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Xu J, Neeman E, Thai KK, Mishra P, Schlessinger D, Clancy H, Myers L, Roubinian N, Liu V, Liu R. Hospital-associated venous thromboembolism prophylaxis use by risk assessment at a large integrated health care network in Northern California. J Hosp Med 2024; 19:449-459. [PMID: 38606546 DOI: 10.1002/jhm.13350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 03/19/2024] [Accepted: 03/19/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Hospital-acquired venous thromboembolism (HA VTE) is a preventable complication in hospitalized patients. OBJECTIVE We aimed to examine the use of pharmacologic prophylaxis (pPPX) and compare two risk assessment methods for HA VTE: a retrospective electronic Padua Score (ePaduaKP) and admitting clinician's choice of risk within the admission orderset (low, moderate, or high). DESIGN, SETTINGS AND PARTICIPANTS We retrospectively analyzed prophylaxis orders for adult medical admissions (2013-2019) at Kaiser Permanente Northern California, excluding surgical and ICU patients. INTERVENTION ePaduaKP was calculated for all admissions. For a subset of these admissions, clinician-assigned HA VTE risk was extracted. MAIN OUTCOME AND MEASURES Descriptive pPPX utilization rates between ePaduaKP and clinician-assigned risk as well as concordance between ePaduaKP and clinician-assigned risk. RESULTS Among 849,059 encounters, 82.2% were classified as low risk by ePaduaKP, with 42.3% receiving pPPX. In the subset with clinician-assigned risk (608,512 encounters), low and high ePaduaKP encounters were classified as moderate risk in 87.5% and 92.0% of encounters, respectively. Overall, 56.7% of encounters with moderate clinician-assigned risk received pPPX, compared to 7.2% of encounters with low clinician-assigned risk. pPPX use occurred in a large portion of low ePaduaKP risk encounters. Clinicians frequently assigned moderate risk to encounters at admission irrespective of their ePaduaKP risk when retrospectively examined. We hypothesize that the current orderset design may have negatively influenced clinician-assigned risk choice as well as pPPX utilization. Future work should explore optimizing pPPX for high-risk patients only.
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Affiliation(s)
- James Xu
- Internal Medicine, Kaiser Foundation Hospitals, San Francisco, California, USA
| | - Elad Neeman
- Department of Hematology and Oncology, The Permanente Medical Group, San Rafael, California, USA
| | - Khanh K Thai
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Pranita Mishra
- Blue Shield of California, Oakland, California, USA
- Department of Pulmonary/Critical Care, Kaiser Permanente Oakland Medical Center, Oakland, California, USA
| | - David Schlessinger
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Heather Clancy
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Laura Myers
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Nareg Roubinian
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Vincent Liu
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Raymond Liu
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
- Department of Hematology and Oncology, The Permanente Medical Group, San Francisco, California, USA
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Tsaftaridis N, Goldin M, Spyropoulos AC. System-Wide Thromboprophylaxis Interventions for Hospitalized Patients at Risk of Venous Thromboembolism: Focus on Cross-Platform Clinical Decision Support. J Clin Med 2024; 13:2133. [PMID: 38610898 PMCID: PMC11013003 DOI: 10.3390/jcm13072133] [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: 02/23/2024] [Revised: 03/23/2024] [Accepted: 04/02/2024] [Indexed: 04/14/2024] Open
Abstract
Thromboprophylaxis of hospitalized patients at risk of venous thromboembolism (VTE) presents challenges owing to patient heterogeneity and lack of adoption of evidence-based methods. Intuitive practices for thromboprophylaxis have resulted in many patients being inappropriately prophylaxed. We conducted a narrative review summarizing system-wide thromboprophylaxis interventions in hospitalized patients. Multiple interventions for thromboprophylaxis have been tested, including multifaceted approaches such as national VTE prevention programs with audits, pre-printed order entry, passive alerts (either human or electronic), and more recently, the use of active clinical decision support (CDS) tools incorporated into electronic health records (EHRs). Multifaceted health-system and order entry interventions have shown mixed results in their ability to increase appropriate thromboprophylaxis and reduce VTE unless mandated through a national VTE prevention program, though the latter approach is potentially costly and effort- and time-dependent. Studies utilizing passive human or electronic alerts have also shown mixed results in increasing appropriate thromboprophylaxis and reducing VTE. Recently, a universal cloud-based and EHR-agnostic CDS VTE tool incorporating a validated VTE risk score revealed high adoption and effectiveness in increasing appropriate thromboprophylaxis and reducing major thromboembolism. Active CDS tools hold promise in improving appropriate thromboprophylaxis, especially with further refinement and widespread implementation within various EHRs and clinical workflows.
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Affiliation(s)
- Nikolaos Tsaftaridis
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY 11030, USA; (N.T.); (M.G.)
- Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, NY 10075, USA
| | - Mark Goldin
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY 11030, USA; (N.T.); (M.G.)
- Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, NY 10075, USA
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
| | - Alex C. Spyropoulos
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY 11030, USA; (N.T.); (M.G.)
- Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, NY 10075, USA
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
- Elmezzi Graduate School of Molecular Medicine, Manhasset, NY 11030, USA
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Savage T, Wang J, Shieh L. A Large Language Model Screening Tool to Target Patients for Best Practice Alerts: Development and Validation. JMIR Med Inform 2023; 11:e49886. [PMID: 38010803 DOI: 10.2196/49886] [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: 06/12/2023] [Revised: 08/04/2023] [Accepted: 10/24/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Best Practice Alerts (BPAs) are alert messages to physicians in the electronic health record that are used to encourage appropriate use of health care resources. While these alerts are helpful in both improving care and reducing costs, BPAs are often broadly applied nonselectively across entire patient populations. The development of large language models (LLMs) provides an opportunity to selectively identify patients for BPAs. OBJECTIVE In this paper, we present an example case where an LLM screening tool is used to select patients appropriate for a BPA encouraging the prescription of deep vein thrombosis (DVT) anticoagulation prophylaxis. The artificial intelligence (AI) screening tool was developed to identify patients experiencing acute bleeding and exclude them from receiving a DVT prophylaxis BPA. METHODS Our AI screening tool used a BioMed-RoBERTa (Robustly Optimized Bidirectional Encoder Representations from Transformers Pretraining Approach; AllenAI) model to perform classification of physician notes, identifying patients without active bleeding and thus appropriate for a thromboembolism prophylaxis BPA. The BioMed-RoBERTa model was fine-tuned using 500 history and physical notes of patients from the MIMIC-III (Medical Information Mart for Intensive Care) database who were not prescribed anticoagulation. A development set of 300 MIMIC patient notes was used to determine the model's hyperparameters, and a separate test set of 300 patient notes was used to evaluate the screening tool. RESULTS Our MIMIC-III test set population of 300 patients included 72 patients with bleeding (ie, were not appropriate for a DVT prophylaxis BPA) and 228 without bleeding who were appropriate for a DVT prophylaxis BPA. The AI screening tool achieved impressive accuracy with a precision-recall area under the curve of 0.82 (95% CI 0.75-0.89) and a receiver operator curve area under the curve of 0.89 (95% CI 0.84-0.94). The screening tool reduced the number of patients who would trigger an alert by 20% (240 instead of 300 alerts) and increased alert applicability by 14.8% (218 [90.8%] positive alerts from 240 total alerts instead of 228 [76%] positive alerts from 300 total alerts), compared to nonselectively sending alerts for all patients. CONCLUSIONS These results show a proof of concept on how language models can be used as a screening tool for BPAs. We provide an example AI screening tool that uses a HIPAA (Health Insurance Portability and Accountability Act)-compliant BioMed-RoBERTa model deployed with minimal computing power. Larger models (eg, Generative Pre-trained Transformers-3, Generative Pre-trained Transformers-4, and Pathways Language Model) will exhibit superior performance but require data use agreements to be HIPAA compliant. We anticipate LLMs to revolutionize quality improvement in hospital medicine.
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Affiliation(s)
- Thomas Savage
- Division of Hospital Medicine, Department of Medicine, Stanford University, Palo Alto, CA, United States
| | - John Wang
- Divison of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Palo Alto, CA, United States
| | - Lisa Shieh
- Division of Hospital Medicine, Department of Medicine, Stanford University, Palo Alto, CA, United States
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Kocher B, Darbellay Farhoumand P, Pulver D, Kopp B, Choffat D, Tritschler T, Vollenweider P, Reny JL, Rodondi N, Aujesky D, Méan M, Baumgartner C. Overuse and underuse of thromboprophylaxis in medical inpatients. Res Pract Thromb Haemost 2023; 7:102184. [PMID: 37745158 PMCID: PMC10514554 DOI: 10.1016/j.rpth.2023.102184] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 08/14/2023] [Accepted: 08/15/2023] [Indexed: 09/26/2023] Open
Abstract
Background Thromboprophylaxis (TPX) prescription is recommended in medical inpatients categorized as high risk of venous thromboembolism (VTE) by validated risk assessment models (RAMs), but how various RAMs differ in categorizing patients in risk groups, and whether the choice of RAM influences estimates of appropriate TPX use is unknown. Objectives To determine the proportion of medical inpatients categorized as high or low risk according to validated RAMs, and to investigate the appropriateness of TPX prescription. Methods This is a prospective cohort study of acutely ill medical inpatients from 3 Swiss university hospitals. Participants were categorized as high or low risk of VTE by validated RAMs (ie, the Padua, the International Medical Prevention Registry on Venous Thromboembolism, simplified, and original Geneva scores). We assessed prescription of any TPX at baseline. We considered TPX prescription in high-risk and no TPX prescription in low-risk patients as appropriate. Results Among 1352 medical inpatients, the proportion categorized as high risk ranged from 29.8% with the International Medical Prevention Registry on Venous Thromboembolism score to 66.1% with the original Geneva score. Overall, 24.6% were consistently categorized as high risk, and 26.3% as low risk by all 4 RAMs. Depending on the RAM used, TPX prescription was appropriate in 58.7% to 63.3% of high-risk (ie, 36.7%-41.3% underuse) and 52.4% to 62.8% of low-risk patients (ie, 37.2%-47.6% overuse). Conclusion The proportion of medical inpatients considered as high or low VTE risk varied widely according to different RAMs. Only half of patients were consistently categorized in the same risk group by all RAMs. While TPX remains underused in high-risk patients, overuse in low-risk patients is even more pronounced.
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Affiliation(s)
- Barbara Kocher
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Pauline Darbellay Farhoumand
- Division of General Internal Medicine, Department of Medicine, Geneva University Hospitals (HUG), Geneva, Switzerland
| | - Damiana Pulver
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Basil Kopp
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Damien Choffat
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Vollenweider
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Jean-Luc Reny
- Division of General Internal Medicine, Department of Medicine, Geneva University Hospitals (HUG), Geneva, Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marie Méan
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Christine Baumgartner
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Haller MD, Cho HJ, Ahn J, Krouss M, Alaiev D, Yoon GH, Dunn AS, Fagan I. Initiative to reduce inappropriate venous thromboembolism prophylaxis in an 11-hospital safety net system: An electronic health records-based approach. J Hosp Med 2023. [PMID: 37051635 DOI: 10.1002/jhm.13104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 03/24/2023] [Accepted: 03/29/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND While pharmacologic prophylaxis has benefits for venous thromboembolism (VTE) prevention in high-risk patients, unnecessary use carries potential harm, including bleeding, heparin-induced thrombocytopenia, and patient discomfort, and should be avoided in low-risk patients. While many quality improvement initiatives aim to reduce underuse, successful models on reducing overuse are sparse in the literature. OBJECTIVE We aimed to create a quality improvement initiative to reduce overuse of pharmacologic VTE prophylaxis. DESIGNS, SETTINGS AND PARTICIPANTS A quality improvement initiative was implemented across 11 safety net hospitals in New York City. INTERVENTION The first electronic health record (EHR) intervention consisted of a VTE order panel that facilitated risk assessment and recommended VTE prophylaxis for high-risk patients only. The second EHR intervention used a best practice advisory that alerted clinicians when prophylaxis was ordered for a patient previously deemed "low risk." Prescribing rates were compared through a three-segment interrupted time series linear regression design. RESULTS Compared to the preintervention period, the first intervention did not change the rate of total pharmacologic prophylaxis immediately after implementation (1.7% relative change, p = .38) or over time (slope difference of 0.20 orders per 1000 patient days, p = .08). Compared to the first intervention period, the second intervention led to an immediate 4.5% reduction in total pharmacologic prophylaxis (p = .04) but increased thereafter (slope difference of 0.24, p = .03) such that weekly rates at the end of the study were similar to rates prior to the second intervention.
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Affiliation(s)
| | - Hyung J Cho
- Department of Quality and Safety, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jennifer Ahn
- NYU Grossman School of Medicine, New York, New York, USA
- Health+Hospitals/Bellevue Hospital, Internal Medicine, New York, New York, USA
| | - Mona Krouss
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Quality and Safety, NYC Health+Hospitals, New York, New York, USA
| | - Daniel Alaiev
- Department of Quality and Safety, NYC Health+Hospitals, New York, New York, USA
| | - Garrett H Yoon
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Andrew S Dunn
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ian Fagan
- NYU Grossman School of Medicine, New York, New York, USA
- Health+Hospitals/Bellevue Hospital, Internal Medicine, New York, New York, USA
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Torres-Quintanilla FJ, Azpiri-López JR, Romero-Ibarguengoitia ME, Ponce-Sierra TH, Martínez-Gallegos EP. Improving thromboprophylaxis in the medical inpatients: The role of the resident in an academic hospital. Phlebology 2023; 38:91-95. [PMID: 36537872 DOI: 10.1177/02683555221147472] [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: 03/05/2023]
Abstract
INTRODUCTION Venous thromboembolism (VTE) is one of the main causes of preventable in-hospital death. It is recommended for hospitals to have an appropriate thromboprophylaxis (TP) protocol to avoid VTE complications. OBJECTIVE To determine the effect of the resident physician feedback to the staff physician in TP appropriateness after the Caprini RAM score implementation. METHODS Caprini RAM was implemented by the residents in medical patients. Patients were divided in low, moderate, high, and highest-risk groups, with TP recommendation accordingly. In cases with inadequate TP, the resident provided feedback to the staff physician for adjustment. Change to appropriate TP was assessed retrospectively. RESULTS A total of 265 records were included. Before intervention, 193 (72.8%) patients had appropriate TP and post-intervention, 207 (78.1%) patients received adequate TP (p < .001). CONCLUSIONS Feedback from the internal medicine resident to staff physician improves appropriate TP in medical inpatients as a quality of care strategy.
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Affiliation(s)
- Francisco J Torres-Quintanilla
- Department of Internal Medicine, Christus Muguerza Hospital Alta Especialidad, 27808Universidad de Monterrey, San Pedro Garza Garcia, Mexico
| | - José R Azpiri-López
- Department of Cardiology, Christus Muguerza Hospital Alta Especialidad, 27808Universidad de Monterrey, San Pedro Garza Garcia, Mexico
| | - Maria E Romero-Ibarguengoitia
- Department of Endocrinology, Christus Muguerza Hospital Alta Especialidad, 27808Universidad de Monterrey, San Pedro Garza Garcia, Mexico
| | - Tadeo H Ponce-Sierra
- Department of Health Quality, Christus Muguerza Hospital Alta Especialidad, 27808Universidad de Monterrey, San Pedro Garza Garcia, Mexico
| | - Eunice P Martínez-Gallegos
- Department of Health Quality, Christus Muguerza Hospital Alta Especialidad, 27808Universidad de Monterrey, San Pedro Garza Garcia, Mexico
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Özdede M, Güven AT, Karadeniz Güven D, Uyaroğlu OA, Durusu Tanriover M. The Collateral Benefit of COVID Pandemic: Improved Pharmacological Venous Thromboembolism Prophylaxis Practices in Non-COVID Patients. Int J Gen Med 2023; 16:1069-1079. [PMID: 36992696 PMCID: PMC10042246 DOI: 10.2147/ijgm.s404827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 03/17/2023] [Indexed: 03/31/2023] Open
Abstract
Background COVID-19 creates a hypercoagulable state with a wide spectrum of clinical manifestations. Of those, venous thromboembolism (VTE) is prevalent, and numerous studies have highlighted the importance of VTE prophylaxis. Pre-pandemic VTE prophylaxis practices have already been poor, despite guidelines. We hypothesized that the gap between guidelines and practices might have been closed due to increased awareness. Materials and Methods Non-COVID-19 patients hospitalized in the internal medicine ward of a university hospital between January 1st, 2021, and June 30th, 2021, were assessed. VTE risk and thromboprophylaxis requirements were assessed using the Padua Prediction Score (PPS). The results were compared with the findings of the study conducted in the same setting before the pandemic. Results A total of 267 patients were included, and 81 patients (30.3%) received prophylaxis. A total of 128 patients' (47.9%) PPS was ≥ 4, and 69 patients (53.9%) received prophylaxis; 12 low-risk patients (8.6%) received prophylaxis although it was not indicated. Compared to the pre-pandemic figures, both appropriate prophylaxis use and overuse rates have risen. While the increment rate of appropriate prophylaxis was statistically significant, the increment rate of overuse did not reach statistical significance. Patients hospitalized for infectious diseases and respiratory failure were more likely to receive appropriate prophylaxis. Conclusion We have demonstrated a significant increase in appropriate pharmacologic prophylaxis rates among high-risk patients. Besides all the collateral damage the pandemic has created, it might also have brought collateral benefits with regards to VTE prophylaxis.
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Affiliation(s)
- Murat Özdede
- Hacettepe University Faculty of Medicine, Department of Internal Medicine, Division of General Internal Medicine, Ankara, Turkey
| | - Alper Tuna Güven
- Başkent University Adana Hospitals, Department of Internal Medicine, Division of General Internal Medicine, Adana, Turkey
- Correspondence: Alper Tuna Güven, Başkent University Adana Hospitals, Department of Internal Medicine, Division of General Internal Medicine, Yüreğir, Adana, Turkey, Tel +90 541 802 2135, Email
| | | | - Oğuz Abdullah Uyaroğlu
- Hacettepe University Faculty of Medicine, Department of Internal Medicine, Division of General Internal Medicine, Ankara, Turkey
| | - Mine Durusu Tanriover
- Hacettepe University Faculty of Medicine, Department of Internal Medicine, Division of General Internal Medicine, Ankara, Turkey
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Karajizadeh M, Hassanipour S, Sharifian R, Tajbakhsh F, Saeidnia HR. The effect of information technology intervention on using appropriate VTE prophylaxis in non-surgical patients: A systematic review and meta-analysis. Digit Health 2022; 8:20552076221118828. [PMID: 36003314 PMCID: PMC9393686 DOI: 10.1177/20552076221118828] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 07/21/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction Clinical decision support systems (CDSSs) play an important role in summarizing the best clinical practices, thereby promoting high standards of care in specific medical fields. These systems can serve as tools for gaining knowledge and mediating between clinical guidelines and physicians thereby providing the right information to the right person at the right time. Objective This review aims to evaluate the effect of CDSSs on adherence to guidelines for venous thromboembolism (VTE) prophylaxis and VTE events compared to routine care without CDSSs in non-surgical patients. Methods In order to conduct a systematic literature review, the published studies were identified through screening EMBASE, the international clinical trials registry, OVID, Cochrane database, PubMed, ISI Web of Science, and Scopus databases, from 1982 to March 2021. The included studies were reviewed by two independent reviewers; the proportion of patients that correctly received VTE prophylaxis has been next extracted for further analysis. Additionally, patients were divided into two groups: CDSS-recommended VTE prophylaxis and routine care without using a CDSS. Results Twelve articles (three randomized controlled trials, seven prospective cohort trials, and two retrospective cohort trials) were in fine analyzed. The use of CDSSs is found to be associated with a significant increase in the rate of using the appropriate prophylaxis for VTE ( p < 0.05) and a significant decrease in the incidence of VTE ( p < 0.05). Conclusion Implementation of CDSSs can help improving the appropriate use of VTE prophylaxis in non-surgical patients. Further, evidence-based and interventional studies on the development of CDSSs can provide more in-depth knowledge on both this tool design and efficiency.
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Affiliation(s)
- Mehrdad Karajizadeh
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Soheil Hassanipour
- Department of Epidemiology, Guilan University of Medical Sciences, Rasht, Iran
| | - Roxana Sharifian
- Health Human Resources Research Center, School of Management & Medical Information Sciences, Department of Health Information Management, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fatemeh Tajbakhsh
- Health Human Resources Research Center, School of Management & Medical Information Sciences, Department of Health Information Management, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamid Reza Saeidnia
- Department of Knowledge and Information Science, Tarbiat Modares University, Tehran, Iran
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Abstract
Acute kidney injury (AKI) is a syndrome of impaired kidney function associated with reduced survival and increased morbidity. International consensus criteria were developed based on changes in serum creatinine and urine output. Based on these definitions, epidemiologic studies have shown strong associations with clinical outcomes including death and dialysis. However, numerous limitations exist for creatinine and urine volume as markers of AKI and novel biomarkers have been developed to detect cellular stress or damage. Persistent AKI and acute kidney disease are relatively new concepts that explore the idea of AKI as a continuum with chronic kidney disease.
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Affiliation(s)
- Siddharth Verma
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh Medical Center, 3550 Terrace Street, Pittsburgh, PA 15213, USA; Center for Critical Care Nephrology, University of Pittsburgh Medical Center, 3550 Terrace Street, Pittsburgh, PA 15213, USA
| | - John A Kellum
- Center for Critical Care Nephrology, University of Pittsburgh Medical Center, 3550 Terrace Street, Pittsburgh, PA 15213, USA; Department of Critical Care Medicine, University of Pittsburgh Medical Center, Center for Critical Care Nephrology, 3347 Forbes Avenue, Suite 220, Pittsburgh, PA 15213, USA.
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10
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Güven AT, Altintop SE, Özdede M, Uyaroğlu OA, Tanriöver MD. Quality gap in venous thromboembolism prophylaxis practices in inpatients: Assessment of prophylaxis practices in a University Hospital. Int J Qual Health Care 2021; 33:6322788. [PMID: 34270730 DOI: 10.1093/intqhc/mzab104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 06/06/2021] [Accepted: 07/15/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a prevalent complication of inpatient care, causing high burden of morbidity and mortality. Prophylaxis reduces the events; thus, these practices are promoted. We aimed to assess the VTE prophylaxis practices in the general internal medicine wards of a tertiary-care university hospital and utilize these data to propose quality improvement projects. OBJECTIVE Assess the pharmacological venous thromboembolism prophylaxis utilization by using the Padua Prediction Score and demonstrate the main determinants of inappropriate prophylaxis use. METHODS Electronic medical records were used to collect data cross-sectionally from 1 January 2019 to 30 June 2019. Padua Prediction Score was used to assess the appropriateness of VTE prophylaxis. Underlying health conditions, hospitalization causes, anti-platelets and use of glucocorticoids were also assessed as confounding factors. RESULTS A total of 295 patients were included. Higher proportion of patients who received VTE prophylaxis were obese and had higher rates of diabetes and coronary artery disease. Prophylaxis was more commonly utilized among patients who were elderly, obese, having an acute infection and/or rheumatologic disorder and prolonged bed rest (P ≤ 0.001, P = 0.01, P = 0.22 and P ≤ 0.001, respectively). Thirty-five patients (11.8%) received VTE prophylaxis, despite 89 patients (30.2%) were high-risk patients. In the high-risk group (n = 89), 27 patients (30.3%) received appropriate pharmacological prophylaxis, while 8 patients (3.9%) received VTE prophylaxis in the low-risk group (total n = 206). A considerable percentage of the high-risk population (69.6%) did not receive VTE prophylaxis. DISCUSSION Underuse constitutes a major challenge in our hospital but differing from other institutions, overuse is not a significant issue. Further studies are needed whether VTE prophylaxis improvement implementations uniformly increase appropriate VTE use.
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Affiliation(s)
- Alper Tuna Güven
- Department of Internal Medicine, Hacettepe University Faculty of Medicine, Hacettepe district, Ankara 06230, Turkey
| | - Sabri Engin Altintop
- Department of Internal Medicine, Hacettepe University Faculty of Medicine, Hacettepe district, Ankara 06230, Turkey
| | - Murat Özdede
- Department of Internal Medicine, Division of General Internal Medicine, Hacettepe University Faculty of Medicine, Ankara 06230, Turkey
| | - Oğuz Abdullah Uyaroğlu
- Department of Internal Medicine, Division of General Internal Medicine, Hacettepe University Faculty of Medicine, Ankara 06230, Turkey
| | - Mine Durusu Tanriöver
- Department of Internal Medicine, Division of General Internal Medicine, Hacettepe University Faculty of Medicine, Ankara 06230, Turkey
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Kantor B, Poénou G, Plaisance L, Toledano E, Mekhloufi Y, Helfer H, Djennaoui S, Mahé I. [Pharmacological Thromboprophylaxis in Acutely Ill Hospitalized Medical Patients]. Rev Med Interne 2021; 43:9-17. [PMID: 33895004 DOI: 10.1016/j.revmed.2021.03.323] [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: 02/19/2021] [Accepted: 03/21/2021] [Indexed: 10/21/2022]
Abstract
Venous thromboembolic events (VTE) occur in approximately 50% of cases during or following hospitalization; VTE are a major cause of morbidity and mortality. Thromboprophylaxis for 6 to 14 days with heparins or fondaparinux has been demonstrated to be effective in VTE prevention in patients hospitalized for acute medical illnesses and reduced mobility. Nevertheless, the level of recommendation has been gradually downgraded as the benefit has been mainly demonstrated on the basis of systematic imaging diagnosed events. Direct oral anticoagulants have been assessed only as an extended prophylaxis, and are currently not recommended in medical thromboprophylaxis. Assessing the risk of VTE and bleeding in medical patients is complex. VTE and bleeding risk assessment scores were constructed but have not been validated. In order to improve the adequacy of prescriptions for thromboprophylaxis, the impact of different interventions has been the subject of several studies but these yielded varying results. The aim of this review is to analyze the indications for thromboprophylaxis in a medical setting with the latest available data.
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Affiliation(s)
- B Kantor
- Inserm UMR_S1140, Innovative Therapies in Haemostasis, université de Paris, hôpital Louis-Mourier, AP-HP, Colombes, 75006 Paris, France
| | - G Poénou
- Inserm UMR_S1140, Innovative Therapies in Haemostasis, université de Paris, hôpital Louis-Mourier, AP-HP, Colombes, 75006 Paris, France
| | - L Plaisance
- Inserm UMR_S1140, Innovative Therapies in Haemostasis, université de Paris, hôpital Louis-Mourier, AP-HP, Colombes, 75006 Paris, France
| | - E Toledano
- Inserm UMR_S1140, Innovative Therapies in Haemostasis, université de Paris, hôpital Louis-Mourier, AP-HP, Colombes, 75006 Paris, France
| | - Y Mekhloufi
- Inserm UMR_S1140, Innovative Therapies in Haemostasis, université de Paris, hôpital Louis-Mourier, AP-HP, Colombes, 75006 Paris, France
| | - H Helfer
- Inserm UMR_S1140, Innovative Therapies in Haemostasis, université de Paris, hôpital Louis-Mourier, AP-HP, Colombes, 75006 Paris, France
| | - S Djennaoui
- Inserm UMR_S1140, Innovative Therapies in Haemostasis, université de Paris, hôpital Louis-Mourier, AP-HP, Colombes, 75006 Paris, France
| | - I Mahé
- Inserm UMR_S1140, Innovative Therapies in Haemostasis, université de Paris, hôpital Louis-Mourier, AP-HP, Colombes, 75006 Paris, France.
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Berkman SA. Post-hospital discharge venous thromboembolism prophylaxis in medically ill patients. Postgrad Med 2021; 133:51-63. [PMID: 33435758 DOI: 10.1080/00325481.2021.1876387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
There is a widely expressed concern about an unmet need for post hospitalization venous thromboembolism (VTE) prophylaxis in medically ill patients, however, physicians and hospitals have been slow to implement this measure. Recommendations against extended VTE prophylaxis in medical patients from the American Society of Hematology (ASH) in 2018 and the withholding of approval of betrixiban by the European Medicines Agency also in 2018 may have been influential in this regard. Furthermore, rivaroxaban the other drug approved for this indication in the U.S has not yet been approved in Europe. In addition, hospital administrators, those monitoring expenses in the U.S, have been reluctant to support a treatment which will mostly involve outpatients. Internal medicine physicians, hospitalists and nursing home physicians have not shared the fervor for post hospital VTE prophylaxis, whether with anticoagulants or aspirin, that their orthopedic surgery colleagues have, particularly in hip and knee arthroplasty. This is despite an increased risk of post hospital discharge thrombosis in both groups of patients. Enter hospitalized patients with COVID-19, a potentially severe medical illness with high hospitalization related thrombosis risk, and questions arise as to whether these medical patients, who are clearly more hypercoagulable during hospitalization than those in previous studies, should warrant post hospital discharge prophylaxis.
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Affiliation(s)
- Samuel A Berkman
- Department of medicine, Division of hematology/Oncology UCLA, California
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13
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Subbe CP, Tellier G, Barach P. Impact of electronic health records on predefined safety outcomes in patients admitted to hospital: a scoping review. BMJ Open 2021; 11:e047446. [PMID: 33441368 PMCID: PMC7812113 DOI: 10.1136/bmjopen-2020-047446] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES Review available evidence for impact of electronic health records (EHRs) on predefined patient safety outcomes in interventional studies to identify gaps in current knowledge and design interventions for future research. DESIGN Scoping review to map existing evidence and identify gaps for future research. DATA SOURCES PubMed, the Cochrane Library, EMBASE, Trial registers. STUDY SELECTION Eligibility criteria: We conducted a scoping review of bibliographic databases and the grey literature of randomised and non-randomised trials describing interventions targeting a list of fourteen predefined areas of safety. The search was limited to manuscripts published between January 2008 and December 2018 of studies in adult inpatient settings and complemented by a targeted search for studies using a sample of EHR vendors. Studies were categorised according to methodology, intervention characteristics and safety outcome.Results from identified studies were grouped around common themes of safety measures. RESULTS The search yielded 583 articles of which 24 articles were included. The identified studies were largely from US academic medical centres, heterogeneous in study conduct, definitions, treatment protocols and study outcome reporting. Of the 24 included studies effective safety themes included medication reconciliation, decision support for prescribing medications, communication between teams, infection prevention and measures of EHR-specific harm. Heterogeneity of the interventions and study characteristics precluded a systematic meta-analysis. Most studies reported process measures and not patient-level safety outcomes: We found no or limited evidence in 13 of 14 predefined safety areas, with good evidence limited to medication safety. CONCLUSIONS Published evidence for EHR impact on safety outcomes from interventional studies is limited and does not permit firm conclusions regarding the full safety impact of EHRs or support recommendations about ideal design features. The review highlights the need for greater transparency in quality assurance of existing EHRs and further research into suitable metrics and study designs.
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Affiliation(s)
- Christian Peter Subbe
- School of Medical Sciences, Bangor University, Bangor, UK
- Medicine, Ysbyty Gwynedd, Bangor, UK
| | | | - Paul Barach
- Pediatrics, Wayne State University, Detroit, Michigan, USA
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14
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Velmahos CS, Kokoroskos N, Tarabanis C, Kaafarani HM, Gupta S, Paranjape CN. Preventable Morbidity and Mortality Among Non-trauma Emergency Surgery Patients: The Role of Personal Performance and System Flaws in Adverse Events. World J Surg 2020; 45:690-696. [PMID: 33174092 DOI: 10.1007/s00268-020-05858-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Preventable morbidity and mortality among emergency surgery patients is not adequately analyzed. We aim to describe and classify preventable complications and deaths in this population. METHODS The medical records and quality control documents of patients with emergency, non-trauma, surgical disease admitted between September 1, 2006, and August 31, 2018, and recorded to have a preventable or potentially preventable morbidity and mortality were reviewed. The primary outcome was a classification of the complications and deaths by a panel of experts, as attributable to issues of personal performance or system deficiencies. RESULTS One hundred and fifty patients were identified (127 complications and 23 deaths). The most commonly encountered preventable complications were surgical-site infection (17%), bleeding (13%), injury to adjacent structures (12%), and anastomotic leak (8%). The majority of complications seemed to stem from personal performance (97%), due to either technical or judgment issues, and only 3% were linked with system flaws, either in the form of communication or inadequate protocols. Alcohol use disorder and duration of operation were different between patients with preventable adverse events related to technical issues and patients related to judgment issues; furthermore, more patients who experienced judgment issues died during hospital stay (p <0.05). CONCLUSION Among emergency surgery patients, who suffer preventable complications and deaths, issues related to personal performance are more frequent than system flaws. Whereas the effort to improve systems should be unwavering, the emphasis on the surgeon's personal responsibility to avoid preventable complications should not be derailed.
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Affiliation(s)
| | | | | | | | - Sanjay Gupta
- Department of Surgery, Newton-Wellesley Hospital, Newton, MA, USA
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15
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Kwan JL, Lo L, Ferguson J, Goldberg H, Diaz-Martinez JP, Tomlinson G, Grimshaw JM, Shojania KG. Computerised clinical decision support systems and absolute improvements in care: meta-analysis of controlled clinical trials. BMJ 2020; 370:m3216. [PMID: 32943437 PMCID: PMC7495041 DOI: 10.1136/bmj.m3216] [Citation(s) in RCA: 166] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/07/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To report the improvements achieved with clinical decision support systems and examine the heterogeneity from pooling effects across diverse clinical settings and intervention targets. DESIGN Systematic review and meta-analysis. DATA SOURCES Medline up to August 2019. ELIGIBILITY CRITERIA FOR SELECTING STUDIES AND METHODS Randomised or quasi-randomised controlled trials reporting absolute improvements in the percentage of patients receiving care recommended by clinical decision support systems. Multilevel meta-analysis accounted for within study clustering. Meta-regression was used to assess the degree to which the features of clinical decision support systems and study characteristics reduced heterogeneity in effect sizes. Where reported, clinical endpoints were also captured. RESULTS In 108 studies (94 randomised, 14 quasi-randomised), reporting 122 trials that provided analysable data from 1 203 053 patients and 10 790 providers, clinical decision support systems increased the proportion of patients receiving desired care by 5.8% (95% confidence interval 4.0% to 7.6%). This pooled effect exhibited substantial heterogeneity (I2=76%), with the top quartile of reported improvements ranging from 10% to 62%. In 30 trials reporting clinical endpoints, clinical decision support systems increased the proportion of patients achieving guideline based targets (eg, blood pressure or lipid control) by a median of 0.3% (interquartile range -0.7% to 1.9%). Two study characteristics (low baseline adherence and paediatric settings) were associated with significantly larger effects. Inclusion of these covariates in the multivariable meta-regression, however, did not reduce heterogeneity. CONCLUSIONS Most interventions with clinical decision support systems appear to achieve small to moderate improvements in targeted processes of care, a finding confirmed by the small changes in clinical endpoints found in studies that reported them. A minority of studies achieved substantial increases in the delivery of recommended care, but predictors of these more meaningful improvements remain undefined.
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Affiliation(s)
- Janice L Kwan
- Sinai Health System, Department of Medicine, 600 University Avenue, Toronto, ON M5G 1X5, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Lisha Lo
- Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, ON, Canada
| | - Jacob Ferguson
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Hanna Goldberg
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Juan Pablo Diaz-Martinez
- Biostatistics Research Unit, University Health Network and Sinai Health System, Toronto, ON, Canada
| | - George Tomlinson
- Biostatistics Research Unit, University Health Network and Sinai Health System, Toronto, ON, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute and Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kaveh G Shojania
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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16
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Shah T, Kitts AB, Gold JA, Horvath K, Ommaya A, Frank O, Sato L, Schwarze G, Upton M, Sandy L. Electronic Health Record Optimization and Clinician Well-Being: A Potential Roadmap Toward Action. NAM Perspect 2020; 2020:202008a. [PMID: 35291737 PMCID: PMC8916811 DOI: 10.31478/202008a] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
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17
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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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18
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Blondon M, Righini M, Nendaz M, Glauser F, Robert-Ebadi H, Prandoni P, Barbar S. External validation of the simplified Geneva risk assessment model for hospital-associated venous thromboembolism in the Padua cohort. J Thromb Haemost 2020; 18:676-680. [PMID: 31782886 DOI: 10.1111/jth.14688] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 11/21/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND The simplified Geneva risk assessment model (RAM) predicts the risk of hospitalization-related venous thromboembolism (VTE) in medical inpatients in its developmental cohort but has not been validated. OBJECTIVES To externally validate the simplified Geneva RAM. PATIENTS/METHODS For this secondary analysis of a prospective cohort set in Padua, we calculated the simplified Geneva RAM for all participants. They were followed up for 90 days for the occurrence of adjudicated VTE. Thirty- and 90-day risks of VTE were estimated by the Kaplan-Meier method, and categories of risks compared with a Cox regression model adjusted for the use of thromboprophylaxis. RESULTS Among 1180 medical inpatients, the 90-day risk of symptomatic VTE was 3.1%. The simplified Geneva RAM classified 56.9% as high risk (≥3 points; 90-day risk of VTE of 5.2%) and 43.1% as low risk (<3 points; 90-day risk of VTE of 0.4%). Compared with low-risk participants, high-risk participants had an 18-fold greater risk of VTE than low-risk participants (hazard ratio [HR] 17.9, 95% confidence interval [CI] 4.3-74.7). A very high-risk category (≥7 points) identified 5.3% of participants with a 9.5% probability of VTE at 90 days. CONCLUSIONS In this external validation study, we confirm the excellent discrimination and clinically adequate calibration of the simplified Geneva RAM as a stratification tool to guide the use of thromboprophylaxis.
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Affiliation(s)
- Marc Blondon
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Mathieu Nendaz
- Unit of Development and Research in Medical Education (UDREM), Faculty of Medicine, University of Geneva, and Division of General Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Frédéric Glauser
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | | | - Sofia Barbar
- Division of General Internal Medicine, Padua and Department of Medicine, University of Padua, Italy
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Shapiro S, Dunnigan A, Keen S, Clarke P. Interventional bundle for venous thromboembolism prevention: ensuring quality and effectiveness. BMJ Open Qual 2019; 8:e000459. [PMID: 31297454 PMCID: PMC6590969 DOI: 10.1136/bmjoq-2018-000459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 05/27/2019] [Accepted: 06/01/2019] [Indexed: 11/18/2022] Open
Abstract
Hospital-associated thromboses (HATs) are a potentially preventable cause of morbidity and mortality. Oxford University Hospitals NHS Foundation Trust was designated a Venous Thromboembolism (VTE) Exemplar Centre by NHS England in 2014. However, following delayed reporting of a potentially preventable HAT in 2015, a benchmarking exercise suggested HATs were being under-reported, and also that the established hospital-wide audits of VTE prevention had significant limitations. The aim of this interventional bundle was to ensure high-quality data for key VTE prevention measures across the hospital, to identify areas for improvement and demonstrate a reduction in the number of potentially preventable HATs over a 2-year period. The project team engaged with hospital leadership and collaborated with hospital-wide stakeholders. A multifaceted approach was taken and 'Plan Do Study Act' cycles were used to test interventions with continuous evaluation of impact. The percentage of inpatients receiving appropriate thromboprophylaxis progressively increased from 94% to 98%. The project did not achieve its secondary aim of a reduction in the number of potentially preventable HATs. Revision of the HAT reporting process resulted in better detection and an initial increase in reporting of potentially preventable HATs, although data suggest that the level of harm from errors is now reducing. The improvement in overall appropriate thromboprophylaxis is considered to be due to robust audits of appropriate thromboprophylaxis, upskilling of ward pharmacists, improved detection of potentially preventable HATs resulting in additional safety nets such as linking the 'outcome recommendation' of the electronic VTE risk assessment directly to electronic prescribing, and increased awareness and education. Combining low-cost actions in a coordinated interventional bundle has produced measurable improvements in our VTE management programme, enhancing patient safety. We believe the model to be sustainable and replicable in other general hospitals.
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Affiliation(s)
- Susan Shapiro
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Anna Dunnigan
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sarah Keen
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Penney Clarke
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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20
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Gerotziafas GT, Papageorgiou L, Salta S, Nikolopoulou K, Elalamy I. Updated clinical models for VTE prediction in hospitalized medical patients. Thromb Res 2018; 164 Suppl 1:S62-S69. [PMID: 29703486 DOI: 10.1016/j.thromres.2018.02.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Revised: 02/06/2018] [Accepted: 02/08/2018] [Indexed: 12/15/2022]
Abstract
Venous thromboembolism (VTE) occurring in hospitalized medical patients is associated with increased length of hospitalization, high rate of acute care hospital transfer, longer inpatient rehabilitation and multiplication of health-care costs. Identification of acutely ill hospitalized medical patients eligible for thromboprophylaxis is a sophisticated process. Global VTE risk stems from the combination of predictors related with the acute medical illness, comorbidities, associated treatments and patients' intrinsic risk factors. Emerging clinical risk factors related to underlying pathologies should be considered when VTE risk is assessed. The Padua Prediction Score (PPS), the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE-RAM) and the Geneva Risk Score are three robust risk assessment models (RAM) which underwent extensive external validation in cohorts of acutely ill hospitalized medical patients. The development of the IMPROVE bleeding risk assessment model and the identification of D-Dimer increase as a biomarker-predictor of VTE are some steps forward for personalized thromboprophylaxis. The beneficial impact of the RAMs in VTE prevention is already seen by the decrease of in-hospital VTE rates when RAMs are incorporated in electronic alert systems.
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Affiliation(s)
- Grigoris T Gerotziafas
- Service d'Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique Hôpitaux de Paris, France; Cancer Biology and Therapeutics, Centre de Recherche Saint-Antoine, INSERM U938, Institut Universitaire de Cancérologie (IUC), Université Pierre et Marie Curie (UPMC) Faculté de Médecine, Sorbonne Universities, Paris, France.
| | - Loula Papageorgiou
- Service d'Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique Hôpitaux de Paris, France; Cancer Biology and Therapeutics, Centre de Recherche Saint-Antoine, INSERM U938, Institut Universitaire de Cancérologie (IUC), Université Pierre et Marie Curie (UPMC) Faculté de Médecine, Sorbonne Universities, Paris, France
| | - Stella Salta
- Service d'Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique Hôpitaux de Paris, France; Cancer Biology and Therapeutics, Centre de Recherche Saint-Antoine, INSERM U938, Institut Universitaire de Cancérologie (IUC), Université Pierre et Marie Curie (UPMC) Faculté de Médecine, Sorbonne Universities, Paris, France
| | - Katerina Nikolopoulou
- Service d'Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique Hôpitaux de Paris, France; Cancer Biology and Therapeutics, Centre de Recherche Saint-Antoine, INSERM U938, Institut Universitaire de Cancérologie (IUC), Université Pierre et Marie Curie (UPMC) Faculté de Médecine, Sorbonne Universities, Paris, France
| | - Ismail Elalamy
- Service d'Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique Hôpitaux de Paris, France; Cancer Biology and Therapeutics, Centre de Recherche Saint-Antoine, INSERM U938, Institut Universitaire de Cancérologie (IUC), Université Pierre et Marie Curie (UPMC) Faculté de Médecine, Sorbonne Universities, Paris, France
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21
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Cheng J, Zhu XQ. Progress in research of venous thromboembolism in hospitalized patients with digestive system diseases. Shijie Huaren Xiaohua Zazhi 2018; 26:1089-1094. [DOI: 10.11569/wcjd.v26.i18.1089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Hospitalized patients with digestive system diseases are at high risk of venous thromboembolism (VTE) due to a variety of factors such as advanced age, prolonged bed rest, medication and so on. VTE can affect the quality of life of patients, the number of days of hospitalization, and the cost of treatment and even threaten their life. This article gives a brief overview of the pathogenesis, risk factors, assessment tools, and preventive methods for VTE to promote better prevention of this disease.
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Affiliation(s)
- Jie Cheng
- Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Xiu-Qin Zhu
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
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22
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Tufano A, Di Minno G. Prophylaxis of venous thromboembolism in Internal Medicine Units: the RAMs issue. Intern Emerg Med 2018. [PMID: 29541919 DOI: 10.1007/s11739-018-1829-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Antonella Tufano
- Clinica Medica, Dipartimento di Medicina Clinica e Chirurgia, Centro di Coordinamento Regionale per le Coagulopatie, Università degli Studi di Napoli "Federico II", Via S. Pansini, 5, 80131, Naples, Italy.
| | - Giovanni Di Minno
- Clinica Medica, Dipartimento di Medicina Clinica e Chirurgia, Centro di Coordinamento Regionale per le Coagulopatie, Università degli Studi di Napoli "Federico II", Via S. Pansini, 5, 80131, Naples, Italy
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23
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Shojania KG, Jennings A, Mayhew A, Ramsay CR, Eccles MP, Grimshaw J. The effects of on-screen, point of care computer reminders on processes and outcomes of care. Cochrane Database Syst Rev 2009; 2009:CD001096. [PMID: 19588323 PMCID: PMC4171964 DOI: 10.1002/14651858.cd001096.pub2] [Citation(s) in RCA: 271] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The opportunity to improve care by delivering decision support to clinicians at the point of care represents one of the main incentives for implementing sophisticated clinical information systems. Previous reviews of computer reminder and decision support systems have reported mixed effects, possibly because they did not distinguish point of care computer reminders from e-mail alerts, computer-generated paper reminders, and other modes of delivering 'computer reminders'. OBJECTIVES To evaluate the effects on processes and outcomes of care attributable to on-screen computer reminders delivered to clinicians at the point of care. SEARCH STRATEGY We searched the Cochrane EPOC Group Trials register, MEDLINE, EMBASE and CINAHL and CENTRAL to July 2008, and scanned bibliographies from key articles. SELECTION CRITERIA Studies of a reminder delivered via a computer system routinely used by clinicians, with a randomised or quasi-randomised design and reporting at least one outcome involving a clinical endpoint or adherence to a recommended process of care. DATA COLLECTION AND ANALYSIS Two authors independently screened studies for eligibility and abstracted data. For each study, we calculated the median improvement in adherence to target processes of care and also identified the outcome with the largest such improvement. We then calculated the median absolute improvement in process adherence across all studies using both the median outcome from each study and the best outcome. MAIN RESULTS Twenty-eight studies (reporting a total of thirty-two comparisons) were included. Computer reminders achieved a median improvement in process adherence of 4.2% (interquartile range (IQR): 0.8% to 18.8%) across all reported process outcomes, 3.3% (IQR: 0.5% to 10.6%) for medication ordering, 3.8% (IQR: 0.5% to 6.6%) for vaccinations, and 3.8% (IQR: 0.4% to 16.3%) for test ordering. In a sensitivity analysis using the best outcome from each study, the median improvement was 5.6% (IQR: 2.0% to 19.2%) across all process measures and 6.2% (IQR: 3.0% to 28.0%) across measures of medication ordering. In the eight comparisons that reported dichotomous clinical endpoints, intervention patients experienced a median absolute improvement of 2.5% (IQR: 1.3% to 4.2%). Blood pressure was the most commonly reported clinical endpoint, with intervention patients experiencing a median reduction in their systolic blood pressure of 1.0 mmHg (IQR: 2.3 mmHg reduction to 2.0 mmHg increase). AUTHORS' CONCLUSIONS Point of care computer reminders generally achieve small to modest improvements in provider behaviour. A minority of interventions showed larger effects, but no specific reminder or contextual features were significantly associated with effect magnitude. Further research must identify design features and contextual factors consistently associated with larger improvements in provider behaviour if computer reminders are to succeed on more than a trial and error basis.
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Affiliation(s)
- Kaveh G Shojania
- Director, University of Toronto Centre for Patient Safety, Sunnybrook Health Sciences Centre, Room D474, 2075 Bayview Avenue, Toronto, Ontario, Canada, M4N 3M5
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