Prophylaxis of venous thromboembolism in the US: improving hospital performance

Enhancing thromboprophylaxis after colorectal cancer surgery in China: Bridging the gap between evidence and implementation through pathway optimization

BACKGROUND

The CRC-VTE trial conducted in China revealed a significant occurrence of venous thromboembolism (VTE) in patients following colorectal cancer (CRC) surgery, raising concerns about implementing thromboprophylaxis measures. The present study aimed to identify and analyze inappropriate aspects of current thromboprophylaxis practices.

METHODS

This study performed an analysis of the CRC-VTE trial, a prospective multicenter study that enrolled 1836 patients who underwent CRC surgery. The primary objective was to identify independent risk factors for VTE after CRC surgery using multivariate logistic regression analysis. Furthermore, among the cases in which VTE occurred, the appropriateness of thromboprophylaxis was assessed based on several factors, including pharmacologic prophylaxis, time to initiate prophylaxis, drug selection, drug dosage, and duration of pharmacologic prophylaxis. Based on the analysis of the current state of thromboprophylaxis and relevant clinical guidelines, a modified Delphi method was used to develop a clinical pathway for VTE prophylaxis after CRC surgery.

RESULTS

In this analysis of 1836 patients, 205 (11.2%) were diagnosed with VTE during follow-up. The multifactorial analysis identified several independent risk factors for VTE, including age (≥70 years), female sex, varicose veins in the lower extremities, intraoperative blood transfusion, and the duration of immobilization exceeding 24 h. None of the patients diagnosed with VTE in the CRC trial received adequate thromboprophylaxis. The main reasons for this inappropriate practice were the omission of thromboprophylaxis, delayed initiation, and insufficient duration of thromboprophylaxis. We developed a specialized clinical pathway for thromboprophylaxis after CRC surgery to address these issues.

CONCLUSIONS

This study offers a comprehensive nationwide evaluation of existing thromboprophylaxis practices in patients after CRC surgery in China. A specialized clinical pathway was developed to address the identified gaps and improve the quality of care. This clinical pathway incorporates explicit, tailored, detailed recommendations for thromboprophylaxis after CRC surgery.

Improved utilisation of venous thromboembolism prophylaxis in renal-impaired patients following a clinical pharmacist intervention

OBJECTIVES

To evaluate the role of the clinical pharmacist in improving venous thromboembolism (VTE) prophylaxis prescription in patients with renal impairment (RI).

METHODS

This was an interventional cross-sectional study conducted in a nephrology ward. Patients' risk scores for VTE and bleeding during hospitalisation (evaluated by the Caprini Risk Assessment Model (RAM), Padua Prediction Score and IMPROVE Bleeding Risk Score, respectively), and the rate of VTE prophylaxis administration to patients, were evaluated before and after a clinical pharmacist's intervention.

RESULTS

In the pre-intervention phase, 34.8% of high-VTE-risk patients, of whom 12.5% were also at high risk of bleeding, received pharmacological prophylaxis. Moreover, 22.2% of low-VTE-risk patients received prophylaxis. In the intervention phase, prophylaxis was administered to all high-risk patients (mechanical prophylaxis in 7% of patients with a high risk of both VTE and bleeding, and heparin in the remainder) and to 3.3% of those at low risk of VTE.

CONCLUSIONS

The clinical pharmacist's intervention using RAMs can improve the rate of thrombosis prophylaxis prescription in patients with RI who have a high risk of VTE.

Venous Thromboembolism Quality Measures Fail to Accurately Measure Quality

Venous thromboembolism (VTE) is 1 of the most common causes of preventable harm for patients in hospitals. Consequently, the Joint Commission, the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, the United Kingdom Care Quality Commission, the Australian Commission on Safety and Quality in Health Care, the Maryland Health Services Cost Review Commission, and the American College of Surgeons have prioritized measuring and reporting VTE outcomes with the goal of reducing the incidence of and preventable harm from VTE. We developed a rubric for defect-free VTE prevention, graded each organizational VTE quality measure, and found that none of the current VTE-related quality measures adequately characterizes VTE prevention efforts or outcomes in hospitalized patients. Effective VTE prevention is multifactorial: clinicians must assess patients’ risk for VTE and prescribe therapy appropriate for each patient’s risk profile, patients must accept the prescribed therapy, and nurses must administer the therapy as prescribed. First, an ideal, defect-free VTE prevention process measure requires: (1) documentation of a standardized VTE risk assessment; (2) prescription of optimal, risk-appropriate VTE prophylaxis; and (3) administration of all risk-appropriate VTE prophylaxis as prescribed. Second, an ideal VTE outcome measure should define potentially preventable VTE as VTE that developed in patients who experienced any VTE prevention process failures.

YouTube as a potential source of information on deep venous thrombosis

Background

No work has been reported on the use of video websites to learn about deep vein thrombosis and the value of education using them. We examined the characteristics and scientific accuracy of videos related to deep vein thrombosis on YouTube.

Methods

YouTube was surveyed using no filter and the key words ‘deep vein thrombosis’ and ‘leg vein clot’ in June 2016. The videos evaluated were divided into three groups in terms of their scientific content, accuracy, and currency: useful, partly useful, and useless.

Results

Of the 1200 videos watched, 715 (59.58%) were excluded with the exclusion criteria. Although most of the videos uploaded (22.9%, n = 111) were created by physicians, the number of views for website-based videos was significantly higher (p = 0.002). When the uploaded videos were assessed in terms of their usefulness, videos from physicians and hospitals were statistically more useful than other videos (p < 0.001).

Conclusions

For videos created by medical professionals to be of higher quality, we believe they should be more up-to-date and comprehensive, and contain animations about treatment modalities and early diagnosis in particular.

Impact of electronic reminders on venous thromboprophylaxis after admissions and transfers

OBJECTIVE

Clinical decision support has the potential to improve prevention of venous thromboembolism (VTE). The purpose of this prospective study was to analyze the effect of electronic reminders on thromboprophylaxis rates in wards to which patients were admitted and transferred. The latter was of particular interest since patient handoffs are considered to be critical safety issues.

METHODS

The trial involved two study periods in the six departments of a university hospital, three of which were randomly assigned to the intervention group displaying reminders during the second period. At 6 h after admission or transfer, the algorithm checked for prophylaxis orders within 0-30 h of the patient's arrival, increasing the specificity of the displayed reminders.

RESULTS

The significant impact of the reminders could be seen by prophylaxis orders placed 6-24 h after admission (increasing from 8.6% (223/2579) to 12% (307/2555); p<0.0001) and transfer (increasing from 2.4% (39/1616) to 3.7% (63/1682); p=0.034). In admission wards, the rate of thromboprophylaxis increased from 62.4% to 67.7% (p<0.0001), and in transfer wards it increased from 80.2% to 84.3% (p=0.0022). Overall, the rate of prophylaxis significantly increased in the intervention group from 69.2% to 74.3% (p<0.0001). No significant changes were observed in the control group. Postponing prophylaxis checks to 6 h after admissions and transfers reduced the number of reminders by 62% and thereby minimized the risk of alert fatigue.

CONCLUSIONS

The reminders improved awareness of VTE prevention in both admission and transfer wards. This approach may contribute to better quality of care and safer patient handoffs.

Assessment of characteristics associated with pharmacologic thromboprophylaxis use in hospitalized patients: a cohort study of 10,016 patients

The aim of the study was to evaluate patient characteristics associated with pharmacologic thromboprophylaxis (PTP) use/nonuse in a general tertiary hospital cohort. Eligible patients were classified according to venous thromboembolism (VTE) risk category by trained nurses. Either standard or low-molecular weight heparin was recommended to intermediate or high-risk VTE patients. Adopting the recommended PTP was at the physician's discretion. At discharge, PTP use was recorded. PTP was recommended to 10,016 patients, of whom 2165 (21.6%) received the recommended thromboprophylaxis. In the multivariate logistic regression, PTP use/nonuse remained independently associated with female sex [odds ratio (OR) 0.75; 95% confidence interval (CI) 0.68-0.84], age (OR 1.04; 95% CI 1.03-1.04), being admitted to the Gynecology-Obstetrics (OR 0.31; 95% CI 0.25-0.39) or surgery (OR 1.26; 95% CI 1.12-1.42), thrombophilia (OR 5.15; 95% CI 2.04-12.98), previous VTE event (OR 2.98; 95% CI 1.78-4.98), diabetes (OR 1.84; 95% CI 1.61-2.10), acute myocardial infarction (OR 5.87; 95% CI 4.81-7.17), and admission to a major orthopedic surgery (OR 3.03; 95% CI 1.98-4.64). PTP in this hospital population was grossly underused. Eight independent variables predicted use/nonuse of PTP. Targeting variables related to the use and nonuse of PTP is important to direct the application of thromboprophylaxis.

Thromboprophylaxis for deep vein thrombosis and pulmonary embolism after total joint arthroplasty in a low incidence population

Postoperative venous thromboembolism is one of the most serious complications following total joint arthroplasty. Pharmacological and mechanical prophylaxis methods are used to reduce the risk of postoperative symptomatic deep vein thrombosis and pulmonary embolism. Use of pharmacological prophylaxis requires a fine balance between the efficacy of the drug in preventing deep vein thrombosis and the adverse effects associated with the use of these drugs. In regions with a low prevalence of deep vein thrombosis such as Korea, there might be a question whether the benefits of using pharmacological prophylaxis outweigh the risks involved. The current article reviews the need for thromboprophylaxis, guidelines, problems with the guidelines, pharmacological prophylaxis use, and the current scenario of deep vein thrombosis, and discusses whether the use of pharmacological prophylaxis should be mandatory in low incidence populations.

Sustained impact of electronic alerts on rate of prophylaxis against venous thromboembolism

Advanced electronic alerts (eAlerts) and computerised physician order entry (CPOE) increase adequate thromboprophylaxis orders among hospitalised medical patients. It remains unclear whether eAlerts maintain their efficacy over time, after withdrawal of continuing medical education (CME) on eAlerts and on thromboprophylaxis indications from the study staff. We analysed 5,317 hospital cases from the University Hospital Zurich during 2006-2009: 1,854 cases from a medical ward with eAlerts (interventiongroup) and 3,463 cases from a surgical ward without eAlerts (controlgroup). In the intervention group, an eAlert with hospital-specific venous thromboembolism (VTE) prevention guidelines was issued in the electronic patient chart 6 hours after admission if no pharmacological or mechanical thromboprophylaxis had been ordered. Data were analysed for three phases: pre-implementation (phase 1), eAlert implementation with CME (phase 2), and post-implementation without CME (phase3). The rates of thromboprophylaxis in the intervention group were 43.4% in phase 1 and 66.7% in phase 2 (p<0.001), and increased further to 73.6% in phase3 (p=0.011). Early thromboprophylaxis orders within 12 hours after admission were more often placed in phase 2 and 3 as compared to phase 1 (67.1% vs. 52.1%, p<0.001). In the surgical control group, the thromboprophylaxis rates in the three phases were 88.6%, 90.7%, 90.6% (p=0.16). Advanced eAlerts may provide sustained efficacy over time, with stable rates of thromboprophylaxis orders among hospitalised medical patients.

[Thromboprophylaxis: medical recommendations and hospital programs]

Venous thromboembolism (VTE) is the most preventable cause of death in hospitalized patients. Hospital-related VTE is associated with more than half of the VTE burden in a community, either in-hospital or after discharge. Selective thromboprophylaxis is recommended for patients at risk. Patient selection for thromboprophylaxis requires proper VTE risk stratification. VTE stratification may be achieved by either risk assessment models (RAM) or by models based on patient's illness and associated risk factors. Whatever the model, a thromboprophylatic recommendation should be formulated for each VTE risk category. VTE thromboprophylaxis may include general measures, mechanic compression procedures, pharmacological intervention or a combined approach. After many decades of consensus statements, a large proportion of at risk patients (20% to 75%) still does not receive proper thromboprophylaxis. This study aims to alert to the relevance of thromboprophylaxis and to suggest hospital thromboprophylatic strategies in a Brazilian setting.

Venous thromboembolism prevention: a systematic review of methods to improve prophylaxis and decrease events in the hospitalized patient

Prevention of venous thromboembolism (VTE) is currently a key initiative internationally and in US hospitals, where there has been a recent focus on national quality initiatives to prevent hospital-acquired VTE. Multiple strategies exist to prevent VTE by increasing prophylaxis rates in the hospitalized setting. Active, multifaceted interventions, including provider education, an active reminder to the provider, and regular audit and feedback to medical and hospital staff, appear to be the most effective current interventions. Active intervention programs have been validated both as electronic alerts, with or without computerized clinical decision support software and, more recently, human alerts, many of which utilize in-hospital pharmacists. A passive strategy, such as guideline dissemination, should not be used as a lone method. Although inappropriate duration remains a key reason as to why at-risk patients do not receive appropriate thromboprophylaxis within the hospital (defined by type, dose, and duration of prophylaxis), few studies address duration compared with hospital length of stay. Preventable VTE is a new quality outcome measure for hospitals but is measured in few studies. Future studies should focus on comparing various multifaceted interventions to assess their effect over time, including endpoints of bleeding for safety, appropriate type, dose, and duration of prophylaxis, overall and preventable VTE, and the impact on unnecessary prophylaxis for patients not at risk.

Adverse drug events associated with disorders of coagulation

Disorders of coagulation are common adverse drug events encountered in critically ill patients and present a serious concern for intensive care unit (ICU) clinicians. Dosing strategies for medications used in the ICU are typically developed for use in noncritically ill patients and, therefore, do not account for the altered pharmacokinetic and pharmacodynamic properties encountered in the critically ill as well as the increased potential for drug-drug interactions, given the far greater number of medications ordered. This substantially increases the risk for coagulation-related adverse reactions, such as a bleeding or prothrombotic events. Although many medications used in the ICU have the potential to cause coagulation disorders, the exact incidence will vary based on the specific medication, dose, concomitant drug therapy, ICU setting, and patient-specific comorbidities. Clinicians must strongly consider these factors when evaluating the risk/benefit ratio for a particular therapy. This review surveys recent literature documenting the risk for adverse drug reactions specific to bleeding and/or clotting with commonly used medications in the ICU.

Adequacy of venous thromboprophylaxis in acutely ill medical patients (IMPART): multisite comparison of different clinical decision support systems

BACKGROUND

The adequacy of thromboprophylaxis prescriptions in acutely ill hospitalized medical patients needs improvement.

OBJECTIVE

To prospectively assess the efficacy of thromboprophylaxis adequacy of various clinical decision support systems (CDSS) with the aim of increasing the use of explicit criteria for thromboprophylaxis prescription in nine Swiss medical services.

METHODS

We randomly assigned medical services to a pocket digital assistant program (PDA), pocket cards (PC) and no CDSS (controls). In centers using an electronic chart, an e-alert system (eAlerts) was developed. After 4 months, we compared post-CDSS with baseline thromboprophylaxis adequacy for the various CDSS and control groups.

RESULTS

Overall, 1085 patients were included (395 controls, 196 PC, 168 PDA, 326 eAlerts), 651 pre- and 434 post-CDSS implementation: 472 (43.5%) presented a risk of VTE justifying thromboprophylaxis (31.8% pre, 61.1% post) and 556 (51.2%) received thromboprophylaxis (54.2% pre, 46.8% post). The overall adequacy (% patients with adequate prescription) of pre- and post-CDSS implementation was 56.2 and 50.7 for controls (P = 0.29), 67.3 and 45.3 for PC (P = 0.002), 66.0 and 64.9 for PDA (P = 0.99), 50.5 and 56.2 for eAlerts (P = 0.37), respectively, eAlerts limited overprescription (56% pre, 31% post, P = 0.01).

CONCLUSION

While pocket cards and handhelds did not improve thromboprophylaxis adequacy, eAlerts had a modest effect, particularly on the reduction of overprescription. This effect only partially contributes to the improvement of patient safety and more work is needed towards institution-tailored tools.