Venous thromboembolism: what is preventing achievement of performance measures and consensus guidelines?

Nurses' knowledge and practice regarding venous-thromboembolism prevention in tertiary hospitals of Addis Ababa, Ethiopia: A cross-sectional study

BACKGROUND

The prevalence of venous thromboembolism is steadily increasing in developing nations including Ethiopia. Nurses play a vital role in the prevention of venous thromboembolism. However, the level of nurses' knowledge, practice, and associated factors in venous thromboembolism prevention is not well-known across Ethiopia. This study aimed to assess nurses' knowledge, practice, and associated factors regarding venous-thromboembolism prevention in tertiary Hospitals of Addis Ababa, Ethiopia METHODS: An institutional-based cross-sectional study was conducted among 339 randomly selected nurses working at tertiary hospitals in Addis Ababa, Ethiopia. A validated questionnaire was used to collect data. Data were analyzed with SPSS version 25. Both descriptive and inferential statistics were used to describe and test the association between selected variables.

RESULTS

Out of the total 339 participants, only (51.6%) and (45.4%) had adequate knowledge and practice towards venous thromboembolism prevention respectively. Attending in-service training (AOR=1.701, p = 0.044) was significantly associated with knowledge of VTE prevention. Educational level (AOR= 3.871, P = 0.048), work experience (AOR=5.207, P<0.001), work location (AOR= 0.507, P = 0.019), working department (AOR= 2.959, P = 0.048), knowledge level (AOR= 0.477, P=0.005) were significantly associated with better preventive practice.

CONCLUSION

This study suggests that nurses' level of knowledge and practice towards venous thromboembolism prevention was inadequate. Nurses' educational level, attending in-service training, work experience, work location, and working department were determinant factors associated with nurses' knowledge and practice towards venous thromboembolism prevention. Therefore, upgrading nurses' educational level and providing in-service training on venous thromboembolism prevention is crucial for positive patient outcomes.

Inpatient prescribing of dual antiplatelet therapy according to the guidelines: a prospective intervention study

Background:

In dual antiplatelet therapy (DAPT), low-dose acetylsalicylic acid is combined with a P2Y12 inhibitor. However, combining antithrombotic agents increases the risk of bleeding. Guidelines on DAPT recommend using this combination for a limited period of between three weeks and 30 months. This implies the risk of DAPT being erroneously continued after the intended stop date.

Objective:

The primary objective of this study is to assess the proportion of hospitalized patients treated with DAPT whose treatment deviated erroneously and unintentionally from the guidelines. We also assessed risk factors and the effect of a pharmacist intervention.

Methods:

All patients admitted to the Spaarne Gasthuis (Haarlem/ Hoofddorp, the Netherlands) who used DAPT between March 25 ^th , 2019, and June 14 ^th , 2019, were, in addition to receiving regular care, reviewed to assess whether their therapy was in line with the guidelines’ recommendation and whether deviations were unintended and erroneous. In the event of an unintended deviation, the pharmacist intervened by contacting the prescriber by phone and giving advice to adjust the antithrombotic therapy in line with the guideline.

Results:

We included 411 patients, of whom 21 patients (5.1%) had a treatment that deviated from the guidelines. For 11 patients (2.7%), the deviation was unintended and erroneous. The major risk factor for erroneous deviation was the use of DAPT before hospital admission (OR 18.7; 95%CI 4.79–72.7). In patients who used DAPT before admission, 18 out of 58 (31.0%) had a deviation from the guidelines of whom 8 (13.8%) were erroneous. For these eight patients, the pharmacist contacted the prescriber, and in these cases the therapy was adjusted in line with the guidelines.

Conclusions:

Adherence to the guidelines recommending DAPT was high within the hospital. However, patients who used DAPT before hospital admission had a higher risk of erroneous prescription of DAPT. Intervention by a pharmacist increased adherence to guidelines and may reduce the number of preventable bleeding cases.

The effect of hospital-based antithrombotic stewardship on adherence to anticoagulant guidelines

Background Anticoagulant therapy is associated with a high risk of complications. Adherence to anticoagulant therapy protocols may lower this risk but adherence is often suboptimal. The introduction of a multidisciplinary antithrombotic team may improve adherence to anticoagulant guidelines among physicians. Objective To determine the effect of hospital-based multidisciplinary antithrombotic stewardship on adherence to anticoagulant guidelines among prescribing physicians. Setting This prospective non-randomised before-and-after study was conducted in patients hospitalized between October 2015 and December 2017 and treated with anticoagulant therapy. Method A multidisciplinary antithrombotic team focusing on education, medication reviews, drafting of local anticoagulant therapy protocols, patient counseling and medication reconciliation at admission and discharge was implemented in two Dutch hospitals. Main outcome measure Primary outcome was the proportion of the admitted patients in which the prescribing physician did adhere to the anticoagulant guidelines. Results The study comprised 1886 patients, of which 941 patients were included in the usual care period and 945 patients in the intervention period. Multivariable logistic regression analysis indicated that adherence was observed significantly more often during the intervention period (adjusted odds ratio [ORadj] 1.58, 95% confidence interval [95% CI] 1.21-2.05). Detailed analysis identified that the significantly higher overall adherence in the intervention period was attributed to dosing of LMWHs (odds ratio [OR] 1.58, 95% CI 1.16-2.14). Conclusion This study shows that introduction of a multidisciplinary antithrombotic stewardship leads to a significantly higher overall adherence to anticoagulant guidelines among prescribing physicians, mainly based on the improvement of dosing of low-molecular-weight-heparins.

Proactivity in VTE prevention: a concept analysis

Venous thromboembolism (VTE) prevention is an international patient safety issue. The author has observed gaps in prescription and provision of VTE prophylaxis, and that the attitude to VTE is often reactive rather than proactive. This concept analysis aims to explore proactivity and apply it to VTE prevention to address this. Ten databases were searched (1992-2012) using the keywords proactive, proactivity, nurse, nursing, VTE/venous thromboembolism, prevent/prevention/preventing, behaviour, DVT/PE (deep vein thrombosis, pulmonary embolism). The Walker and Avant (2010) method of concept analysis identified the defining attributes as personal initiative, taking charge and feedback-seeking behaviour. Antecedents and consequences have been identified, and empirical referents are demonstrated. Defining proactivity in VTE prevention has the potential to increase prescription and, crucially, provision of prophylaxis, thereby improving patient care, reducing avoidable harm and improving the patient experience.

Clinical practice guidelines: what are they and how should they be disseminated?

Clinical practice guidelines summarize the available evidence for patient management in a format that is easy for clinicians to use. These guidelines usually use methodologically rigorous principles for retrieving and evaluating the literature and for establishing consensus among work group members, but implementation by clinicians is often incomplete. The reasons why guidelines fail to gain widespread acceptance vary with the topic and clinician group. Successful dissemination of practice guidelines requires an understanding of the barriers to implementation and the use of multiple strategies to address these. This article examines the factors affecting implementation and the approaches to overcoming these obstacles.

A randomized controlled trial of a mixed Kinesio taping–compression technique on venous symptoms, pain, peripheral venous flow, clinical severity and overall health status in postmenopausal women with chronic venous insufficiency

Objectives:

To investigate the effect of a mixed Kinesio taping treatment in women with chronic venous insufficiency.

Design:

A double-blinded randomized clinical trial.

Setting:

Clinical setting.

Participants:

One hundred and twenty postmenopausal women with mild–moderate chronic venous insufficiency were randomly assigned to an experimental group receiving standardized Kinesio taping treatment for gastrocnemius muscle enhancement and ankle functional correction, or to a placebo control group for simulated Kinesio taping.

Main outcomes variables:

Venous symptoms, pain, photoplethysmographic measurements, bioelectrical impedance, temperature, severity and overall health were recorded at baseline and after four weeks of treatment.

Results:

The 2 × 2 mixed model ANCOVA with repeated measurements showed statistically significant group * time interaction for heaviness ( F = 22.99, p = 0.002), claudication ( F = 8.57, p = 0.004), swelling ( F = 22.58, p = 0.001), muscle cramps ( F = 7.14, p = 0.008), venous refill time (right: F = 9.45, p = 0.023; left: F = 14.86, p = 0.001), venous pump function (right: F = 35.55, p = 0.004; left: F = 17.39 p = 0.001), extracellular water (right: F = 35.55, p = 0.004; left: F = 23.84, p = 0.001), severity ( F = 18.47, p = 0.001), physical function ( F = 9.15, p = 0.003) and body pain ( F = 3.36, p = 0.043). Both groups reported significant reduction in pain.

Conclusion:

Mixed Kinesio taping-compression therapy improves symptoms, peripheral venous flow and severity and slightly increases overall health status in females with mild chronic venous insufficiency. Kinesio taping may have a placebo effect on pain.

Prevention of venous thromboembolism in pregnancy: a review of guidelines, 2000-2011

INTRODUCTION

Pregnant women are four to five times more likely than nonpregnant women to develop venous thromboembolism (VTE). The aim of this review is to provide an overview of guidelines in the literature on VTE risk assessment, screening for thrombophilias, and thromboprophylaxis dissemination among pregnant women.

METHODS

We performed a review of the published literature to identify evidence-based guidelines published between the years 2000 and 2011. We searched for guidelines from U.S. and international organizations that identified clinically based practice recommendations to healthcare providers on how VTE risk should be assessed, thrombophilias screened, and thromboprophylaxis disseminated among pregnant women.

RESULTS

We found nine guidelines that met our requirements for assessing VTE risk and found seven guidelines addressing thrombophilia screening. Seven of the nine agreed that all women should undergo a risk factor assessment for VTE either in early pregnancy or in the preconception period. Seven of the nine agreed that pregnant women with more than one additional VTE risk factor be considered for thromboprophylaxis, and five of the seven groups addressing thrombophilia screening agreed that selected at-risk populations should be considered for thrombophilia screening.

CONCLUSIONS

There is some agreement between U.S. and international guidelines that women should be assessed for VTE risk during preconception and again in pregnancy. Although there is agreement that the general population of women should not be screened for thrombophilias, no agreement exists as to the clinical subgroups for which screening should be done.