Evaluating the Current Practice of Post Cesarean Thromboprophylaxis and Enhancing Guideline Adherence in Al-Najaf Hospitals

Background:

Venous thromboembolism (VTE) is one of the most common cardiovascular disorders in the United States and is manifested as deep vein thrombosis (DVT) and pulmonary embolism (PE) which represented as the most important cause of death in pregnant women after cesarean section. Venous thromboembolism (VTE) is representing the second direct cause of death which is accounting for 13.8% of all mother’s death in the world. The most common risk factor of venous thromboembolism (VTE) is cesarean section.

Objective:

The study aims to study the current practice of post-cesarean thromboprophylaxis in dosing calculation and duration of therapy.

Methods:

Between September 2020 and January 2021, an observational- interventional prospective pre and post-study, was conducted in all hospital of Najaf in the City center and the suburbs that contain gynecology and obstetric ward to assess the current practice of post-cesarean thromboprophylaxis and to evaluate the impact of pharmacist intervention program to improve guideline adherence then after intervention. Another 102 patients were enrolled to analyze the change thromboprophylaxis according to the guideline.

Results:

From patient data, the rate of adherence to guidelines raised significantly among the post-intervention patients’ group by thromboprophylaxis dose according to body weight was increase significantly (p<0.001) from 56.9% in the observation phase to 83.3% after intervention and about the duration of thromboprophylaxis is significantly (p<0.001) from 18.6% in the observation phase to 52.0% after the intervention.

Conclusion:

This study showed that the clinical pharmacist’s multifaceted intervention has resulted in encouraging guideline implementations as reflected by improving the proper use of thromboprophylaxis the duration anddosing calculations according to body weight.

Physicians' perceptions and preferences for implementing venous thromboembolism (VTE) clinical practice guidelines: a qualitative study using the Theoretical Domains Framework (TDF)

BACKGROUND

Venous thromboembolism is a primary cause of morbidity and mortality in hospitalised patients. Clinical practice guidelines were developed to prevent venous thromboembolism events. This study adopted the Theoretical Domains Framework to explore the beliefs and perceptions of physicians adoption of clinical practice guidelines for the uptake of venous thromboembolism prevention guidelines.

METHODS

Semi-structured interviews were conducted with a stratified purposive sample of internal medicine physicians in an acute hospital. The interview topic guide was developed using the Theoretical Domains Framework to identify the factors perceived to influence the practice. Two researchers coded the interview transcripts using thematic content analysis. Emerging relevant themes were mapped to TDF domains.

RESULTS

A total of sixteen medical physicians were interviewed over a six-month period. Nine theoretical domains derived from thirty-three belief statements were identified as relevant to the target behaviour; knowledge (education about the importance of VTE guidelines); beliefs about capabilities (with practice VTE tool easier to implement); beliefs about consequences (positive consequences in reducing the development of VTE, length of stay, financial burden and support physician decision) and (negative consequence risk of bleeding); reinforcement (recognition and continuous reminders); goals (patient safety goal); environmental context and resources (workload and availability of medications were barriers, VTE coordinator and electronic medical record were enablers); social influences (senior physicians and patient/family influence the VTE practice); behavioural regulation (monitoring and mandatory hospital policy); and nature of the behaviour.

CONCLUSIONS

Using the Theoretical Domains Framework, factors thought to influence the implementation of VTE clinical practice guidelines were identified which can be used to design theoretically based interventions by targeting specific psychological constructs and linking them to behaviour change techniques to change the clinical practice of physicians.

Assessment of knowledge and practice of venous thromboembolism (VTE) prophylaxis after cesarean section among gynecologists and obstetricians in Al-Najaf hospitals

Venous Thromboembolism (VTE) is associated with high morbidity and mortality rates after cesarean sections. VTE is likely four-time greater following cesarean section than normal vaginal delivery. Despite a large number of published studies and the availability of well-evidenced guideline recommendations for VTE prevention, it is evident that these guidelines are poorly implemented with suboptimal use of a prophylactic thrombotic agent. The objective of our study was to assess the knowledge and practice of gynecologists and obstetricians about guidelines of VTE prophylaxis after cesarean section. An observational study included 57 gynecologists and obstetricians from all hospitals in Al-Najaf province. The study used a validated questionnaire consisting of 40 items where the correct response scored 1, giving an overall total score of 40. The total overall knowledge and practice score was calculated for participants, and the knowledge and practice levels were evaluated. Only 57 participants out of 67 completed the study giving a response rate of 85%. The mean overall score of practice and adherence was 0.51±0.09. This study showed inadequate practice towards VTE and poor adherence to prophylaxis guidelines because of many barriers, mainly the cost, poor patient adherence, and inconvenience to use guidelines in our patients.

Trends of Inpatient Venous Thromboembolism in United States Before and After the Surgeon General's Call to Action

Venous thromboembolism (VTE) is an important cause of morbidity and mortality in the United States (US). The increasing rates of VTE in the US resulted in the surgeon general issuing a call to action to reduce VTE in 2008. The objective of our study was to analyze the national trends of inpatient VTE in the US from 2004 to 2013 (5 years before and after 2008). We used the dataset National Inpatient Sample, Healthcare Cost and Utilization Project and measured trends of inpatient VTE by annual % change using joinpoint regression software. From 2004 to 2013 the National Inpatient Sample contained data on 78 million hospitalizations (weighted n = 385 million). In these 1.6 million had a diagnosis of VTE (2.0%, weighted n = 7.7 million) including 1.2 million with deep venous thrombosis (DVT) (1.53%, weighted n = 5.9 million) and 588,878 with pulmonary embolism (PE) (0.74%, weighted n = 2.8 million). Joinpoint regression analysis showed that rates of DVT and PE are increasing consistently from 2004 to 2013(1.27% to 1.80% for DVT and 0.52% to 0.92% for PE). The increasing rates of DVT and PE were consistent in all subgroups except few exceptions. In conclusion inpatient VTE rates continue to rise even after 5 years from the surgeon general's a call to action except in certain high-risk patients. Further research is needed to curb the VTE in patients especially among those perceived to be at lower risk of VTE.

Evaluation of a nurse-led intervention to improve adherence to recommended guidelines for prevention of venous thromboembolism for hip and knee arthroplasty patients: A quasi-experimental study

AIMS AND OBJECTIVES

To measure adherence to a nurse-led evidence-based venous thromboembolism prevention programme (intervention) compared to usual care in hip and knee arthroplasty patients and associated clinical outcomes.

BACKGROUND

Venous thromboembolism morbidity and mortality of hospitalised patients is a major concern for health professionals. Venous thromboembolism prevention guidelines have been developed; however, adherence to guidelines is variable.

PARTICIPANTS

There were 410 potential participants who were adult patients that were booked for elective hip or knee arthroplasty at the two study sites during a 2-year period (2011-2013). Of these, 27 did not meet the inclusion criteria, and the remainder were eligible for inclusion in the study (intervention site n = 196 and control site n = 187, total population n = 383).

METHODS

This study adopted a quasi-experimental design, using an intervention and control study site, conducted in two private hospitals in a regional area in Australia.

RESULTS

The intervention group had a mean compliance score of 11.09, higher than the control group score of 7.19. This is equivalent to a compliance rate of 85% and 55%, respectively, and indicates that adherence at the study site was significantly higher. Patient adherence and outcomes in the postdischarge period were not significantly different between the study sites.

CONCLUSION

This study demonstrated a nurse-led intervention achieved high adherence with translating evidence-based guidelines into routine patient care for hip and knee arthroplasty patients. Nurses can be critical to implementing clinical practice guidelines and adopting preventive programmes in acute care to improve patient outcomes and reduce postoperative venous thromboembolism in arthroplasty patients.

RELEVANCE TO CLINICAL PRACTICE

This research demonstrates the capacity of nurses to lead the translation of evidence-based practice guidelines for prevention of venous thromboembolism into routine patient care.

Secondary prophylaxis decision-making in venous thromboembolism: interviews on clinical practice in thirteen countries

OBJECTIVES

Secondary prevention of venous thromboembolism (VTE) remains a topical and contentious point of debate for thrombosis experts around the globe. This discussion centers around two aspects: optimum treatment duration and which type and dosage of thromboprophylaxis to prescribe. Collectives of thrombosis experts have tried to steer the debate by issuing periodical best-practice guidelines. However, the lack of adherence to said guidelines is such that there is a growing body of research devoted to this very problem. Most of the studies on the subject retrospectively observe a single setting, which leaves important questions as to the generalizability of their findings. As each setting appears to face its own unique challenges, the overarching question of why there is so much variance between physicians when it comes to the secondary prevention of VTE is never fully addressed.

METHODS

For this study, we asked thirteen senior-level physicians representing equally as many countries about the current state of clinical practice regarding the secondary prevention of VTE.

RESULTS

The discussion identifies several barriers to adequate VTE prevention, and hints at area-specific idiosyncrasies that may explain why physicians from different locales treat VTE patients differently.

CONCLUSION

Universal treatment guidelines may not fully translate to clinical practice in many areas, and that promoting local guidelines to supplement the universal guidelines may be beneficial.

The early management of DVT in the North West of England: A nation-wide problem?

BACKGROUND

Despite NICE guidelines, the early management of deep vein thrombosis (DVT) in UK hospitals varies widely. We investigated the variation in clinical pathways used in NHS hospitals in North West England.

METHODS

A detailed questionnaire was sent to seventeen University or District General hospitals with an Accident and Emergency department. Copies of protocols or patient pathways were requested.

RESULTS

15 hospitals responded despite our repeated requests for information. Of those, four hospitals did not provide any DVT protocol, guideline or service for DVT. In seven (63.6%) hospitals, possible DVT patients were assessed in A&E, and four (36.4%) in Acute Medical Admission Units. During the day, initial assessment was by a Specialist Nurse (SN)/Advance Nurse Practitioner (ANP) in 4 (36.4%) hospitals, by a doctor in 5 out of 11 hospitals (45.5%) and a combination of ANP and doctors in 2 out of 11 (18.2%) hospitals. Out of hours assessment was conducted by a doctor in all 11 hospitals (100%). Two (18.2%) hospitals used the 2003 Wells score, three (27.3%) used the 1997 Wells score and six (54.5%) hospitals used 'in house' modified Wells score. The score required to trigger further investigation varied between different hospitals. Only four (36.4%) hospitals could arrange US imaging within four hours of presentation.

CONCLUSION

This lack of co-ordinated services for the management of DVT in the North West England is likely to reflect national practice. A national programme is urgently needed to ensure patients with suspected DVT are managed using standardised and consistent protocols.

Treatment options for venous thromboembolism: lessons learnt from clinical trials

Venous thromboembolism (VTE), comprising deep vein thrombosis and pulmonary embolism, is a common condition associated with a significant clinical and economic burden. Anticoagulant therapy is the mainstay of treatment for VTE, having been shown to reduce the risk of death in patients with pulmonary embolism, and recurrence or extension of thrombi in patients with deep vein thrombosis during the initial treatment period. Long-term anticoagulation is indicated in some individuals with VTE, depending on individual risk of VTE recurrence and anticoagulant-related bleeding. Management of VTE in clinical practice is often complex because patients' characteristics and treatment needs may differ considerably from those encountered in clinical trials. Current guidelines recommend the use of either low molecular weight heparins or fondaparinux overlapping with and followed by a vitamin K antagonist for the initial treatment of VTE, with the vitamin K antagonist continued when long-term anticoagulation is required. These traditional anticoagulants have practical limitations that have led to the development of direct oral anticoagulants that directly target either Factor Xa or thrombin and are administered at a fixed dose without the need for routine coagulation monitoring. This review discusses practical considerations for hospital physicians and haematologists in the management of VTE treatment, including the potential for the direct oral anticoagulants to simplify treatment.

Venous thromboembolism prophylaxis guideline compliance: a pilot study of augmented medication charts

INTRODUCTION

Venous thromboembolism (VTE) is a common complication of hospital admission. The incidence of hospital-acquired deep vein thrombosis is approximately 10-40% amongst medical and general surgical patients without prophylaxis. Pulmonary embolism accounts for 5-10% of deaths in hospitalised patients, making hospital-acquired VTE the most common preventable cause of in-hospital death. Studies suggest that prophylactic measures are widely under- and inappropriately used.

AIMS

We hypothesised that the introduction of a medication chart with a dedicated VTE prophylaxis section would improve compliance with local guidelines.

METHODS

Trial medication charts were piloted over a 4-week period in one surgical and two medical wards. Data on compliance with hospital guidelines were collected before and after introduction using a detailed chart review. The difference in prescribing compliance was assessed with the Chi-squared test.

RESULTS

70 patients were assessed before and 38 after the introduction of the new charts. Initially, only 58.6% (n = 41) of patients' prescriptions were in compliance with local guidelines. In 28.6% (n = 20) of patients, VTE prophylaxis was needed and not prescribed. 7.1% (n = 5) of patients were prescribed an inappropriately low dose of low molecular weight heparin (LMWH) prophylaxis. 2.9% (n = 2) of patients were prescribed inappropriately high dose of LMWH prophylaxis. After introduction of the new medication chart, compliance with guidelines rose to 71% (n = 27, p = 0.09).

CONCLUSION

Compliance with VTE guidelines is inadequate. Medication charts with specific sections on VTE assessment and prophylaxis may increase compliance with guidelines.

Guideline adherence in management of stable chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is the only leading cause of death with rising morbidity and mortality. Clinical practice guidelines (CPGs) to optimize pharmacotherapy for patients with COPD have been updated based on promising results of randomized clinical trials. We examined the frequency of and factors associated with guideline adherence by physicians in clinical practice at an academic medical center.

METHODS

Patients with a clinical diagnosis of COPD, confirmed by spirometry, who presented to the ambulatory clinics, were enrolled. The primary outcome was provider's adherence to the 2007 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. Subjects were categorized as guideline-concordant who received a rescue inhaler (all patients), or at least one long-acting bronchodilator (stage II), or at least one long-acting bronchodilator plus an inhaled corticosteroid (stage III-IV). Demographics, clinical information and type of provider were recorded. Provider type was classified as primary care physician (PCP), pulmonologist, or co-management by both.

RESULTS

Among 450 subjects who met study criteria, 246 (54.7%) received guideline-concordant treatment. Age, sex, race, disease severity, and co-morbidities were not associated with guideline adherence. Multivariate analysis showed that patients co-managed by a PCP and pulmonologist had a higher likelihood of receiving guideline-concordant treatment than those managed by one or the other (Odds Ratio: 4.59; 95% Confidence Interval: 2.92, 7.22, p < 0.001).

CONCLUSIONS

Just over half of stable COPD patients receive guideline-concordant care. Co-management by a PCP and pulmonologist increases the likelihood of receiving guideline-concordant inhaler therapy.

Multidisciplinary Approach to Improve Venous Thromboembolism Risk Assessment and Prophylaxis Rates in Hospitalized Patients

Background:

Venous thromboembolism (VTE) is a preventable disease in hospitalized patients; however, VTE prophylaxis is underutilized. Effective strategies for the assessment of individual patients' VTE risk and the provision of VTE prophylaxis are needed.

Objective:

To evaluate the efficacy of a multidisciplinary intervention designed to improve VTE risk assessment and prophylaxis in at-risk hospitalized patients.

Methods:

The multidisciplinary intervention to improve VTE risk assessment and prophylaxis consisted of 3 strategies: a broad educational effort, nursing assessment, and pharmacist follow-up. Educational programs were delivered to nursing, pharmacy, and physician staff. Upon admission, all patients were assessed for VTE risk factors by nursing staff. Pharmacists reviewed reports of patients screened to have at least 1 VTE risk factor; for patients not prescribed VTE prophylaxis, pharmacists placed a progress note and VTE prophylaxis order form in the chart. If no prophylaxis was prescribed by the following day, the pharmacist contacted the physician with a verbal recommendation. The impact of this intervention was evaluated by comparing the proportion of patients assessed for VTE risk factors on admission and the proportion of VTE prophylaxis candidates who received prophylaxis, both before and after implementation.

Results:

A total of 310 patients were included during the 2-month study period. An increase in patients assessed for the presence of VTE risk factors was observed after the intervention (41% vs 87%, p < 0.001). Similarly, an increase in patients prescribed prophylaxis was observed after the intervention (36% vs 63%, p < 0.001).

Conclusions:

This multidisciplinary approach including education, nursing assessment, and pharmacist follow-up resulted in a significant increase in the rates of VTE risk assessment and prophylaxis.

Venous Thromboembolism (VTE) Risk Assessment and Prophylaxis: A Comprehensive Systematic Review of the Facilitators and Barriers to Healthcare Worker Compliance with Clinical Practice Guidelines in the Acute Care Setting

BACKGROUND

Even though guidelines for venous thromboembolism risk assessment and prophylaxis are available, patients with identifiable risk factors admitted to acute hospitals are not receiving appropriate prophylaxis. The incidence of venous thromboembolism in hospitalized patients is higher than that of people living in the community who have similar demographics. Knowledge of barriers to healthcare professional compliance with clinical practice guidelines and facilitators to improve compliance will aid appropriate use of venous thromboembolism clinical practice guidelines.

OBJECTIVES

The main objective of this review was to identify the barriers and facilitators to healthcare professional compliance with clinical practice guidelines for venous thromboembolism assessment and prophylaxis.

INCLUSION CRITERIA

Studies were considered for inclusion regardless of the designation of the healthcare professional involved in the acute care setting.The focus of the review was compliance with venous thromboembolism clinical practice guidelines and identified facilitators and barriers to clinical use of these guidelines.Any experimental, observational studies or qualitative research studies were considered for inclusion in this review.The outcomes of interest were compliance with venous thromboembolism guidelines and identified barriers and facilitators to compliance.

SEARCH STRATEGY

A comprehensive, three-step search strategy was conducted for studies published from May 2003 to November 2011, aimed to identify both published and unpublished studies in the English language across six major databases.

METHODOLOGICAL QUALITY

Retrieved papers were assessed by two independent reviewers prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute.

DATA COLLECTION

Both quantitative and qualitative data were extracted from papers included in the review using standardized data tools from the Joanna Briggs Institute.

DATA SYNTHESIS

Quantitative data was pooled using narrative summary due to heterogeneity in the ways in which data was reported. Qualitative data was pooled using Joanna Briggs Institute software.

RESULTS

Twenty studies were included in the review with methodological quality ranging from low to high.Reported compliance at baseline ranged from 6.25% to 70.4% and compliance post intervention ranged from 36% to 100%.Eight main categories of barriers and nine main categories of facilitators were identified. The quantitative and qualitative studies identified very similar barriers and facilitators which fell under the same categories. The studies all had components of education involved in their intervention and the review found that passive dissemination or one mode of intervention was not enough to affect and sustain change in clinical practice.

CONCLUSIONS

This review identified 20 studies that assessed compliance with venous thromboembolism clinical practice guidelines, and identified barriers and facilitators to that compliance. The studies showed that many different forms of intervention can improve compliance with clinical practice guidelines. They provided evidence that interventions can be developed for the specific audience and setting they are being used for, and that not all interventions are appropriate for all areas, such as computer applications not being suitable where system capacity is lacking.Healthcare professionals need to be aware of venous thromboembolism clinical practice guidelines and improve patient outcomes by using them in the hospital setting. There are a number of interventions that can improve guideline compliance, keeping in mind the barriers and adjusting practice to avoid them.Venous thromboembolism compliance within rural Australian hospitals has not been determined, however as inequalities have been identified in other areas of healthcare between urban and rural regions this would be a logical area to research.