MS

thesisThe objective of the study was to develop a computerized reminder system to ensure that preoperative deep vein thrombosis (DVT) prophylaxis (anticoagulation or compression devices) was provided for eligible patients. The study design was a prospective trial with historic controls. The setting was LDS Hospital in Salt Lake City, Utah, a tertiary care teaching center. The alternate hypothesis stated that a computerized reminder system would increase the rate of DVT prophylaxis in surgical patients. A local consensus was developed among surgeons as to which procedures should receive DVT prophylaxis. The historic rate of DVT prophylaxis was measured for these procedures at 83.8% (794 of 948 eligible cases). A computerized reminder system was implemented on the hospital's computer system, which flagged patients scheduled for a procedure for which DVT prophylaxis was indicated. The rate of DVT prophylaxis was then remeasured. For the 3 months after the introduction of the reminder, compliance with DVT prophylaxis rose to 99.3% (1118 out of 1126 eligible cases). Fourteen of 54 types of procedures showed statistically significant improvement in the rate of DVT prophylaxis between the study group and the historic controls. The procedures which did not show improvement had a small number of cases (n90%). When individual procedures were combined into groups of similar surgeries, 7 of 10 groups showed statistically significant improvement. Similarly, 3 of 4 surgical divisions showed statistically significant improvement. For all cases combined, the rate of DVT prophylaxis showed highly significant improvement (p<.001) between the historic controls (83.8%) and the study group (99.3%). The conclusion of the study was that a computerized reminder appeared to be an effective method of increasing the rate of DVT prophylaxis in surgical patient

Designing and implementing effective venous thromboembolism prevention protocols: lessons from collaborative efforts

Hospital acquired venous thromboembolism (VTE) is a major source of morbidity and mortality, yet proven prevention measures are often underutilized. The lack of a validated VTE risk assessment model, difficulty integrating VTE risk assessment and prevention protocols into the routine process of care, and the lack of standardized metrics for VTE prophylaxis have all been barriers. Recently, a VTE risk assessment/prevention protocol has been validated, leading to portable strategies achieving breakthrough levels of adequate prophylaxis in a variety of inpatient settings. VTE prevention protocol design and implementation strategies have been collected in implementation guides available from the Society of Hospital Medicine and the Agency for Healthcare Research and Quality. These guides were the centerpieces of national collaborative efforts to improve VTE involving over 150 medical centers, honing the approach to accelerate improvement described in this article. Embedding a VTE prevention protocol into admission, transfer, and perioperative order sets is a key strategy. A VTE prevention protocol is defined as a VTE risk assessment with no more than three levels of risk, tightly linked to recommended prophylaxis for each level. A balance between the need to provide protocol guidance and the need for efficiency and ease-of-use by the clinician must be maintained. The power of this protocol driven approach is bolstered by a quality improvement framework, multidisciplinary teams, ongoing monitoring of the process, and real time identification and mitigation of non-adherents via a technique that measures progress and prompts concurrent intervention, an approach we call “measure-vention.

Impact of electronic reminders on venous thromboprophylaxis after admissions and transfers

Objective Clinical decision support has the potential to improve prevention of venous thromboembolism (VTE). The purpose of this prospective study was to analyze the effect of electronic reminders on thromboprophylaxis rates in wards to which patients were admitted and transferred. The latter was of particular interest since patient handoffs are considered to be critical safety issues. Methods The trial involved two study periods in the six departments of a university hospital, three of which were randomly assigned to the intervention group displaying reminders during the second period. At 6 h after admission or transfer, the algorithm checked for prophylaxis orders within 0-30 h of the patient's arrival, increasing the specificity of the displayed reminders. Results The significant impact of the reminders could be seen by prophylaxis orders placed 6-24 h after admission (increasing from 8.6% (223/2579) to 12% (307/2555); p<0.0001) and transfer (increasing from 2.4% (39/1616) to 3.7% (63/1682); p=0.034). In admission wards, the rate of thromboprophylaxis increased from 62.4% to 67.7% (p<0.0001), and in transfer wards it increased from 80.2% to 84.3% (p=0.0022). Overall, the rate of prophylaxis significantly increased in the intervention group from 69.2% to 74.3% (p<0.0001). No significant changes were observed in the control group. Postponing prophylaxis checks to 6 h after admissions and transfers reduced the number of reminders by 62% and thereby minimized the risk of alert fatigue. Conclusions The reminders improved awareness of VTE prevention in both admission and transfer wards. This approach may contribute to better quality of care and safer patient handoff

Prevalence of venous thromboembolism risk factors and prophylactic adequacy among general surgical patients in a tertiary care hospital

AbstractIntroductionVenous thromboembolism (VTE) is a disease manifested as deep vein thrombosis and pulmonary embolism. General surgical procedures are associated with significant risk of precipitating VTE, and despite the surging evidences, it is often overlooked. The study attempted at estimating the prevalence of VTE and bleeding risk factors coupled with the adequacy of thromboprophylaxis administered.MethodologyThe study spanning 1-year duration was executed through collection of data from patients older than 18 years, admitted to the general surgery department of a tertiary care hospital. The data were collected using internally validated data collection form and the appraisal of data was done using SPSS 18.ResultsAmong the 400 subjects enrolled, number of patients in low, moderate, and high risk, as per the Caprini score, was 24%, 35%, and 41%, respectively, with the difference being significant with p<0.001. Bleeding risk was positive in 28% subjects and 36% received any form of prophylaxis other than early ambulation. 28% subjects were identified to have received adequate thromboprophylaxis.ConclusionAlthough the prevalence of 41% individuals at high risk for VTE is comparable to the global prevalence of 41.5%, prophylactic adequacy of 28% was lower than the 33% observed globally. Meticulous planning coupled with operational interventions, such as institutional multidisciplinary thromboprophylactic team, can be an effective strategy at enhancing the prophylactic standards and thereby attaining optimal patient outcomes

Skala punktowa opracowana przez Polską Grupę Roboczą na podstawie skali Josepha Capriniego dotycząca oceny stopnia zagrożenia rozwoju powikłań zakrzepowo-zatorowych w chirurgii

Background. Thromboembolic risk assessment is crucial for the appropriate prescription of thromboprophylaxis. Such assessments are facilitated by scoring systems. We aimed to develop a scoring system intended for surgeons, which would allow them to assess this risk in a rapid, reproducible and reliable manner and therefore to use the most effective thromboprophylaxis. Material and methods. The Polish Working Group was established to draw up a scoring system for thromboembolic risk assessment. Joseph Caprini&#8217;s scoring system was the starting point and model for the Group&#8217;s efforts, which were supplemented by bibliographical data and the members&#8217; own experience. The obtained total score forms the basis for including the patient in a particular risk group, which is associated with a particular thromboprophylaxis regimen. Results and conclusions. The scoring system is a simple tool that could gain widespread acceptance among surgeons representing various specialties. As the scoring system has not been verified in clinical practice, it may only be used supportively for now in the assessment of venous thromboembolism. Acta Angiol 2011; 17, 1: 49&#8211;76Wstęp. Ocena zagrożenia powikłaniami zakrzepowo-zatorowymi stanowi podstawę odpowiedniej ordynacji profilaktyki przeciwzakrzepowej. Narzędziem ułatwiającym dokonanie tej oceny jest skala punktowa. Celem pracy było przygotowanie skali punktowej adresowanej do chirurgów, która umożliwi szybką, powtarzalną i jednoznaczną ocenę takiego ryzyka oraz zastosowanie najskuteczniejszej profilaktyki przeciwzakrzepowej. Materiał i metody. W celu przygotowania skali punktowej służącej ocenie zagrożenia związanego z ryzykiem wystąpienia powikłań zakrzepowo-zatorowych powołano Polską Grupę Roboczą. Punktem wyjściowym oraz wzorem do opracowania chirurgicznej skali punktowej stała się skala Josepha Capriniego. Podczas prac korzystano z danych z piśmiennictwa oraz doświadczenia własnego członków Polskiej Grupy Roboczej. Suma uzyskanych w skali punktów stanowi podstawę włączenia chorych do grupy ryzyka, co wiąże się z zastosowaniem rekomendowanej formy profilaktyki. Wyniki i wnioski. Zaprezentowana skala punktowa może stanowić proste narzędzie powszechnie stosowane przez lekarzy dyscyplin zabiegowych. Skali dotychczas nie sprawdzano w praktyce klinicznej, zatem stanowi ona jedynie formę pomocy w ocenie ryzyka rozwoju żylnej choroby zakrzepowo-zatorowej. Acta Angiol 2011; 17, 1: 49&#8211;7

The Anticoagulation of Calf Thrombosis (ACT) project: study protocol for a randomized controlled trial

<p>Abstract</p> <p>Background</p> <p>Half of all lower limb deep vein thrombi (DVT) in symptomatic ambulatory patients are located in the distal (calf) veins. While proximal disease warrants therapeutic anticoagulation to reduce the associated risks, distal DVT often goes untreated. However, a proportion of untreated distal disease will undoubtedly propagate or embolize. Concern also exists that untreated disease could lead to long-term post thrombotic changes. Currently, it is not possible to predict which distal thrombi will develop such complications. Whether these potential risks outweigh those associated with unrestricted anticoagulation remains unclear. The Anticoagulation of Calf Thrombosis (ACT) trial aims to compare therapeutic anticoagulation against conservative management for patients with acute symptomatic distal deep vein thrombosis.</p> <p>Methods</p> <p>ACT is a pragmatic, open-label, randomized controlled trial. Adult patients diagnosed with acute distal DVT will be allocated to either therapeutic anticoagulation or conservative management. All patients will undergo 3 months of clinical and assessor blinded sonographic follow-up, followed by 2-year final review. The project will commence initially as an external pilot study, recruiting over a 16-month period at a single center to assess feasibility measures and clinical event rates. Primary outcome measures will assess feasibility endpoints. Secondary clinical outcomes will be collected to gather accurate data for the design of a definitive clinical trial and will include: (1) a composite endpoint combining thrombus propagation to the popliteal vein or above, development of symptomatic pulmonary embolism or sudden death attributable to venous thromboembolic disease; (2) the incidence of major and minor bleeding episodes; (3) the incidence of post-thrombotic leg syndrome at 2 years using a validated screening tool; and (4) the incidence of venous thromboembolism (VTE) recurrence at 2 years.</p> <p>Discussion</p> <p>The ACT trial will explore the feasibility of comparing therapeutic anticoagulation to conservative management in acute distal DVT, within a modern cohort. We also aim to provide contemporary data on clot propagation, bleeding rates and long-term outcomes within both groups. These results will inform the conduct of a definitive study if feasibility is established.</p> <p>Trial registration</p> <p>Current Controlled Trials <a href="http://www.controlled-trials.com/ISRCTN75175695">ISRCTN75175695</a></p