for non-surgical patients recommend VTE- and bleeding risk assessment to guide prophylactic strategies. These recommendations differ between guidelines and implementation is suboptimal. Assessing a guideline's implementability characteristics helps predicting the ease of implementation and reveals barriers. OBJECTIVES We aimed to compare guidelines' risk assessment recommendations and critically appraise the implementability characteristics. MATERIAL AND METHODS Two guidelines, one from the American College of Chest Physicians and one from the National Institute for Health and Care Excellence were selected for comparison. Risk assessment methods and subsequent prophylactic recommendations were compared. Eight experts then appraised the guideline recommendations on intrinsic implementability characteristics using the GuideLine Implementability Appraisal (GLIA) instrument. GLIA identifies barriers and facilitators for guideline implementation in nine dimensions. RESULTS Eleven out of 20 individual VTE-risk factors and 2 out of 19 individual bleeding-risk factors used, were present in both guidelines. Additionally, a high VTE- or bleeding risk was defined differently between the two guidelines. The GLIA appraisal identified implementation barriers within all recommendations analyzed. On content level, barriers were identified in recommendations addressing bleeding risk assessment, mechanical prophylaxis and critical care patients. On implementability level, barriers were identified in decidability, flexibility, effect on process of care and computability dimensions. CONCLUSION Depending on the guideline used, VTE-prophylaxis will most likely be provided to different non-surgical patient populations, primarily due to discordance in bleeding risk assessment. Revising the recommendations, taking into account the most apparent implementation barriers, should be considered. However, insufficient evidence to support the recommendations currently complicates this.
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Rwabihama JP, Audureau E, Laurent M, Rakotoarisoa L, Jegou M, Saddedine S, Krypciak S, Herbaud S, Benzengli H, Segaux L, Guery E, Ambime G, Rabus MT, Perilliat JG, David JP, Paillaud E. Prophylaxis of Venous Thromboembolism in Geriatric Settings: A Cluster-Randomized Multicomponent Interventional Trial. J Am Med Dir Assoc 2018; 19:497-503. [PMID: 29580885 DOI: 10.1016/j.jamda.2018.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 02/07/2018] [Accepted: 02/11/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate the efficacy of an intervention on the practice of venous thromboembolism prevention. DESIGN A multicenter, prospective, controlled, cluster-randomized, multifaceted intervention trial consisting of educational lectures, posters, and pocket cards reminding physicians of the guidelines for thromboprophylaxis use. SETTINGS Twelve geriatric departments with 1861 beds total, of which 202, 803, and 856 in acute care, post-acute care, and long-term care wards, respectively. PARTICIPANTS Patients hospitalized between January 1 and May 31, 2015, in participating departments. MEASUREMENTS The primary endpoint was the overall adequacy of thromboprophylaxis prescription at the patient level, defined as a composite endpoint consisting of indication, regimen, and duration of treatment. Geriatric departments were divided into an intervention group (6 departments) and control group (6 departments). The preintervention period was 1 month to provide baseline practice levels, the intervention period 2 months, and the postintervention period 1 month in acute care and post-acute care wards or 2 months in long-term care wards. Multivariable regression was used to analyze factors associated with the composite outcome. RESULTS We included 2962 patients (1426 preintervention and 1536 postintervention), with median age 85 [79;90] years. For the overall 18.9% rate of inadequate thromboprophylaxis, 11.1% was attributable to underuse and 7.9% overuse. Intervention effects were more apparent in post-acute and long-term care wards although not significantly [odds ratio 1.44 (95% confidence interval 0.78;2.66), P = .241; and 1.44 (0.68, 3.06), P = .345]. Adequacy rates significantly improved in the postintervention period for the intervention group overall (from 78.9% to 83.4%; P = .027) and in post-acute care (from 75.4% to 86.3%; P = .004) and long-term care (from 87.0% to 91.7%; P = .050) wards, with no significant trend observed in the control group. CONCLUSIONS/IMPLICATIONS This study failed to demonstrate improvement in prophylaxis adequacy with our intervention. However, the intervention seemed to improve practices in post-acute and long-term care but not acute care wards.
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Affiliation(s)
- Jean Paul Rwabihama
- Université Paris-Est, UPEC, DHU A-TVB, IMRB-EA 7376 CEpiA (Clinical Epidemiology and Aging Unit), Créteil, France; Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Joffre-Dupuytren, Draveil, France.
| | - Etienne Audureau
- Université Paris-Est, UPEC, DHU A-TVB, IMRB-EA 7376 CEpiA (Clinical Epidemiology and Aging Unit), Créteil, France; Assistance Publique-Hôpitaux de Paris, Service de Santé Publique, Hôpital Henri Mondor, Créteil, France
| | - Marie Laurent
- Université Paris-Est, UPEC, DHU A-TVB, IMRB-EA 7376 CEpiA (Clinical Epidemiology and Aging Unit), Créteil, France; Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Albert Chenevier-Henri Mondor, Créteil, France
| | - Lalaina Rakotoarisoa
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital George Clemenceau, Champceuil, France
| | - Marc Jegou
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Emile Roux, Limeil Brévannes, France
| | - Sofiane Saddedine
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Emile Roux, Limeil Brévannes, France
| | - Sébastien Krypciak
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Henri Mondor, Créteil, France
| | - Stéphane Herbaud
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Henri Mondor, Créteil, France
| | - Hind Benzengli
- Assistance Publique-Hôpitaux de Paris, Service de Pharmacie, Hôpital Joffre-Dupuytren, Draveil, France
| | - Lauriane Segaux
- Université Paris-Est, UPEC, DHU A-TVB, IMRB-EA 7376 CEpiA (Clinical Epidemiology and Aging Unit), Créteil, France; Assistance Publique-Hôpitaux de Paris, Service de Santé Publique, Hôpital Henri Mondor, Créteil, France
| | - Esther Guery
- Assistance Publique-Hôpitaux de Paris, Service de Santé Publique, Hôpital Henri Mondor, Créteil, France
| | - Gabin Ambime
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Joffre-Dupuytren, Draveil, France
| | - Marie-Thérèse Rabus
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Joffre-Dupuytren, Draveil, France
| | - Jean-Guy Perilliat
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Joffre-Dupuytren, Draveil, France
| | - Jean-Philippe David
- Université Paris-Est, UPEC, DHU A-TVB, IMRB-EA 7376 CEpiA (Clinical Epidemiology and Aging Unit), Créteil, France; Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Emile Roux, Limeil Brévannes, France
| | - Elena Paillaud
- Université Paris-Est, UPEC, DHU A-TVB, IMRB-EA 7376 CEpiA (Clinical Epidemiology and Aging Unit), Créteil, France; Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Henri Mondor, Créteil, France
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Paz Rios LH, Fuentes HE, Oramas DM, Andrade XA, Al-Ogaili A, Iskander M, Iskander F, Iskandar ANA, Kowacz W, Iwanski A, Acob C, Diaz Quintero L, Salazar-Adum JP, Tafur A, Caprini JA. Validation of a Patient-Completed Caprini Risk Assessment Tool for Spanish, Arabic, and Polish Speakers. Clin Appl Thromb Hemost 2017; 24:502-512. [PMID: 29258392 PMCID: PMC6714665 DOI: 10.1177/1076029617746505] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Targeted prophylaxis for venous thromboembolism (VTE) using the Caprini risk score (CRS)
is effective reducing postoperative VTE. Despite its availability as preventive strategy,
risk scoring remains underutilized. Critics to the CRS contend the time it takes to
complete, and its limitation to English language. Aim is to create and validate
patient-completed CRS tools for Spanish, Arabic, and Polish speakers. We translated the
first patient-completed CRS to Spanish, Arabic, and Polish. We conducted a pilot study
followed by the validation study. Using PASS version 11, we determined that a sample size
of 37 achieved a power of 80%, to detect a difference of 0.1 between the null hypothesis
correlation of 0.5 and the alternative hypothesis correlation of 0.7 using a 2-sided
hypothesis test, significance level of .05. We tabulated and categorized scores using SPSS
version 23 to estimate κ, linear correlation, and Bland Altman test. κ value >0.8 was
defined as “almost perfect agreement.” From 129 recruited patients, 50 (39%) spoke
Spanish, 40 (31%) spoke Arabic, and 39 (30%) spoke Polish; average age 51 (16.69) years,
58 (45%) were men, with less than college education (67%). Mean (standard deviation) CRS
was 5 (3.90), the majority (63%) above moderate VTE risk. We report excellent agreement
comparing physician and patient results (κ = 0.93) and high correlation 0.97
(P < .01) for the overall score. Bland Altman did not show trend for
extreme values. We created and validated the first Spanish, Arabic, and Polish versions of
the patient-completed CRS, with excellent correlation and agreement when compared to
CRS-trained physician-completed form. Based on these results, the physician needs to
calculate the body mass index. Completing the form was not time-consuming.
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Affiliation(s)
- Luis H. Paz Rios
- Department of Internal Medicine, John H. Stroger Jr, Hospital of Cook
County, Chicago, IL, USA
- Luis H. Paz Rios, Department of Internal Medicine,
John Stroger Jr. Hospital of Cook County, 1900 West Polk Street, Chicago, IL 60612, USA.
| | - Harry E. Fuentes
- Department of Internal Medicine, John H. Stroger Jr, Hospital of Cook
County, Chicago, IL, USA
| | - Diana M. Oramas
- Department of Pathology, University of Illinois at Chicago, Chicago, IL,
USA
| | - Xavier A. Andrade
- Department of Internal Medicine, John H. Stroger Jr, Hospital of Cook
County, Chicago, IL, USA
| | - Ahmed Al-Ogaili
- Department of Internal Medicine, John H. Stroger Jr, Hospital of Cook
County, Chicago, IL, USA
| | - Mina Iskander
- Department of Internal Medicine, John H. Stroger Jr, Hospital of Cook
County, Chicago, IL, USA
| | - Fady Iskander
- Department of Internal Medicine, John H. Stroger Jr, Hospital of Cook
County, Chicago, IL, USA
| | | | - Wictoria Kowacz
- Department of Internal Medicine, John H. Stroger Jr, Hospital of Cook
County, Chicago, IL, USA
| | - Adam Iwanski
- Department of Internal Medicine, John H. Stroger Jr, Hospital of Cook
County, Chicago, IL, USA
| | - Christine Acob
- Department of Internal Medicine, John H. Stroger Jr, Hospital of Cook
County, Chicago, IL, USA
| | - Luis Diaz Quintero
- Department of Internal Medicine, Northshore University Healthsystem,
Evanston, IL, USA
| | | | - Alfonso Tafur
- Department of Cardiology-Vascular Medicine, Northshore University
Healthsystem, Evanston, IL, USA
| | - Joseph A. Caprini
- Pritzker School of Medicine, NorthShore University HealthSystem, IL,
USA
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25
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Fuentes HE, Paz LH, Al-Ogaili A, Andrade XA, Oramas DM, Salazar-Adum JP, Diaz-Quintero L, Acob C, Tafur A, Caprini J. Validation of a Patient-Completed Caprini Risk Score for Venous Thromboembolism Risk Assessment. TH OPEN 2017; 1:e106-e112. [PMID: 31249916 PMCID: PMC6524847 DOI: 10.1055/s-0037-1607339] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 08/29/2017] [Indexed: 02/08/2023] Open
Abstract
Introduction
Individualized risk assessment for venous thromboembolism (VTE) using the Caprini risk score (CRS), coupled with targeted prophylaxis based on the score, is effective in reducing postoperative VTE. Critics contend that using this tool is time consuming for health care providers. We decided to create a patient-completed CRS and conducted a prospective study to compare the scores calculated by a patient with those calculated by a blinded physician for the same patient.
Methods
In phase 1, we interviewed patients in our deep vein thrombosis (DVT) support group who had a history of thrombosis and included their family members to determine areas of misunderstanding in the original CRS. We created a patient-completed form based on these interviews. In phase 2, we further optimized the questions after a CRS-trained, blinded physician scored 20 hospitalized patients during the pilot study. In the final (third) phase, we measured the agreement level between the new form filled out by the trained physicians and those filled out by the patients. The study was approved by our local institutional review board. Using PASS version 11, we determined that a sample size of 37 individuals achieves a power of 80%, to detect a 0.1 difference between the null hypothesis correlation of 0.5 and the alternative hypothesis correlation of 0.7 using a two-sided hypothesis test with a significance level of 0.05. We tabulated the individuals' answers and categorized the scores by using SPSS version 23 to estimate the kappa value, linear correlation, and the Bland–Altman test. A kappa value greater than 0.8 indicated an “almost perfect agreement.”
Results
We tested the first patient-completed CRS version (phase 2) in a 20-patient pilot study. A poor agreement was observed with the body mass index (BMI) responses in multiple iterations, and so we excluded the BMI calculation from the final patient-completed CRS form. We recruited 42 patients with an average age of 55, mostly female (45%), who completed less than college education (62%) to fill out the updated CRS form (phase 3). An almost perfect agreement was found for both the individual questions and the overall score comparing physician and patient answers, resulting in a high correlation (
r
= 0.95). In Bland–Altman, we did not find any trend for extreme values.
Conclusion
We created and validated a patient-completed CRS form that has an excellent agreement level with the physician-completed form. From the results, the physician only needs to calculate the BMI. The average time for a patient to complete the form was 5 minutes. The average time for the physician to finalize the score was approximately 6 minutes. Implementation studies are needed to assess the correlation of the aggregated score, derived from this form, with the occurrence of perioperative VTE.
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Affiliation(s)
- H E Fuentes
- Department of Medicine, Division of Internal Medicine, John Stroger Jr. Hospital, Chicago, Illinois, United States
| | - L H Paz
- Department of Medicine, Division of Internal Medicine, John Stroger Jr. Hospital, Chicago, Illinois, United States
| | - A Al-Ogaili
- Department of Medicine, Division of Internal Medicine, John Stroger Jr. Hospital, Chicago, Illinois, United States
| | - X A Andrade
- Department of Medicine, Division of Internal Medicine, John Stroger Jr. Hospital, Chicago, Illinois, United States
| | - D M Oramas
- Department of Pathology, University of Illinois at Chicago, Chicago, Illinois, United States
| | - J P Salazar-Adum
- Department of Medicine, Division of Internal Medicine, NorthShore University HealthSystem, Evanston, Illinois, United States
| | - L Diaz-Quintero
- Department of Medicine, Division of Internal Medicine, NorthShore University HealthSystem, Evanston, Illinois, United States
| | - C Acob
- Department of Medicine, Division of Internal Medicine, John Stroger Jr. Hospital, Chicago, Illinois, United States
| | - A Tafur
- Department of Medicine, Division of Cardiology and Vascular Medicine, NorthShore University HealthSystem, Evanston, Illinois, United States
| | - J Caprini
- NorthShore University HealthSystem-Emeritus, Pritzker School of Medicine, Evanston, Illinois, United States
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Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss strategies to reduce rates of hypoglycemia in the non-critical care setting. RECENT FINDINGS Strategies to reduce hypoglycemia rates should focus on the most common causes of iatrogenic hypoglycemia. Creating a standardized insulin order set with built-in clinical decision support can help reduce rates of hypoglycemia. Coordination of blood glucose monitoring, meal tray delivery, and insulin administration is an important and challenging task. Protocols and processes should be in place to deal with interruptions in nutrition to minimize risk of hypoglycemia. A glucose management page that has all the pertinent information summarized in one page allows for active surveillance and quick identification of patients who may be at risk of hypoglycemia. Finally, education of prescribers, nurses, food and nutrition services, and patients is important so that every member of the healthcare team can work together to prevent hypoglycemia. By implementing strategies to reduce hypoglycemia, we hope to lower rates of adverse events and improve quality of care while also reducing hospital costs. Future research should focus on the impact of an overall reduction in hypoglycemia to determine whether the expected benefits are achieved.
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Affiliation(s)
- Kristen Kulasa
- Division of Endocrinology, Diabetes, and Metabolism, University of California, San Diego, 200 West Arbor Drive, MC#8409, San Diego, CA, 92103, USA.
| | - Patricia Juang
- Division of Endocrinology, Diabetes, and Metabolism, University of California, San Diego, 200 West Arbor Drive, MC#8409, San Diego, CA, 92103, USA
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Stein A. Race and ethnicity as predictors of hospital-acquired conditions after total hip arthroplasty and total knee arthroplasty. Int J Orthop Trauma Nurs 2017; 27:16-22. [PMID: 28673450 DOI: 10.1016/j.ijotn.2017.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 05/22/2017] [Accepted: 05/30/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Anne Stein
- Northern Michigan University, 1401 Presque Isle Ave, Marquette, MI 49855, United States.
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Northup A, Wilcox S. Thromboprophylaxis Failure in the Adult Medical Inpatient. Am J Med Sci 2017; 354:107-116. [PMID: 28864367 DOI: 10.1016/j.amjms.2017.03.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 03/01/2017] [Accepted: 03/03/2017] [Indexed: 01/12/2023]
Abstract
Venous thromboembolism (VTE), a leading cause of morbidity and mortality among hospitalized patients, is often due to prophylaxis failure rather than omission, but few studies have identified the risk factors for failure. Risk factors for thromboprophylaxis failure include personal or family history of VTE, use of vasopressors or inotropes, increased body mass index, cranial surgery, intensive care patient, leukocytosis, indwelling central venous catheter and admission from a long-term care facility. Identifying patients at risk for thromboprophylaxis failure should prompt close observation during hospitalization for signs of VTE, close observation after discharge and potentially more aggressive prophylaxis strategies, although no specific guidelines exist for medical patients at this time.
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Affiliation(s)
- Amanda Northup
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina.
| | - Susan Wilcox
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina; Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, South Carolina; Division of Emergency Medicine, Medical University of South Carolina, Charleston, South Carolina
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Maynard GA, Holdych J, Kendall H, Harrison K, Montgomery PA, Kulasa K. IMPROVING GLYCEMIC CONTROL SAFELY IN CRITICAL CARE PATIENTS: A COLLABORATIVE SYSTEMS APPROACH IN NINE HOSPITALS. Endocr Pract 2017; 23:583-593. [PMID: 28225315 DOI: 10.4158/ep161569.or] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Safely improve glycemic control in the critical care units of nine hospitals. METHODS Critical care adult inpatients from nine hospitals with ≥4 point-of-care blood glucose (BG) readings over ≥2 days were targeted by collaborative improvement efforts to reduce hyper- and hypoglycemia. Balanced glucometric goals for each hospital were set targeting improvement from baseline or goals deemed desirable from Society of Hospital Medicine (SHM) benchmarking data. Collaborative interventions included standardized insulin infusion protocols, hypoglycemia prevention bundles, audit and feedback, education, and measure-vention (coupling measurement of patients "off protocol" with concurrent interventions to correct suboptimal care). RESULTS All sites improved glycemic control. Six reached prespecified levels of improvement of the day-weighted mean BG. The day-weighted mean BG for the cohort decreased by 7.7 mg/dL (95% confidence interval [CI], 7.0 mg/dL to 8.4 mg/dL) to 151.3 mg/dL. Six of nine sites showed improvement in the percent intensive care unit (ICU) days with severe hyperglycemia (any BG >299 mg/dL). ICU severe hyperglycemic days declined from 8.6 to 7.2% for the cohort (relative risk, 0.84; 95% CI, 0.80 to 0.88). Patient days with any BG <70 mg/dL were reduced by 0.4% (95% CI, 0.06% to 0.6%), from 4.5 to 4.1%, for a small but statistically significant reduction in hypoglycemia. Seven of nine sites showed improvement. CONCLUSION Multihospital improvements in ICU glycemic control, severe hyperglycemia, and hypoglycemia are feasible. Balanced goals for glycemic control and hypoglycemia in the ICU using SHM benchmarks and metrics enhanced successful improvement efforts with good staff acceptance and sustainability. ABBREVIATIONS BG = blood glucose CMI = case-mix index CY = calendar year DKA = diabetic ketoacidosis EMR = electronic medical record GBMF = Gordon and Betty Moore Foundation ICU = intensive care unit IIP = insulin infusion protocol SHM = Society of z Hospital Medicine.
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Improving Glycemic Control Safely in Non-Critical Care Patients: A Collaborative Systems Approach in Nine Hospitals. Jt Comm J Qual Patient Saf 2017; 43:179-188. [PMID: 28325206 DOI: 10.1016/j.jcjq.2017.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Practice variations in insulin management and glycemic adverse events led nine Dignity Health hospitals to initiate a collaborative effort to improve hypoglycemia, uncontrolled hyperglycemia, and glycemic control. METHODS Non-critical care adult inpatients with ≥4 point-of-care blood glucose (BG) readings in a ≥2-day period were included. Balanced glucometric goals for each hospital were individualized to improve performance by 10%-20% from baseline or achieve top performance derived from Society of Hospital Medicine (SHM) benchmarking studies. Baseline measures (2011) were compared to mature results (postintervention, 2014). Protocols for insulin management and hypoglycemia prevention were piloted at one facility and were then spread to the cohort. Interventions included standardized order sets, education, mentoring from physician experts, feedback of metrics, and measure-vention (coupling measurement of patients "off protocol" with concurrent intervention to correct lapses in care). RESULTS The day-weighted mean BG for the cohort improved by 11.4 mg/dL (95% confidence interval [CI]: 11.0-11.8]; all nine sites improved. Eight of the sites reduced severe hyperglycemic days, and the percentage of patient-days with any BG > 299 mg/dL for the total cohort improved from 11.6% to 8.8% (relative risk, 0.76 [95% CI: 0.74-0.78]). The percentage of patient-days with any BG < 70 mg/dL remained unchanged at 3.6%. Eight of the sites either reduced hypoglycemia by 20% or achieved SHM best-quartile rates. CONCLUSION Multihospital improvements in glycemic control and severe hyperglycemia without significant increases in hypoglycemia are feasible using portable low-cost toolkits and metrics.
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Gharaibeh L, Younes N, Albsoul-Younes A. Role of the clinical pharmacist in improving the appropriateness of venous thromboembolism prophylaxis in hospitalised patients in Jordan. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2017. [DOI: 10.1002/jppr.1230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Lubna Gharaibeh
- Faculty of Pharmacy; Department of Biopharmaceutics and Clinical Pharmacy; University of Jordan; Amman Jordan
| | - Nidal Younes
- Faculty of Medicine; Department of General Surgery; University of Jordan; Amman Jordan
| | - Abla Albsoul-Younes
- Faculty of Pharmacy; Department of Biopharmaceutics and Clinical Pharmacy; University of Jordan; Amman Jordan
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de Bastos M, Barreto SM, Caiafa JS, Boguchi T, Silva JLP, Rezende SM. Derivation of a risk assessment model for hospital-acquired venous thrombosis: the NAVAL score. J Thromb Thrombolysis 2016; 41:628-35. [PMID: 26446587 DOI: 10.1007/s11239-015-1277-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Venous thrombosis (VT) is a preventable cause of death in hospitalized patients. The main strategy to decrease VT incidence is timely thromboprophylaxis in at-risk patients. We sought to evaluate the reliability of risk assessment model (RAM) data, the incremental usefulness of additional variables and the modelling of an adjusted score (the NAVAL score). We used the RAM proposed by Caprini for initial assessment. A 5 % systematic sample of data was independently reviewed for reliability. We evaluated the incremental usefulness of six variables for VT during the score modelling by logistic regression. We then assessed the NAVAL score for calibration, reclassification and discrimination performances. We observed 11,091 patients with 37 (0.3 %) VT events. Using the Caprini RAM, high-risk and moderate-risk patients were respectively associated with a 17.4 (95 % confidence interval [CI] 6.1-49.9) and 4.2 (95 % CI 1.6-11.0) increased VT risk compared with low-risk patients. Four independent variables were selected for the NAVAL score: "Age", "Admission clinic", "History of previous VT event" and "History of thrombophilia". The area under the receiver-operating-characteristic curve for the NAVAL score was 0.72 (95 % CI 0.63-0.81). The Net Reclassification Index (NRI) for the NAVAL score compared with the Caprini RAM was -0.1 (95 % CI -0.3 to 0.1; p = 0.28). We conclude that the NAVAL score is a simplified tool for the stratification of VT risk in hospitalized patients. With only four variables, it demonstrated good performance and discrimination, but requires external validation before clinical application. We also confirm that the Caprini RAM can effectively stratify VT risk in hospitalized patients in our population.
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Affiliation(s)
- Marcos de Bastos
- Instituto de Previdência dos Servidores do Estado de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
| | - Sandhi M Barreto
- Departamento de Medicina Preventiva e Social, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Jackson S Caiafa
- Departamento de Angiologia, Hospital Naval Marcílio Dias, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Tânia Boguchi
- Serviço de Estatística, Departamento de Matemática e Estatística da Pontifícia, Universidade Católica de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - José Luiz Padilha Silva
- Grupo de Estudos de Medicina Tropical, Pós-Graduação em Ciências da Saúde da Faculdade de Medicina da, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Suely M Rezende
- Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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Minami CA, Yang AD, Ju M, Culver E, Seifert K, Kreutzer L, Halverson T, O'Leary KJ, Bilimoria KY. Evaluation of an institutional project to improve venous thromboembolism prevention. J Hosp Med 2016; 11 Suppl 2:S29-S37. [PMID: 27925424 DOI: 10.1002/jhm.2663] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 08/25/2016] [Accepted: 08/28/2016] [Indexed: 11/06/2022]
Abstract
BACKGROUND Northwestern Memorial Hospital (NMH) was historically a poor performer on the venous thromboembolism (VTE) outcome measure. As this measure has been shown to be flawed by surveillance bias, NMH embraced process-of-care measures to ensure appropriate VTE prophylaxis to assess healthcare-associated VTE prevention efforts. OBJECTIVE To evaluate the impact of an institution-wide project aimed at improving hospital performance on VTE prophylaxis measures. DESIGN A retrospective observational study. SETTING NMH, an 885-bed academic medical center in Chicago, Illinois PATIENTS: Inpatients admitted to NMH from January 1, 2013 to May 1, 2013 and from October 1, 2014 to April 1, 2015 were eligible for evaluation. INTERVENTION Using the define-measure-analyze-improve-control (DMAIC) process-improvement methodology, a multidisciplinary team implemented and iteratively improved 15 data-driven interventions in 4 broad areas: (1) electronic medical record (EMR) alerts, (2) education initiatives, (3) new EMR order sets, and (4) other EMR changes. MEASUREMENTS The Joint Commission's 6 core measures and the Surgical Care Improvement Project (SCIP) SCIP-VTE-2 measure. RESULTS Based on 3103 observations (1679 from January 1, 2013 to May 1, 2013, and 1424 from October 1, 2014 to April 1, 2015), performance on the core measures improved. Performance on measure 1 (chemoprophylaxis) improved from 82.5% to 90.2% on medicine services, and from 94.4% to 97.6% on surgical services. The largest improvements were seen in measure 4 (platelet monitoring), with a performance increase from 76.7% adherence to 100%, and measure 5 (warfarin discharge instructions), with a performance increase from 27.4% to 88.8%. CONCLUSION A systematic hospital-wide DMAIC project improved VTE prophylaxis measure performance. Sustained performance has been observed, and novel control mechanisms for continued performance surveillance have been embedded in the hospital system. Journal of Hospital Medicine 2016;11:S29-S37. © 2016 Society of Hospital Medicine.
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Affiliation(s)
- Christina A Minami
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University and Northwestern Memorial Hospital, Chicago, Illinois
- Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Anthony D Yang
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University and Northwestern Memorial Hospital, Chicago, Illinois
| | - Mila Ju
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University and Northwestern Memorial Hospital, Chicago, Illinois
| | | | | | - Lindsey Kreutzer
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University and Northwestern Memorial Hospital, Chicago, Illinois
| | | | - Kevin J O'Leary
- Division of Hospital Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Karl Y Bilimoria
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University and Northwestern Memorial Hospital, Chicago, Illinois
- Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Electronic Alerts, Comparative Practitioner Metrics, and Education Improves Thromboprophylaxis and Reduces Thrombosis. Am J Med 2016; 129:1124.e17-26. [PMID: 27288858 DOI: 10.1016/j.amjmed.2016.05.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 05/19/2016] [Accepted: 05/19/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND Venous thromboembolism chemoprophylaxis remains underutilized in hospitalized medical patients at high risk for venous thromboembolism. We assessed the effect of a health care quality-improvement initiative comprised of a targeted electronic alert, comparative practitioner metrics, and practitioner-specific continuing medical education on the rate of appropriate venous thromboembolism chemoprophylaxis provided to medical inpatients at high risk for venous thromboembolism. METHODS We performed a multicenter prospective observational cohort study in an urban Utah hospital system. All medical patients admitted to 1 of 2 participating hospitals from April 1, 2010 to December 31, 2012 were eligible. Patients were members of the "control" (April 1, 2010 to December 31, 2010), "intervention" (January 1, 2011 to December 31, 2011), or "subsequent year" (January 1, 2012 to December 31, 2012) group. The primary outcome was the rate of appropriate chemoprophylaxis among patients at high risk for venous thromboembolism. Secondary outcomes included rates of symptomatic venous thromboembolism, major bleeding, all-cause mortality, heparin-induced thrombocytopenia, physician satisfaction, and alert fatigue. RESULTS The rate of appropriate chemoprophylaxis among patients at high risk for venous thromboembolism increased (66.1% control period vs 81.0% intervention period vs 88.1% subsequent year; P <.001 for each comparison). A significant reduction of 90-day symptomatic venous thromboembolism accompanied the quality initiative (9.3% control period, 9.7% intervention period, 6.7% subsequent year; P = .009); 30-day venous thromboembolism rates also significantly decreased. CONCLUSIONS A multifaceted intervention was associated with increased appropriate venous thromboembolism chemoprophylaxis among medical inpatients at high risk for venous thromboembolism and reduced symptomatic venous thromboembolism. The effect of the intervention was sustained.
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Abstract
Venous thromboembolism (VTE) is a major cause of morbidity and mortality and is associated with substantial healthcare costs. Identification of patients at risk of developing VTE enables appropriate thromboprophylaxis to be implemented. Although no predisposing risk factors can be identified in many patients in whom VTE develops, most have at least one underlying risk factor which can be categorized according to whether it confers low, moderate, or high risk. Clinical trials have demonstrated the effectiveness of thromboprophylaxis, both non-pharmacological and pharmacological, in a host of medical settings and there is sufficient evidence to support routine prophylaxis in many groups of patients. The implementation of decision making tools based on risk factor assessment improves the prescription of appropriate VTE prophylaxis. Nonetheless, thromboprophylaxis is often inadequate, with haphazard risk assessment and application of guidelines, leading to easily preventable instances of VTE. The most commonly used agents for pharmacological thromboprophylaxis of VTE are low dose unfractionated heparin; a low molecular weight heparin such as dalteparin, enoxaparin or tinzaparin; fondaparinux; warfarin; or aspirin. However, these have a number of drawbacks, principally the need for parenteral administration (with heparins) and frequent coagulation monitoring (with warfarin). The optimal anticoagulant would be orally administered, with a wide therapeutic window, rapid onset of action, predictable pharmacodynamics and pharmacokinetics, minimal interactions with food and other drugs, an ability to inhibit free and clot-bound coagulation factors, low, non-specific binding, and no requirement for routine coagulation monitoring or dose adjustment. A number of novel, single-target oral anticoagulants have been developed that appear to fulfill many of these requirements. This narrative review discusses the use of guidelines and risk assessment tools to identify patients at risk of VTE; it provides an overview of appropriate prophylaxis strategies in these patients with a summary of clinical trial results with novel oral anticoagulants.
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Minami CA, Sheils CR, Bilimoria KY, Johnson JK, Berger ER, Berian JR, Englesbe MJ, Guillamondegui OD, Hines LH, Cofer JB, Flum DR, Thirlby RC, Kazaure HS, Wren SM, O'Leary KJ, Thurk JL, Kennedy GD, Tevis SE, Yang AD. Process improvement in surgery. Curr Probl Surg 2015; 53:62-96. [PMID: 26806271 DOI: 10.1067/j.cpsurg.2015.11.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 11/10/2015] [Indexed: 11/22/2022]
Affiliation(s)
- Christina A Minami
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, Chicago, IL; Center for Healthcare Studies in the Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Catherine R Sheils
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, Chicago, IL; University of Rochester School of Medicine, University of Rochester, Rochester, NY
| | - Karl Y Bilimoria
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, Chicago, IL; Center for Healthcare Studies in the Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL.
| | - Julie K Johnson
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, Chicago, IL; Center for Healthcare Studies in the Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Elizabeth R Berger
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Julia R Berian
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Surgery, University of Chicago Medical Center, Chicago, IL
| | - Michael J Englesbe
- Department of Surgery, University of Michigan Health Systems, Ann Arbor, MI
| | | | - Leonard H Hines
- Department of Surgery, University of Tennessee College of Medicine, Knoxville, TN
| | - Joseph B Cofer
- Department of Surgery, University of Tennessee College of Medicine, Chattanooga, TN
| | - David R Flum
- Department of Surgery, University of Washington School of Medicine, Seattle, WA
| | | | - Hadiza S Kazaure
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Sherry M Wren
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Kevin J O'Leary
- Division of Hospital Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Jessica L Thurk
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Gregory D Kennedy
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Sarah E Tevis
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Anthony D Yang
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, Chicago, IL; Center for Healthcare Studies in the Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
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Hidden costs associated with venous thromboembolism: impact of lost productivity on employers and employees. J Occup Environ Med 2015; 56:979-85. [PMID: 25046319 DOI: 10.1097/jom.0000000000000208] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine productivity loss and indirect costs with deep vein thrombosis (DVT) and pulmonary embolism (PE). METHODS Medical and pharmacy claims with short-term disability (STD) and long-term disability (LTD) claims from 2007 to 2010 were analyzed from the Integrated Benefits Institute's Health and Productivity Benchmarking (IBI-HPB) database (STD and LTD claims) and IMS LifeLink™ data (medical and pharmacy claims), which were indirectly linked using a weighting approach matching from IBI-HPB patients' demographic distribution. RESULTS A total of 5442 DVT and 6199 PE claims were identified. Employees with DVT lost 57 STD and 440 LTD days per disability incident. The average per claim productivity loss from STD and LTD was $7414 and $58181, respectively. Employees with PE lost 56 STD and 364 LTD days per disability incident. The average per claim productivity loss from STD and LTD was $7605 and $48,751, respectively. CONCLUSIONS Deep vein thrombosis and PE impose substantial economic burdens.
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Grier MA. Prevention of venous thromboembolism in adult patients with cancer in the acute care setting. Clin J Oncol Nurs 2015; 18:290-5. [PMID: 24751360 DOI: 10.1188/14.cjon.18-03ap] [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: 11/17/2022]
Abstract
Adult patients with cancer in the acute care setting face numerous potential complications related to malignancy. Risk for development of venous thromboembolism (VTE) is among the most critical of adverse outcomes for this patient population, ultimately leading to increased morbidity and mortality rates. Nurses must be familiar with the general pathophysiology of VTE and pathophysiology specific to oncology to prevent the occurrence of this complex hematologic process. Knowledge of pharmacologic prevention methods, such as low-dose unfractionated heparin, low-molecular weight heparin, and warfarin, as well as mechanical prophylaxis such as graduated compression stockings and intermittent pneumatic compression devices, is essential to preventing VTE. The ability to develop and implement an educational plan tailored to the specific learning needs of each patient also is a vital skill that must be incorporated into the practice of nurses caring for patients with cancer in the acute care setting to prevent the incidence of VTE in this population.
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Lee JA, Grochow D, Drake D, Johnson L, Reed P, van Servellen G. Evaluation of hospital nurses' perceived knowledge and practices of venous thromboembolism assessment and prevention. JOURNAL OF VASCULAR NURSING 2015; 32:18-24. [PMID: 24534084 DOI: 10.1016/j.jvn.2013.06.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Revised: 05/30/2013] [Accepted: 06/03/2013] [Indexed: 10/25/2022]
Abstract
Venous thromboembolism (VTE) is a preventable cause of hospital death. Bedside registered nurses (RNs) are a key group that can be the first to recognize risks of patients in acute care settings. The purpose of this study was to identify bedside hospital RNs' perceived knowledge of VTE, their assessment practices, their self-efficacy in conducting VTE prevention care, and their perceived barriers to performing VTE risk assessment. An anonymous web-based survey on VTE risk assessment and prevention was conducted with RNs who provided direct patient care at two hospitals. RNs who were not directly involved in bedside patient care such as managers and educators were excluded. A total of 221 RNs completed the survey. Most participants rated their overall knowledge of VTE risk assessment between "good" (44%) and "fair" (28%). VTE assessment frequencies performed by participants varied widely. Participants reported high confidence in their ability to educate patients and families about VTE symptoms, prevention, and treatments. Participants were least confident in their own ability to conduct a thorough VTE risk assessment. Greater self-reported VTE knowledge was associated with greater VTE assessment frequency and self-efficacy for VTE preventive care. The most common perceived barriers in performing VTE risk assessment were lack of knowledge (21%) and lack of time (21%). The findings demonstrate a substantial need for focused education about VTE prevention for hospital nurses and support for hospital systems to monitor VTE care. Despite the Joint Commission emphasis on VTE risk assessment in all hospitalized patients, there remains a gap between current, evidence-based recommendations for VTE prevention and reported nursing practices.
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Affiliation(s)
- Jung-Ah Lee
- Program in Nursing Science, University of California, Irvine, Irvine, California.
| | - Donna Grochow
- Nursing Quality, Research & Education, Magnet Program, University of California, Irvine Medical Center, Orange, California
| | - Diane Drake
- Mission Hospital, St. Joseph Health Systems, Mission Viejo, California
| | - Linda Johnson
- Patient Care of Mission Hospital, St. Joseph Health Systems, Mission Viejo, California
| | - Preston Reed
- Program in Nursing Science, University of California, Irvine, Irvine, California
| | - Gwen van Servellen
- School of Nursing, University of California, Los Angeles, Los Angeles, California
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Is the incidence trend of heparin-induced thrombocytopenia decreased by the increased use of low-molecular-weight-heparin? Mediterr J Hematol Infect Dis 2015; 7:e2015029. [PMID: 25960857 PMCID: PMC4418371 DOI: 10.4084/mjhid.2015.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Accepted: 03/13/2015] [Indexed: 01/24/2023] Open
Abstract
Background The increasing trend of using low-molecular-weight-heparin (LMWH) versus unfractionated heparin (UFH) in hospitalized adult patients is raising concerns about the incidence of heparin-induced thrombocytopenia (HIT). Method A retrospective study analyzed the requests for heparin-induced antibodies by enzyme-linked immunosorbent assay (ELISA) among adult hospitalized patients during the period from January 2011 to December 2013. These patients received either UFH or LMWH for prevention or therapeutic indications. Those with positive immune-mediated HIT were identified and considered as case patients. Result The usage of LMWH and UFH and development of HIT was determined during the study period. The incidence of HIT in patients receiving UFH and those receiving LMWH was 4.09 per thousand patients and 0.48 per thousand patients, respectively, (p<0.0001) with an overall incidence of 2.49 per thousand patients. Conclusion The increased trend of using LMWH over UFH among hospitalized adult patients was observed and can be said to contribute to the diminished overall incidence of HIT.
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Michtalik HJ, Carolan HT, Haut ER, Lau BD, Streiff MB, Finkelstein J, Pronovost PJ, Durkin N, Brotman DJ. Use of provider-level dashboards and pay-for-performance in venous thromboembolism prophylaxis. J Hosp Med 2015; 10:172-8. [PMID: 25545690 PMCID: PMC4351181 DOI: 10.1002/jhm.2303] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 11/21/2014] [Accepted: 11/30/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND Despite safe and cost-effective venous thromboembolism (VTE) prevention measures, VTE prophylaxis rates are often suboptimal. Healthcare reform efforts emphasize transparency through programs to report performance and payment incentives through pay-for-performance programs. OBJECTIVE To sequentially examine an individualized physician dashboard and pay-for-performance program to improve VTE prophylaxis rates among hospitalists. DESIGN Retrospective analysis of 3144 inpatient admissions. After a baseline observation period, VTE prophylaxis compliance was compared during both interventions. SETTING A 1060-bed tertiary care medical center. PARTICIPANTS Thirty-eight part-time and full-time academic hospitalists. INTERVENTIONS A Web-based hospitalist dashboard provided VTE prophylaxis feedback. After 6 months of feedback only, a pay-for-performance program was incorporated, with graduated payouts for compliance rates of 80% to 100%. MEASUREMENTS Prescription of American College of Chest Physicians' guideline-compliant VTE prophylaxis and subsequent pay-for-performance payments. RESULTS Monthly VTE prophylaxis compliance rates were 86% (95% confidence interval [CI]: 85-88), 90% (95% CI: 88-93), and 94% (95% CI: 93-96) during the baseline, dashboard, and combined dashboard/pay-for-performance periods, respectively. Compliance significantly improved with the use of the dashboard (P = 0.01) and addition of the pay-for-performance program (P = 0.01). The highest rate of improvement occurred with the dashboard (1.58%/month; P = 0.01). Annual individual physician performance payments ranged from $53 to $1244 (mean $633; standard deviation ±$350). CONCLUSIONS Direct feedback using dashboards was associated with significantly improved compliance, with further improvement after incorporating an individual physician pay-for-performance program. Real-time dashboards and physician-level incentives may assist hospitals in achieving higher safety and quality benchmarks.
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Affiliation(s)
- Henry J. Michtalik
- Department of Medicine of the Johns Hopkins University, Baltimore, Maryland, USA
- Armstrong Institute for Patient Safety and Quality, Baltimore, Maryland, USA
| | - Howard T. Carolan
- Armstrong Institute for Patient Safety and Quality, Baltimore, Maryland, USA
| | - Elliott R. Haut
- Department of Surgery of the Johns Hopkins University, Baltimore, Maryland, USA
- Department of Anesthesiology and Critical Care Medicine of the Johns Hopkins University, Baltimore, Maryland, USA
- Department of Health Policy & Management of the Johns Hopkins University, Baltimore, Maryland, USA
- Armstrong Institute for Patient Safety and Quality, Baltimore, Maryland, USA
| | - Brandyn D. Lau
- Department of Surgery of the Johns Hopkins University, Baltimore, Maryland, USA
- Armstrong Institute for Patient Safety and Quality, Baltimore, Maryland, USA
| | - Michael B. Streiff
- Department of Medicine of the Johns Hopkins University, Baltimore, Maryland, USA
- Armstrong Institute for Patient Safety and Quality, Baltimore, Maryland, USA
| | - Joseph Finkelstein
- Department of Medicine of the Johns Hopkins University, Baltimore, Maryland, USA
| | - Peter J. Pronovost
- Department of Surgery of the Johns Hopkins University, Baltimore, Maryland, USA
- Department of Anesthesiology and Critical Care Medicine of the Johns Hopkins University, Baltimore, Maryland, USA
- Department of Health Policy & Management of the Johns Hopkins University, Baltimore, Maryland, USA
- Armstrong Institute for Patient Safety and Quality, Baltimore, Maryland, USA
| | - Nowella Durkin
- Department of Medicine of the Johns Hopkins University, Baltimore, Maryland, USA
| | - Daniel J. Brotman
- Department of Medicine of the Johns Hopkins University, Baltimore, Maryland, USA
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Introducing the No Preventable Harms campaign: creating the safest health care system in the world, starting with catheter-associated urinary tract infection prevention. Am J Infect Control 2015; 43:254-9. [PMID: 25728151 DOI: 10.1016/j.ajic.2014.11.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 11/14/2014] [Accepted: 11/18/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND Endemic health care-associated safety problems, including health care-associated infection, account for substantial morbidity and mortality. We outline a regional No Preventable Harms campaign to reduce these safety problems and describe the initial results from the first initiative focusing on catheter-associated urinary tract infection (CAUTI) prevention. METHODS We formed a think tank composed of multidisciplinary experts from within a 7-hospital Midwestern Veterans Affairs network to identify hospital-acquired conditions that had strong evidence on how to prevent the harm and outcome data that could be easily collected to evaluate improvement efforts. The first initiative of this campaign focused on CAUTI prevention. Quantitative data on CAUTI rates and qualitative data from site visit interviews were used to evaluate the initiative. RESULTS Quantitative data showed a significant reduction in CAUTI rates per 1,000 catheter days for nonintensive care units across the region (2.4 preinitiative and 0.8 postinitiative; P = .001), but no improvement in the intensive care unit rate (1.4 preinitiative and 2.1 postinitiative; P = .16). Themes that emerged from our qualitative data highlight the need for considering local context and the importance of communication when developing and implementing regional initiatives. CONCLUSIONS A regional collaborative can be a valuable strategy for addressing important endemic patient safety problems.
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Minami CA, Bilimoria KY. Are Higher Hospital Venous Thromboembolism Rates an Indicator of Better Quality?: Evaluation of the Validity of a Hospital Quality Measure. Adv Surg 2015; 49:185-204. [PMID: 26299499 DOI: 10.1016/j.yasu.2015.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Christina A Minami
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Center for Healthcare Studies, Northwestern Memorial Hospital, Feinberg School of Medicine, Northwestern University, 633 North Saint Clair Street, 20th Floor, Chicago, IL 60611, USA
| | - Karl Y Bilimoria
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Center for Healthcare Studies, Northwestern Memorial Hospital, Feinberg School of Medicine, Northwestern University, 633 North Saint Clair Street, 20th Floor, Chicago, IL 60611, USA.
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Maynard G, Kulasa K, Ramos P, Childers D, Clay B, Sebasky M, Fink E, Field A, Renvall M, Juang PS, Choe C, Pearson D, Serences B, Lohnes S. Impact of a hypoglycemia reduction bundle and a systems approach to inpatient glycemic management. Endocr Pract 2014; 21:355-67. [PMID: 25536971 DOI: 10.4158/ep14367.or] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Uncontrolled hyperglycemia and iatrogenic hypoglycemia represent common and frequently preventable quality and safety issues. We sought to demonstrate the effectiveness of a hypoglycemia reduction bundle, proactive surveillance of glycemic outliers, and an interdisciplinary data-driven approach to glycemic management. METHODS POPULATION all hospitalized adult non-intensive care unit (non-ICU) patients with hyperglycemia and/or a diagnosis of diabetes admitted to our 550-bed academic center across 5 calendar years (CYs). INTERVENTIONS hypoglycemia reduction bundle targeting most common remediable contributors to iatrogenic hypoglycemia; clinical decision support in standardized order sets and glucose management pages; measure-vention (daily measurement of glycemic outliers with concurrent intervention by the inpatient diabetes team); educational programs. MEASURES AND ANALYSIS Pearson chi-square value with relative risks (RRs) and 95% confidence intervals (CIs) were calculated to compare glycemic control, hypoglycemia, and hypoglycemia management parameters across the baseline time period (TP1, CY 2009-2010), transitional (TP2, CY 2011-2012), and mature postintervention phase (TP3, CY 2013). Hypoglycemia defined as blood glucose <70 mg/dL, severe hypoglycemia as <40 mg/dL, and severe hyperglycemia >299 mg/dL. RESULTS A total of 22,990 non-ICU patients, representing 94,900 patient-days of observation were included over the 5-year study. The RR TP3:TP1 for glycemic excursions was reduced significantly: hypoglycemic stay, 0.71 (95% CI, 0.65 to 0.79); severe hypoglycemic stay, 0.44 (95% CI, 0.34 to 0.58); recurrent hypoglycemic day during stay, 0.78 (95% CI, 0.64 to 0.94); severe hypoglycemic day, 0.48 (95% CI, 0.37 to 0.62); severe hyperglycemic day (>299 mg/dL), 0.76 (95% CI, 0.73 to 0.80). CONCLUSION Hyperglycemia and hypoglycemia event rates were both improved, with the most marked effect on severe hypoglycemic events. Most of these interventions should be portable to other hospitals.
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Abstract
PURPOSE OF REVIEW Default options dramatically influence the behavior of decision makers and may serve as effective decision support tools in the ICU. Their use in medicine has increased in an effort to improve efficiency, reduce errors, and harness the potential of healthcare technology. RECENT FINDINGS Defaults often fall short of their predicted influence when employed in critical care settings as quality improvement interventions. Investigations reporting the use of defaults are often limited by variations in the relative effect across sites. Preimplementation experiments and long-term monitoring studies are lacking. SUMMARY Defaults in the ICU may help or harm patients and clinical efficiency depending on their format and use. When constructing and encountering defaults, providers should be aware of their powerful and complex influences on decision making. Additional evaluations of the appropriate creation of healthcare defaults and their resulting intended and unintended consequences are needed.
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Affiliation(s)
- Joanna Hart
- Division of Pulmonary, Allergy and Critical Care Medicine, Leonard Davis Institute of Health Economics and Fostering Improvement in End-of-Life Decision Science (FIELDS) Program at the Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Scott D. Halpern
- Division of Pulmonary, Allergy and Critical Care Medicine, Leonard Davis Institute of Health Economics and Fostering Improvement in End-of-Life Decision Science (FIELDS) Program at the Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Center for Epidemiology and Biostatistics and Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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46
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Chung JW, Ju MH, Kinnier CV, Haut ER, Baker DW, Bilimoria KY. Evaluation of hospital factors associated with hospital postoperative venous thromboembolism imaging utilisation practices. BMJ Qual Saf 2014; 23:947-56. [PMID: 25136140 DOI: 10.1136/bmjqs-2014-003150] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Recent research suggests that hospital rates of postoperative venous thromboembolism (VTE) are subject to surveillance bias: the more hospitals 'look for' VTE, the more VTE they find. However, little is known about what drives variation in hospital VTE imaging rates. We conducted an observational study to examine hospital and market characteristics that were associated with hospital-level rates of postoperative VTE imaging, focusing on hospitals with particularly high rates. METHODS For Medicare beneficiaries undergoing 11 major operations (2009-2010) at 2820 hospitals, hospital-level postoperative VTE imaging use rates were calculated. Hospital characteristics associated with hospital VTE imaging use rates were examined including case severity, size, ownership, VTE process measure adherence, accreditations, staffing, malpractice environment, and county market factors. Associations between explanatory variables and VTE imaging rates were assessed using quantile regressions at the 25th, median, 75th and 90th quantiles. RESULTS Mean postoperative VTE imaging rates ranged from 85.26 (SD=67.38) per 1000 discharges in the lowest quartile of hospitals ranked by VTE imaging rates to 168.86 (SD=76.70) in the highest quartile. Drivers of high imaging rates at the 90th quantile were high resident-to-bed ratio (coefficient=51.35, p<0.01), Joint Commission accreditation (coefficient=19.05, p<0.01), presence of other hospitals in the same market with high imaging rates (coefficient=15.29, p<0.01), average case severity (coefficient=11.97, p<0.01), local malpractice costs (coefficient=11.29, p<0.01), and market competition (coefficient=11.03, p<0.01). CONCLUSIONS Hospital teaching status, resident-to-bed ratio, malpractice environment and local market factors drive hospital postoperative VTE imaging use, suggesting that non-clinical forces predominantly drive hospital VTE imaging practices.
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Affiliation(s)
- Jeanette W Chung
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Mila H Ju
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Christine V Kinnier
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Elliott R Haut
- Department of Surgery, Anesthesiology & Critical Care Medicine and Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David W Baker
- Division of General Internal Medicine and Geriatrics, Northwestern University, Chicago, Illinois, USA
| | - Karl Y Bilimoria
- Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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47
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Restuccia JD, Mohr D, Meterko M, Stolzmann K, Kaboli P. The association of hospital characteristics and quality improvement activities in inpatient medical services. J Gen Intern Med 2014; 29:715-22. [PMID: 24424776 PMCID: PMC4000331 DOI: 10.1007/s11606-013-2759-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 12/06/2013] [Accepted: 12/27/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Quality of U.S. health care has been the focus of increasing attention, with deficiencies in patient care well recognized and documented. However, relatively little is known about the extent to which hospitals engage in quality improvement activities (QIAs) or factors influencing extent of QIAs. OBJECTIVE To identify 1) the extent of QIAs in Veterans Administration (VA) inpatient medical services; and 2) factors associated with widespread adoption of QIAs, in particular use of hospitalists, non-physician providers, and extent of goal alignment between the inpatient service and senior managers on commitment to quality. DESIGN Cross-sectional, descriptive study of QIAs using a survey administered to Chiefs of Medicine (COM) at all 124 VA acute care hospitals. We conducted hierarchical regression, regressing QIA use on facility contextual variables, followed by use of hospitalists, non-physician providers, and goal alignment/quality commitment. MAIN MEASURES Outcome measures pertained to use of a set of 27 QIAs and to three dimensions--infrastructure, prevention, and information gathering--that were identified by factor analysis among the 27 QIAs overall. KEY RESULTS Survey response rate was 90 % (111/124). Goal alignment/quality commitment was associated with more widespread use of all four QIA categories [infrastructure (b = 0.42; p < 0.001); prevention (b = 0.24; p < 0.001); information gathering (b = 0.28; p = <0.001); and overall QIA (b = 0.31; p < 0.001)], as was greater use of hospitalists [infrastructure (b = 0.55; p = 0.03); prevention (b = 0.61; p < 0.001); information gathering (b = 0.75; p = 0.01); and overall QIAs (b = 0.61; p < 0.001)]; higher occupancy rate was associated with greater infrastructure QIAs (b = 1.05, p = 0.02). Non-physician provider use, hospital size, university affiliation, and geographic region were not associated with QIAs. CONCLUSION As hospitals respond to changes in healthcare (e.g., pay for performance, accountable care organizations), this study suggests that practices such as use of hospitalists and leadership focus on goal alignment/quality commitment may lead to greater implementation of QIAs.
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Affiliation(s)
- Joseph D Restuccia
- Center for Organizational Leadership and Management Research (COLMR), Boston VA Healthcare System, Boston, MA, USA,
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Streiff MB, Brady PJ, Grant AM, Grosse SD, Wong B, Popovic T. CDC Grand Rounds: preventing hospital-associated venous thromboembolism. MMWR. MORBIDITY AND MORTALITY WEEKLY REPORT 2014; 63:190-3. [PMID: 24598595 PMCID: PMC4584727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Deep venous thrombosis (DVT) is a blood clot in a large vein, usually in the leg or pelvis. Sometimes a DVT detaches from the site of formation and becomes mobile in the blood stream. If the circulating clot moves through the heart to the lungs it can block an artery supplying blood to the lungs. This condition is called pulmonary embolism. The disease process that includes DVT and/or pulmonary embolism is called venous thromboembolism (VTE). Each year in the United States, an estimated 350,000-900,000 persons develop incident VTE, of whom approximately 100,000 die, mostly as sudden deaths, the cause of which often goes unrecognized. In addition, 30%-50% of persons with lower-extremity DVT develop postthrombotic syndrome (a long-term complication that causes swelling, pain, discoloration, and, in severe cases, ulcers in the affected limb). Finally, 10%-30% of persons who survive the first occurrence of VTE develop another VTE within 5 years.
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Affiliation(s)
| | - P. Jeffrey Brady
- Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality
| | - Althea M. Grant
- Div of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, CDC
| | - Scott D. Grosse
- Div of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, CDC,Corresponding author: Scott Grosse, , 404-498-3074
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Fuzinatto F, Waldemar FSD, Wajner A, Elias CAA, Fernandez JF, Hopf JLDS, Barreto SSM. A clinical decision support system for venous thromboembolism prophylaxis at a general hospital in a middle-income country. J Bras Pneumol 2013; 39:138-46. [PMID: 23670498 PMCID: PMC4075831 DOI: 10.1590/s1806-37132013000200004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Accepted: 01/07/2013] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE: To determine the impact that implementing a combination of a computer-based clinical decision support system and a program of training seminars has on the use of appropriate prophylaxis for venous thromboembolism (VTE). METHODS: We conducted a cross-sectional study in two phases (prior to and after the implementation of the new VTE prophylaxis protocol) in order to evaluate the impact that the combined strategy had on the use of appropriate VTE prophylaxis. The study was conducted at Nossa Senhora da Conceição Hospital, a general hospital in the city of Porto Alegre, Brazil. We included clinical and surgical patients over 18 years of age who were hospitalized for ≥ 48 h. The pre-implementation and post-implementation phase samples comprised 262 and 261 patients, respectively. RESULTS: The baseline characteristics of the two samples were similar, including the distribution of patients by risk level. Comparing the pre-implementation and post-implementation periods, we found that the overall use of appropriate VTE prophylaxis increased from 46.2% to 57.9% (p = 0.01). Looking at specific patient populations, we observed that the use of appropriate VTE prophylaxis increased more dramatically among cancer patients (from 18.1% to 44.1%; p = 0.002) and among patients with three or more risk factors (from 25.0% to 42.9%; p = 0.008), two populations that benefit most from prophylaxis. CONCLUSIONS: It is possible to increase the use of appropriate VTE prophylaxis in economically constrained settings through the use of a computerized protocol adhered to by trained professionals. The underutilization of prophylaxis continues to be a major problem, indicative of the need for ongoing improvement in the quality of inpatient care.
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Affiliation(s)
- Fernanda Fuzinatto
- Nossa Senhora da Conceição Hospital and Porto Alegre Hospital de Clínicas, Porto Alegre, Brazil.
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50
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Weizman AV, Nguyen GC. Quality of care delivered to hospitalized inflammatory bowel disease patients. World J Gastroenterol 2013; 19:6360-6366. [PMID: 24151354 PMCID: PMC3801306 DOI: 10.3748/wjg.v19.i38.6360] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Revised: 07/24/2013] [Accepted: 08/06/2013] [Indexed: 02/06/2023] Open
Abstract
Hospitalized patients with inflammatory bowel disease (IBD) are at high risk for morbidity, mortality, and health care utilization costs. While the literature on trends in hospitalization rates for this disease is conflicting, there does appear to be significant variation in the delivery of care to this complex group, which may be a marker of suboptimal quality of care. There is a need for improvement in identifying patients at risk for hospitalization in an effort to reduce admissions. Moreover, appropriate screening for a number of hospital acquired complications such as venous thromboembolism and Clostridium difficile infection is suboptimal. This review discusses areas of inpatient care for IBD patients that are in need of improvement and outlines a number of potential quality improvement initiatives such as pay-for-performance models, quality improvement frameworks, and healthcare information technology.
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