Guidance for the diagnosis of pulmonary embolism during pregnancy: Consensus and controversies

International audienc

Appropriateness of Dabigatran and Rivaroxaban Prescribing for Hospital Inpatients

ABSTRACTBackground: Recent approval of the new oral anticoagulants dabigatran and rivaroxaban has led to rapid changes in anticoagulant prescribing practices. Postmarketing reports have highlighted safety concerns with these agents, and their use outside of evidence-based recommendations was noted at the authors’ centre.Objectives: To determine the incidence of and risk factors associated with inappropriate prescribing of dabigatran and rivaroxaban.Methods:This retrospective cohort study investigated randomly selected dabigatran or rivaroxaban prescriptions for patients admitted to a tertiary teaching hospital between January 2010 and December 2012. Appropriateness of prescribing was determined from the documented indication, drug dosage, patient’s renal function, and presence of drug interactions, if applicable.Results: Among a total of 321 medication orders reviewed, the incidence of inappropriate use was 31.2% (34/109) for dabigatran and 26.9% (57/212) for rivaroxaban. Of the 97 reasons for inappropriate use that were identified, the most common were prescribing for an unapproved indication (49/97 [50.5%]), concomitant prescribing of another anti -coagulant (22/97 [22.7%]), and high prescribed dose (9/97 [9.3%]). The prescribing service was found to be an independent risk factor for inappropriate prescribing (p = 0.041). Corrections were made to 23.1% (21/91) of the incorrect regimens before hospital discharge. In a sensitivity analysis using calculated ideal body weight to estimate renal function, the overall incidence of inappropriate prescribing increased to 31.5% (101/321).Conclusions: The proportion of patients with inappropriate prescribing of dabigatran or rivaroxaban in clinical practice was higher than expected. Educational interventions and pharmacy-led initiatives with a focus on appropriate indications, concomitant anticoagulant prescribing, and review of dosage regimens are recommended to improve patient safety.RÉSUMÉContexte : La récente approbation de deux nouveaux anticoagulants oraux, le dabigatran et le rivaroxaban, a mené à de rapides changements dans les habitudes de prescription pour l’anticoagulothérapie. Des rapports de pharmacovigilance ont relevé des risques pour la santé relativement à ces agents. De plus, on a noté au centre où travaillent les auteurs que ces médicaments n’étaient pas toujours utilisés selon les recommandations fondées sur des données probantes.Objectifs : Déterminer quelle est l’incidence des prescriptions inadéquates de dabigatran et de rivaroxaban et quels sont les facteurs de risque qui y sont associés.Méthodes : La présente étude de cohorte rétrospective a examiné des ordonnances choisies au hasard de dabigatran ou de rivaroxaban, lesquelles étaient destinées à des patients admis dans un hôpital universitaire de soins tertiaires entre janvier 2010 et décembre 2012. La pertinence des prescriptions était établie à l’aide des informations consignées sur l’indication, la posologie, la fonction rénale du patient et la presence d’interactions médicamenteuses, le cas échéant.Résultats : Parmi l’ensemble des 321 ordonnances analysées, l’incidence d’utilisation inadéquate était de 31,2 % (34/109) pour le dabigatran et de 26,9 % (57/212) pour le rivaroxaban. Des 97 raisons d’utilisation ina- déquate qui ont été recensées, les plus fréquentes étaient : la prescription pour une indication non approuvée (49/97 [50,5 %]), la prescription concomitante d’un autre anticoagulant (22/97 [22,7 %]) et la prescription d’une dose élevée (9/97 [9,3 %]). Le service auquel appartenait le prescripteur s’est révélé être un facteur de risque indépendant de prescription inadéquate (p = 0.041). Des corrections ont été apportées à 23,1 % (21/91) des schémas erronés avant que le congé ne soit donné. Dans une analyse de sensibilité qui s’appuyait sur le calcul du poids idéal pour estimer la fonction rénale, le taux global d’incidence de prescription inadéquate augmentait à 31,5 % (101/321).Conclusions : La proportion de patients pour qui la prescription de dabigatran ou de rivaroxaban était inadéquate dans la pratique Clinique était plus élevée que prévu. Afin d’améliorer la sécurité des patients, on recommande l’adoption d’interventions éducatives et d’initiatives dirigées par les services de pharmacie qui porteront sur les indications adéquates, la prescription concomitante d’anticoagulants et la révision des schémas posologiques

Appropriateness of Dabigatran and Rivaroxaban Prescribing for Hospital Inpatients

BACKGROUND: Recent approval of the new oral anticoagulants dabigatran and rivaroxaban has led to rapid changes in anticoagulant prescribing practices. Postmarketing reports have highlighted safety concerns with these agents, and their use outside of evidence-based recommendations was noted at the authors’ centre. OBJECTIVES: To determine the incidence of and risk factors associated with inappropriate prescribing of dabigatran and rivaroxaban. METHODS: This retrospective cohort study investigated randomly selected dabigatran or rivaroxaban prescriptions for patients admitted to a tertiary teaching hospital between January 2010 and December 2012. Appropriateness of prescribing was determined from the documented indication, drug dosage, patient’s renal function, and presence of drug interactions, if applicable. RESULTS: Among a total of 321 medication orders reviewed, the incidence of inappropriate use was 31.2% (34/109) for dabigatran and 26.9% (57/212) for rivaroxaban. Of the 97 reasons for inappropriate use that were identified, the most common were prescribing for an unapproved indication (49/97 [50.5%]), concomitant prescribing of another anticoagulant (22/97 [22.7%]), and high prescribed dose (9/97 [9.3%]). The prescribing service was found to be an independent risk factor for inappropriate prescribing (p = 0.041). Corrections were made to 23.1% (21/91) of the incorrect regimens before hospital discharge. In a sensitivity analysis using calculated ideal body weight to estimate renal function, the overall incidence of inappropriate prescribing increased to 31.5% (101/321). CONCLUSIONS: The proportion of patients with inappropriate prescribing of dabigatran or rivaroxaban in clinical practice was higher than expected. Educational interventions and pharmacy-led initiatives with a focus on appropriate indications, concomitant anticoagulant prescribing, and review of dosage regimens are recommended to improve patient safety

Effectiveness of Unfractionated Heparin in Normal Saline versus Dextrose for Achieving and Maintaining Therapeutic Anti–Factor Xa Levels in Patients with Non-ST-Elevation Acute Coronary Syndrome

ABSTRACTBackground: Unfractionated heparin (UFH) administered by IV infusion is effective in preventing myocardial infarction and death after non-ST-elevation acute coronary syndrome. At the authors’ centre, preparations of UFH in 0.9% sodium chloride (normal saline; UFHNS) were used during a shortage of commercially available UFH in dextrose 5% in water (UFH-D5W), the usual preparation. Anecdotal observations raised concerns about the effectiveness of the saline-based preparation in achieving minimally therapeutic anticoagulation.Objective: To compare the effectiveness of UFH-NS and UFH-D5W for achieving and maintaining therapeutic anti–factor Xa levels in patients with non-ST-elevation acute coronary syndrome.Methods: A retrospective cohort study was conducted with 2 groups of 100 consecutive patients who received either UFH-NS or UFH-D5W for a minimum of 24 h after non-ST-elevation acute coronary syndrome in accordance with a weight-based dosing nomogram.Results: A minimally therapeutic level of anti-Xa (≥ 0.31 IU/mL) was achieved within 24 h for 92% of the patients receiving UFH-D5W and 67% of those receiving UFH-NS (absolute risk difference 25%, 95% confidence interval [CI] 13.4%–36.6%; p < 0.001). Infusion of UFHNS was associated with lower probability of achieving minimally therapeutic anticoagulation (hazard ratio [HR] 2.30, 95% CI 1.68–3.15; p < 0.001) and maintaining therapeutic anticoagulation (HR 2.31, 95% CI 1.69–3.17; p < 0.001) relative to UFH-D5W. Significant differences in the numbers of patients with subtherapeutic and therapeutic anticoagulation, favouring UFH-D5W, were observed at each of the first, second, and third anti-Xa measurements (p < 0.05). Patients receiving UFH-NS required a greater median number of adjustments to the infusion rate during the first 48 h (1.0 v. 0.5 adjustment per day, p < 0.001). There was no difference between groups in terms of major reductions in hemoglobin.Conclusions: Infusion of UFH-NS was inferior to UFH-D5W for achieving and maintaining therapeutic anticoagulation in patients with non-ST-elevation acute coronary syndrome. Until further study,RÉSUMÉContexte : La perfusion intraveineuse d’héparine non fractionnée (HNF) est efficace pour prévenir l’infarctus du myocarde et la mortalité après la survenue d’un syndrome coronarien aigu sans élévation du segment ST. Au centre hospitalier des auteurs, des préparations de ce médicament dans du chlorure de sodium à 0,9 % (solution physiologique salée [SP]; HNF-SP) ont été utilisées lors d’une pénurie de solutions commercialisées d’HNF dans du dextrose à 5 % dans l’eau (HNF-D5E) d’usage habituel. Quelques observations ont soulevé des inquiétudes quant à l’efficacité des préparations à base de SP pour obtenir une anticoagulation thérapeutique minimale.Objectif : Comparer l’efficacité de l’HNF dans la SP et le D5E pour obtenir et maintenir des concentrations thérapeutiques d’anti-facteur Xa chez des patients ayant subi un syndrome coronarien aigu sans élévation du segment ST.Méthodes : Une étude de cohorte rétrospective a été menée à partir de deux séries consécutives de 100 patients qui ont reçu de l’HNF dans une SP ou du D5E pendant un minimum de 24 heures après la survenue du syndrome coronarien aigu sans élévation du segment ST, selon un nomogramme posologique en fonction du poids.Résultats : Des concentrations thérapeutiques minimales d’anti-Xa (≥ 0,31 UI/mL) ont été obtenues en 24 heures chez 92 % des patients ayant reçu l’HNF-D5E et chez 67 % de ceux ayant reçu l’HNF-SP (différence de risque absolu de 25 %, intervalle de confiance [IC] à 95 % de 13,4 % à 36,6 %; p < 0,001). La perfusion de la préparation à base de SP a été associée à une probabilité plus faible d’obtenir une anticoagulation thérapeutique minimale (rapport de risque [RR] de 2,30, IC à 95 % de 1,68 à 3,15; p < 0,001) et de maintenir une anticoagulation thérapeutique (RR de 2,31, IC à 95 % de 1,69 à 3,17; p < 0,001) par rapport à la préparation dans du D5E. Des différences significatives dans le nombre de patients ayant obtenu une anticoagulation thérapeutique et subthérapeutique, en faveur de l’HNF-D5E, ont été observées à chacune des premières, deuxièmes et troisièmes mesures des concentrations d’anti-Xa (p < 0,05). Les patients ayant reçu l’HNF-SP ont requis un nombre médian supérieur d’ajustements de la vitesse de perfusion pendant les 48 premières heures (1,0 contre 0,5 ajustement par jour, p < 0,001). Il n’y avait aucune différence entre les groupes en termes de réductions importantes de l’hémoglobine.Conclusions : La perfusion d’HNF-SP s’est révélée inférieure à celle de l’HNF-D5E pour obtenir et maintenir une anticoagulation thérapeutique chez les patients ayant subi un syndrome coronarien aigu sans élévation du segment ST. Jusqu’à ce que d’autres études soient menées, la perfusion d’héparine dans une solution physiologique salée doit être utilisée avec circonspection et les patients doivent être surveillés étroitement afin d’assurer l’obtention en temps opportun et le maintien d’une anticoagulation thérapeutique

Improving physician hand hygiene compliance using behavioural theories: a study protocol

Abstract Background Healthcare-associated infections affect 10% of patients in Canadian acute-care hospitals and are significant and preventable causes of morbidity and mortality among hospitalized patients. Hand hygiene is among the simplest and most effective preventive measures to reduce these infections. However, compliance with hand hygiene among healthcare workers, specifically among physicians, is consistently suboptimal. We aim to first identify the barriers and enablers to physician hand hygiene compliance, and then to develop and pilot a theory-based knowledge translation intervention to increase physicians’ compliance with best hand hygiene practice. Design The study consists of three phases. In Phase 1, we will identify barriers and enablers to hand hygiene compliance by physicians. This will include: key informant interviews with physicians and residents using a structured interview guide, informed by the Theoretical Domains Framework; nonparticipant observation of physician/resident hand hygiene audit sessions; and focus groups with hand hygiene experts. In Phase 2, we will conduct intervention mapping to develop a theory-based knowledge translation intervention to improve physician hand hygiene compliance. Finally, in Phase 3, we will pilot the knowledge translation intervention in four patient care units. Discussion In this study, we will use a behavioural theory approach to obtain a better understanding of the barriers and enablers to physician hand hygiene compliance. This will provide a comprehensive framework on which to develop knowledge translation interventions that may be more successful in improving hand hygiene practice. Upon completion of this study, we will refine the piloted knowledge translation intervention so it can be tested in a multi-site cluster randomized controlled trial.</p

Improving physician hand hygiene compliance using behavioural theories: a study protocol

BACKGROUND: Healthcare-associated infections affect 10% of patients in Canadian acute-care hospitals and are significant and preventable causes of morbidity and mortality among hospitalized patients. Hand hygiene is among the simplest and most effective preventive measures to reduce these infections. However, compliance with hand hygiene among healthcare workers, specifically among physicians, is consistently suboptimal. We aim to first identify the barriers and enablers to physician hand hygiene compliance, and then to develop and pilot a theory-based knowledge translation intervention to increase physicians’ compliance with best hand hygiene practice. DESIGN: The study consists of three phases. In Phase 1, we will identify barriers and enablers to hand hygiene compliance by physicians. This will include: key informant interviews with physicians and residents using a structured interview guide, informed by the Theoretical Domains Framework; nonparticipant observation of physician/resident hand hygiene audit sessions; and focus groups with hand hygiene experts. In Phase 2, we will conduct intervention mapping to develop a theory-based knowledge translation intervention to improve physician hand hygiene compliance. Finally, in Phase 3, we will pilot the knowledge translation intervention in four patient care units. DISCUSSION: In this study, we will use a behavioural theory approach to obtain a better understanding of the barriers and enablers to physician hand hygiene compliance. This will provide a comprehensive framework on which to develop knowledge translation interventions that may be more successful in improving hand hygiene practice. Upon completion of this study, we will refine the piloted knowledge translation intervention so it can be tested in a multi-site cluster randomized controlled trial