Is Interchangeability Possible? Understanding and Evaluating the Evidence Base-Implications for Quality and Safety

Geno Merli, a board-certified specialist in internal medicine and physical medicine and rehabilitation, is Director of the Jefferson Center for Vascular Disease at Jefferson Medical College and Senior Vice President and Chief Medical Officer at Thomas Jefferson University Hospital. Dr. Merli received his medical degree from Jefferson Medical College and completed his residency in rehabilitation medicine and internal medicine at Thomas Jefferson University Hospital. Dr. Merli is a nationally recognized expert in the areas of prophylaxis for and management of deep-vein thrombosis and pulmonary embolism (DVT/PE), as well as for the medical consultation of surgical patients. His research interests have focused on prophylaxis for DVT/PE and the management of DVT in acute spinal cord injury, total joint replacement, trauma, and high-risk cancer patients. Former editor-in-chief of Internal Medicine, Dr. Merli currently serves on the editorial board of Patient Care, Journal of the Society of Hospital Medicine, and The Hospitalist. He is also a reviewer for the Archives of Internal Medicine, Annals of Internal Medicine, Chest, Journal of Thrombosis and Thrombolysis, Journal of Thrombosis and Hemostasis and JAMA. He is co-editor of the book Medical Management of the Surgical Patient and co-chairs for a national course on the perioperative care of the surgical patient with medical problems. Dr. Merli is a fellow of the American College of Physicians and a member of American Venous Forum, the Society of Hospital Medicine, American Medical Association, Society of Vascular Medicine and Biology, and the International Society of Thrombosis and Hemostasis

Management of intracranial bleeding associated with dabigatran use in a neuroscience hospital

Dabigatran, an alternative to warfarin for prevention of stroke with non-valvular atrial fibrillation (AF), offers advantages of a fixed dosage, minimal laboratory monitoring and limited medication interactions. Dabigatran requires dosage adjustment in renal dysfunction and is contraindicated if severe dysfunction. No identified dabigatran reversal agent exists. Methods: As part of an ongoing quality initiative, novel anticoagulant associated adverse events (AE) are monitored at a dedicated neuroscience hospital. Results: 5 cases of intracranial bleeding associated with dabigatran occurred from 12/2011-4/2012. All patients were on anticoagulation for AF, the most common dose of dabigatran was 150 mg BID. Mean admission values were as follows: age 83.2 yrs (range 79-90), serum creatinine 1.48 mg/dL (range 0.9- 3.5), creatinine clearance 45.6 mL/min (18-59) and aPTT 49 seconds (range 32- 60). Strategies for the management of bleeding included withholding dabigatran, supportive care, administration of blood products and hemodialysis, when required. Dialysis was initiated on 3 patients. One patient had 3 dialysis sessions in an effort to normalize coagulation assays and had transfusions with 10 units of platelets and 4 units of fresh frozen plasma in an effort to stabilize bleeding. One patient died. Mean time for aPTT to normalize when abnormal on admission was 30.8 hours (range 21-37). Conclusions: Appropriate patient selection is required to prevent dabigatran associated AE, especially in the setting of advanced age and kidney dysfunction. aPTT values may remain prolonged for extended periods, despite efforts to normalize. Hospitals need a defined management plan for major bleeding associated with novel anticoagulants

Quantifying Patient Reported and Documented Compliance with Adjuncts to Venous Thromboembolism Prophylaxis

Objectives: 1. Measure patient compliance with pharmacologic, mechanical and ambulatory prophylactic measures. 2. Evaluate for agreement between nursing documentation and patient reported compliance with mechanical and ambulatory prophylactic measures.https://jdc.jefferson.edu/patientsafetyposters/1042/thumbnail.jp

How good are we at determining risk? Quantifying the accuracy of clinician determined risk for VTE prophylaxis

Objectives: Create and validate a simple tool for concurrent audits of risk stratification, compliance and documentation Evaluate accuracy of clinician risk stratification and prophylatic ordering practice compared with a standardized Caprini RAM across different assigned risk categories Provide recommendations for EPIC VTE Prophylaxis CDS Developmenthttps://jdc.jefferson.edu/patientsafetyposters/1050/thumbnail.jp

Preoperative Teleconsultation Visits are as Efficient as In-person Appointments in Avoiding Unnecessary Cancellation of Elective Surgical Procedures

The COVID-19 pandemic has presented many challenges in health care, not the least of which was the need to find alternatives to an in-person evaluation to reduce the risk of transmission of the virus. Despite the discontinuation of elective procedures at Thomas Jefferson University Hospital in Philadelphia (TJUH), Pennsylvania in March 2020, there was a subset of patients that required urgent surgical procedures. Consequently, there needed to be a different approach to the presurgical assessment of these patients. At our institution teleconsultation had gained acceptance by patients and providers prior to the COVID-19 pandemic, therefore a program was rapidly developed utilizing teleconsultation to assess these patients. The question we sought to answer was, in patients undergoing surgery, does completing the preoperative surgical consult through teleconsultation affect the cancellation rate on the day of surgery? Definitions - Teleconsultation – refers to synchronous visits in which a nurse practitioner or physician interfaces in real-time with a patient by video-conferencing. - Medically Optimized – patient completed the pre-admission testing process and was deemed an acceptable risk for surgery

Surgical Pulmonary Embolectomy Outcomes for Acute Pulmonary Embolism

Introduction: Acute pulmonary embolism (PE) is associated with significant mortality. Surgical embolectomy is a viable treatment option; however, it remains controversial due to variable outcomes. This review investigates patient outcomes following surgical embolectomy for acute PE. Methods: Electronic search was performed to identify articles reporting surgical embolectomy for treatment of PE. 32 studies were included comprising 936 patients. Demographic, perioperative, and outcome data were extracted and pooled for systematic review. Results: Mean patient age was 56.3 [95% CI 52.5; 60.1] years and 50% [46; 55] were male. 82% had right ventricular dysfunction [62; 93], 80% [67; 89] had unstable hemodynamics, and 9% [5; 16] experienced cardiac arrest. Massive PE and submassive PE were present in 83% of patients [43; 97] and 13% [2; 56], respectively. Before embolectomy, 33% of patients [14; 60] underwent systemic thrombolysis and 14% [8; 24] catheter embolectomy. Preoperatively, 47% of patients were ventilated [26; 70] and 36% had percutaneous cardiopulmonary support [11; 71]. Mean operative time and mean cardiopulmonary bypass time were 170 [101; 239] and 56 [42; 70] minutes, respectively. Intraoperative mortality was 4% [2; 8]. Mean hospital and ICU stay were 10 [6; 14] and 2 [1; 3] days, respectively. Mean postoperative systolic pulmonary artery pressure (sPAP) was significantly decreased from preoperative (sPAP 57.8 mmHg [53; 62.7]) to postoperative period (sPAP 31.3 mmHg [24.9; 37.8]), p \u3c0.01). In-hospital mortality was 16% [12; 21]. Overall survival at five years was 73% [64; 81]. Discussion: Surgical embolectomy is an acceptable treatment option with favorable outcomes

Concise Update on Perioperative DVT/PE Prophylaxis in the Surgical Patient

Presentation: 24 minute

Consult Guys

View additional Consult Guys recordings sponsored by the Annals of Internal Medicine on YouTube. Presentation: 52 minute