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George B, Gonzales S, Patel K, Petit S, Franck AJ, Bovio Franck J. Impact of a Clinical Decision-Support Tool on Venous Thromboembolism Prophylaxis in Acutely Ill Medical Patients. J Pharm Technol 2020; 36:141-147. [PMID: 34752541 DOI: 10.1177/8755122520930288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Adherence to guideline-based venous thromboembolism (VTE) prophylaxis recommendations is often inadequate. Effective improvement strategies are needed. Objective: The purpose of this quality improvement initiative was to increase use of the facility's preferred pharmacologic VTE prophylaxis, reduce unnecessary VTE prophylaxis use, and reduce use of pharmacologic VTE prophylaxis in high bleeding risk patients, in accordance with guideline-based recommendations. Methods: Clinical pharmacists spearheaded the development and implementation of a clinical decision-support tool (CDST) integrated within a Veterans Health Administration electronic health record (EHR). The CDST focused on VTE prophylaxis in acutely ill medical patients and guided prescribers to guideline-based recommendations. Following review and approval, the CDST underwent activation in the EHR. A subsequent intervention occurred, year 2 post-intervention, which embedded this CDST into the EHR admission process and admission menus. A drug message was added in the EHR to alert prescribers that low-molecular-weight heparin was the preferred agent. Measures were evaluated pre-intervention, year 1 post-intervention, and year 2 post-intervention. Results: After intervention, there were statistically significant increases in the proportion of patients receiving the facility's preferred pharmacologic VTE prophylaxis agent, enoxaparin, and a statistically significant decrease in the proportion of unwarranted VTE prophylaxis. The proportion of inappropriate pharmacologic VTE prophylaxis in high bleeding risk patients decreased, but this result did not reach statistical significance. Conclusion: The improvements observed suggest the beneficial role of CDSTs integrated into the EHR to increase adherence to guideline-based VTE prophylaxis recommendations.
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Affiliation(s)
- Brandon George
- Orlando Veterans Affairs Healthcare System, Orlando, FL, USA.,North Florida/South Georgia Veterans Health System, Gainesville, FL, USA
| | - Samantha Gonzales
- North Florida/South Georgia Veterans Health System, Gainesville, FL, USA.,Southern Arizona Veterans Affairs Health Care System, Tucson, AZ, USA
| | - Krishna Patel
- North Florida/South Georgia Veterans Health System, Gainesville, FL, USA.,San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Stephanie Petit
- North Florida/South Georgia Veterans Health System, Gainesville, FL, USA.,North Florida/South Georgia Veterans Health System, Jacksonville, FL, USA
| | - Andrew J Franck
- North Florida/South Georgia Veterans Health System, Gainesville, FL, USA
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Ye F, Stalvey C, Khuddus MA, Winchester DE, Toklu HZ, Mazza JJ, Yale SH. A systematic review of mobility/immobility in thromboembolism risk assessment models for hospitalized patients. J Thromb Thrombolysis 2018; 44:94-103. [PMID: 28484939 DOI: 10.1007/s11239-017-1501-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Hospitalized patients are at risk of venous thromboembolism (VTE) and prophylaxis is often suboptimal due to difficulty in identifying at-risk patients. Simple and validated risk-assessment models (RAMs) are available to assist clinicians in identifying patients who have a high risk for developing VTE. Despite the well-documented association of immobility with increased risk of thrombosis, immobility is not consistently defined in clinical studies. We conducted a systematic review of published VTE RAMs and used objective criteria to determine how the term immobility is defined in RAMs. We identified 17 RAMs with six being externally validated. The concept of immobility is vaguely described in different RAMs, impacting the validity of these models in clinical practice. The wide variability in defining mobility in RAMs precluded its accurate clinical application, further limiting generalization of published RAMs. Externally validated RAMs with clearly defined qualitative or quantitative terms of immobility are needed to assess VTE risk in real-time at the point-of-care.
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Affiliation(s)
- Fan Ye
- Department of Medicine and Graduate Medical Education, North Florida Regional Medical Center, Gainesville, FL, 32605, USA.,College of Medicine, University of Central Florida, Orlando, FL, 32827, USA
| | - Carolyn Stalvey
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, 32610, USA
| | - Matheen A Khuddus
- North Florida Regional Medical Center, The Cardiac and Vascular Institute, Gainesville, FL, 32605, USA
| | - David E Winchester
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, 32610, USA
| | - Hale Z Toklu
- Department of Medicine and Graduate Medical Education, North Florida Regional Medical Center, Gainesville, FL, 32605, USA
| | - Joseph J Mazza
- Marshfield Clinic Research Foundation, Marshfield, WI, 54449, USA
| | - Steven H Yale
- Department of Medicine and Graduate Medical Education, North Florida Regional Medical Center, Gainesville, FL, 32605, USA. .,College of Medicine, University of Central Florida, Orlando, FL, 32827, USA. .,Department of Internal Medicine, North Florida Regional Medical Center, 6500 Newberry Road, Gainesville, FL, 32614, USA.
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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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Roberts LN, Porter G, Barker RD, Yorke R, Bonner L, Patel RK, Arya R. Comprehensive VTE prevention program incorporating mandatory risk assessment reduces the incidence of hospital-associated thrombosis. Chest 2014; 144:1276-1281. [PMID: 23681495 DOI: 10.1378/chest.13-0267] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND VTE is a common complication of hospitalization and is associated with significant morbidity and mortality. The use of appropriate thromboprophylaxis can significantly reduce the risk of VTE but remains underutilized. In England, a comprehensive approach to VTE prevention was launched in 2010. This study aimed to evaluate the impact of the implementation of the national program in a single center. METHODS A prospective quality improvement program was established at King's College Hospital NHS Foundation Trust in 2010. The multidisciplinary thrombosis team launched mandatory documented VTE risk assessment and updated thromboprophylaxis guidance. Root cause analysis of hospital-associated thrombosis (HAT) was implemented to identify system failures, enable outcome measurement, and facilitate learning to improve VTE prevention practice. The key outcomes were the incidence of HAT and the proportion of events preventable with appropriate thromboprophylaxis. RESULTS Documented VTE risk assessment improved from <40% to > 90% in the first 9 months. Four hundred twenty-five episodes of HAT were identified over 2 years. A significant reduction in the incidence of HAT was observed following sustained achievement of 90% risk assessment (risk ratio, 0.88; 95% CI, 0.74-0.98; P = .014). The proportion of HAT attributable to inadequate thromboprophylaxis fell significantly from 37.5% to 22.4% (P = .005). CONCLUSIONS Mandatory VTE risk assessment can significantly reduce preventable HAT and thereby improve patient safety.
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Affiliation(s)
- Lara N Roberts
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, England.
| | - Gayle Porter
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, England
| | - Richard D Barker
- Department of Information and Communication Technology, King's College Hospital NHS Foundation Trust, London, England; Division of Asthma, Allergy and Lung Biology, King's College Hospital NHS Foundation Trust, London, England
| | - Richard Yorke
- Department of Information and Communication Technology, King's College Hospital NHS Foundation Trust, London, England
| | - Lynda Bonner
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, England
| | - Raj K Patel
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, England
| | - Roopen Arya
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, England
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Abstract
Abstract
Venous thromboembolism is a significant cause of illness and death worldwide. Large bodies of evidence support the heightened risk status of hospitalized medical patients, and that prophylactic measures significantly reduce the risk of thrombosis, yet these patients often fail to receive adequate prophylactic therapy. This failure may be accounted for by a lack of awareness of the relevant indications, poorly designed implementation systems, and clinical concerns over the side effects of anticoagulant medications. This article briefly summarizes our understanding of the clinical factors relevant to the evaluation of venous thromboembolism risk in hospitalized medical patients. We describe our approach to the use of thromboprophylaxis, through which we aim to minimize the disease burden of this under-recognized and preventable pathology.
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Does using the WHO surgical checklist improve compliance to venous thromboembolism prophylaxis guidelines? Surgeon 2010; 9:309-11. [PMID: 22041642 DOI: 10.1016/j.surge.2010.11.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2010] [Revised: 11/09/2010] [Accepted: 11/10/2010] [Indexed: 11/21/2022]
Abstract
BACKGROUND Using the World Health Organisation (WHO) surgical checklist has been shown to improve the safety of patients undergoing surgery. Its effect on the compliance to venous thromboembolism (VTE) guidelines has not been established before. Our objective was to assess if using the WHO checklist improved compliance to VTE prophylaxis guidelines. METHODS Compliance to NICE VTE guidelines were prospectively assessed in all general surgery patients over two separate audit periods, before and after 6 months of the routine use of the WHO checklist. Correct completion of the checklist was verified. RESULTS 370 patients (173 [47%] male, 197 [53%] female, mean age 61.6 yrs). Non compliance to NICE VTE guidelines was reduced form 16/233 (6.9%) to 3/137 (2.1%) after introduction of the checklist (p = 0.046 Fisher exact test). Non compliance was reduced in both emergency and elective procedures. CONCLUSIONS Establishment of the WHO checklist for routine use in all general surgery patients may significantly improve VTE guideline compliance of all general surgery patients.
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