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Walker TR, Bochner RE, Alaiev D, Talledo J, Tsega S, Krouss M, Cho HJ. Reducing low-value ED coags across 11 hospitals in a safety net setting. Am J Emerg Med 2023; 73:88-94. [PMID: 37633078 DOI: 10.1016/j.ajem.2023.08.016] [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: 04/03/2023] [Revised: 08/01/2023] [Accepted: 08/06/2023] [Indexed: 08/28/2023] Open
Abstract
BACKGROUND Prothrombin/international normalized ratio and activated partial thromboplastin time (PT/INR and aPTT) are frequently ordered in emergency departments (EDs), but rarely affect management. They offer limited utility outside of select indications. Several quality improvement initiatives have shown reduction in ED use of PT/INR and aPTT using multifaceted interventions in well-resourced settings. Successful reduction of these low-value tests has not yet been shown using a single intervention across a large hospital system in a safety net setting. This study aims to determine if an intervention of two BPAs is associated with a reduction in PT/INR and aPTT usage across a large safety net system. METHODS This initiative was set at a large safety net system in the United States with 11 acute care hospitals. Two Best Practice Advisories (BPAs) discouraging inappropriate PT/INR and aPTT use were implemented from March 16, 2022-August 30, 2022. Order rate per 100 ED patients during the pre-intervention period was compared to the post-intervention period on both the system and individual hospital level. Complete blood count (CBC) testing served as a control, and packed red blood cell transfusions served as a balancing measure. An interrupted time series regression analysis was performed to capture immediate and temporal changes in ordering for all tests in the pre and post-intervention periods. RESULTS PT/INR tests exhibited an absolute decline of 4.11 tests per 100 ED encounters (95% confidence interval -5.17 to -3.05; relative reduction of 18.9%). aPTT tests exhibited absolute decline of 4.03 tests per 100 ED encounters (95% CI -5.10 to -2.97; relative reduction of 19.8%). The control measure, CBC, did not significantly change (-0.43, 95% CI -2.83 to 1.96). Individual hospitals showed variable response, with absolute reductions from 2.02 to 9.6 tests per 100 ED encounters for PT/INR (relative reduction 12.1%-30.5%) and 2.07 to 10.04 for aPTT (relative reduction 12.1%-31.4%). Regression analysis showed that the intervention caused an immediate 25.7% decline in PT/INR and 24.7% decline in aPTT tests compared to the control measure. The slope differences (rate of order increase pre vs post intervention) did not significantly decline compared to the control. CONCLUSIONS This BPA intervention reduced PT/INR and aPTT use across 11 EDs in a large, urban, safety net system. Further study is needed in implementation to other non-safety net settings.
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Affiliation(s)
- Talia R Walker
- NYC Health + Hospitals/Lincoln, Department of Emergency Medicine, 234 E 149th Street, Bronx, NY 10451, United States of America.
| | - Risa E Bochner
- NYC Health + Hospitals/Harlem, Department of Pediatrics, 506 Lenox Ave, New York, NY 10037, United States of America.
| | - Daniel Alaiev
- NYC Health + Hospitals, Department of Quality & Safety, 50 Water Street, 16(th) Floor, New York, NY, United States of America.
| | - Joseph Talledo
- NYC Health + Hospitals, Department of Quality & Safety, 50 Water Street, 16(th) Floor, New York, NY, United States of America.
| | - Surafel Tsega
- NYC Health + Hospitals, Department of Quality & Safety, 50 Water Street, 16(th) Floor, New York, NY, United States of America; NYC Health + Hospitals/Kings County, Department of Internal Medicine, 451 Clarkson Avenue, Brooklyn, NY 11203, United States of America.
| | - Mona Krouss
- NYC Health + Hospitals, Department of Quality & Safety, 50 Water Street, 16(th) Floor, New York, NY, United States of America; NYC Health + Hospitals/Elmhurst, Department of Internal Medicine, 79-01 Broadway, Elmhurst, NY 11373, United States of America.
| | - Hyung J Cho
- Brigham and Women's Hospital, Department of Quality & Safety, 75 Francis St, Boston, MA 02115, United States of America
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Metze M, Platz M, Pfrepper C, Petros S. [Coagulation diagnostics in the clinical routine-Part 1 : Evaluation of the risk of bleeding before surgery, interventions and diagnostics in bleeding diathesis]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2022; 63:619-630. [PMID: 35925131 DOI: 10.1007/s00108-022-01331-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/04/2022] [Indexed: 06/15/2023]
Abstract
This article on coagulation diagnostics is published in two parts covering five common clinical scenarios for coagulation diagnostics. Part 1 deals with the diagnostics prior to invasive interventions and coagulation diagnostics to clarify a tendency to bleeding. The global parameters Quick and activated partial thromboplastin time are established for monitoring certain anticoagulants; however, they are not predictive with respect to the risk of bleeding prior to elective invasive interventions. In this context, disorders of primary hemostasis are frequent, which are insufficiently detected by the global parameters. Most clinical bleeding tendencies are due to acquired causes. These include anticoagulants and diseases which can be accompanied by tendency to bleeding. For coagulation tests preanalytical issues are essential in order to avoid false results. The interpretation should always be made in the context of the current physiological state.
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Affiliation(s)
- Michael Metze
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland.
| | - Martin Platz
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland
| | - Christian Pfrepper
- Klinik und Poliklinik für Hämatologie, Zelltherapie und Hämostaseologie, Bereich Hämostaseologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Sirak Petros
- Klinik und Poliklinik für Hämatologie, Zelltherapie und Hämostaseologie, Bereich Hämostaseologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
- Interdisziplinäre Internistische Intensivmedizin, Universitätsklinikum Leipzig, Leipzig, Deutschland
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Long B, Long DA, Koyfman A. Emergency medicine misconceptions: Utility of routine coagulation panels in the emergency department setting. Am J Emerg Med 2020; 38:1226-1232. [PMID: 32029342 DOI: 10.1016/j.ajem.2020.01.057] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 12/17/2019] [Accepted: 01/28/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Coagulation panels are ordered for a variety of conditions in the emergency department (ED). OBJECTIVE This narrative review evaluates specific conditions for which a coagulation panel is commonly ordered but has limited utility in medical decision-making. DISCUSSION Coagulation panels consist of partial thromboplastin time (PTT) or activated partial thromboplastin time (aPTT), prothrombin time (PT), and international normalized ratio (INR). These tests evaluate the coagulation pathway which leads to formation of a fibrin clot. The coagulation panel can monitor warfarin and heparin therapy, evaluate for vitamin K deficiency, evaluate for malnutrition or severe systemic disease, and assess hemostatic function in the setting of bleeding. The utility of coagulation testing in chest pain evaluation, routine perioperative assessment, prior to initiation of anticoagulation, and as screening for admitted patients is low, with little to no change in patient management based on results of these panels. Coagulation testing should be considered in systemically ill patients, those with a prior history of bleeding or family history of bleeding, patients on anticoagulation, or patients with active hemorrhage and signs of bleeding. Thromboelastography and rotational thromboelastometry offer more reliable measures of coagulation function. CONCLUSIONS Little utility for coagulation assessment is present for the evaluation of chest pain, routine perioperative assessment, initiation of anticoagulation, and screening for admitted patients. However, coagulation panel assessment should be considered in patients with hemorrhage, patients on anticoagulation, and personal history or family history of bleeding.
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Affiliation(s)
- Brit Long
- Brooke Army Military Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States.
| | - Drew A Long
- Brooke Army Military Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, United States
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Carr IM, Koegelenberg CFN, von Groote-Bidlingmaier F, Mowlana A, Silos K, Haverman T, Diacon AH, Bolliger CT. Blood loss during flexible bronchoscopy: a prospective observational study. ACTA ACUST UNITED AC 2012; 84:312-8. [PMID: 22889938 DOI: 10.1159/000339507] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 05/14/2012] [Indexed: 12/30/2022]
Abstract
BACKGROUND Haemorrhage remains a complication of flexible bronchoscopy. OBJECTIVES We aimed to measure the actual blood loss in patients at low risk of bleeding and to assess its association with the underlying pulmonary pathology, superior vena cava (SVC) syndrome, procedure(s) performed and laboratory values. METHODS We screened all patients scheduled for flexible bronchoscopy and enrolled 234 subjects over 18 months. Subjects with a history of haemorrhagic tendency, platelets <20 × 10(3)/µl, a history of anti-coagulation or anti-platelet therapy and a history or clinical evidence of liver failure were excluded. Blood loss during the procedure was measured from aspirated secretions with a haemoglobin detector and categorised into minimal (<5 ml), mild (5-20 ml), moderate (20-100 ml) and severe bleeding (>100 ml). RESULTS Overall, 210 subjects had minimal, 19 had mild and 5 had moderate bleeding. No subject experienced severe blood loss. Patients with SVC syndrome had the highest mean blood loss (6.0 ml) when compared to bronchogenic carcinoma without SVC syndrome (p = 0.033) and other diagnosis (p = 0.026). The blood loss with trans-bronchial needle aspiration (TBNA, mean 3.4 ml) was significantly less than with TBNA combined with endobronchial or transbronchial biopsy (mean 5.0 ml, p < 0.001). Anaemia, a platelet count of 25-155 × 10(3)/µl and an international normalized ratio of >1.3 were not associated with an increased risk of bleeding. CONCLUSIONS We found no severe bleeding in this cohort preselected to have a low clinical risk of bleeding. Moreover, our data suggest that clinical screening and a platelet count ≥20 × 10(3)/µl alone may be sufficient to identify low-risk patients.
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Affiliation(s)
- Ighsaan M Carr
- Division of Pulmonology, Department of Medicine, University of Stellenbosch and Tygerberg Academic Hospital, Cape Town, South Africa
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Abstract
The activated partial thromboplastin time (PTT) is the grandchild of the Lee-White whole blood clot time (WBCT). Both tests were developed to assist the diagnostic process for patients who exhibited features consistent with hemophilia, i.e., the pretest probability was extremely high. Probably <0.1%-1.0% of PTTs ordered in current medical practice fit that indication with the most common indication now being routine admission order; i.e., a pretest probability that is extremely low. The question asked of the PTT has evolved from 'why does this patient bleed?' to 'will this patient bleed?' As the PTT was never intended to answer that question, one must be careful regarding interpretation of results of that test. As many situations not related to hemorrhage are associated with perturbations of the PTT, a prolonged PTT is not strongly predictive of hemorrhage nor does a normal PTT provide shelter against hemorrhagic risk.
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Affiliation(s)
- C S Kitchens
- Department of Medicine, University of Florida, FL, USA.
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Wood-Baker R, Burdon J, McGregor A, Robinson P, Seal P. Fibre-optic bronchoscopy in adults: a position paper of The Thoracic Society of Australia and New Zealand. Intern Med J 2001; 31:479-87. [PMID: 11720062 DOI: 10.1046/j.1445-5994.2001.00104.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Fibre-optic bronchoscopy in adults is a common procedure in clinical respiratory practice. Under controlled conditions it is safe, resulting in relatively few significant adverse events. The present position paper updates guidelines previously published by The Thoracic Society of Australia and New Zealand and is based on evidence obtained by searching the Medline and Embase databases. The level of evidence to support recommendations is indicated in the text. Where no evidence has been found, the guidelines reflect the opinions of the authors. Specific recommendations are made regarding sedation and anaesthesia, the cleaning of bronchoscopes and the training of bronchoscopists.
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Affiliation(s)
- R Wood-Baker
- Department of Respiratory Medicine, Royal Hobart Hospital, Hobart, Tasmania, Australia
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Schramm B, Leslie K, Myles PS, Hogan CJ. Coagulation studies in preoperative neurosurgical patients. Anaesth Intensive Care 2001; 29:388-92. [PMID: 11512650 DOI: 10.1177/0310057x0102900410] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Unselected preoperative coagulation testing is known to have low positive yield. However, no study has specifically evaluated neurosurgical patients. A retrospective study of 1211 patients having neurosurgery over a one-year period was therefore conducted. Preoperative test results (activated partial thromboplastin time [aPTT], prothrombin time [PT] and platelet count) and historical factors indicating a potential bleeding tendency were recorded. Abnormality was defined as a test result outside the normal range for our laboratory. Seventeen per cent of all test results were abnormal. However, if abnormality was redefined as a test result indicating potential bleeding tendency (low platelet count, prolonged aPTT and/or PT), only 7.2% of results were abnormal. Many patients had factors on history indicating a potential bleeding tendency, but only a prolonged aPTT, cranial surgery and the use of anti-hypertensive and anaesthetic drugs preoperatively predicted postoperative bleeding. Prolonged aPTT was predictable on history in most patients. We conclude that routine screening of all preoperative neurosurgical patients in our hospital is unnecessary.
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Affiliation(s)
- B Schramm
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, Victoria
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