Evaluation of a Standardized Perioperative Management Protocol in the Adult Hematology Anticoagulation Management Service.

BACKGROUND: In North America, 250,000 patients on vitamin K antagonists require surgical procedures each year. Temporary interruption of oral anticoagulation and perioperative bridging therapy with unfractionated heparin or low-molecular-weight heparin are recommended by the American College of Chest Physicians 2012 for select patients. OBJECTIVES: The study objectives are to evaluate adherence and nonadherence to the Johns Hopkins clinic guidelines for perioperative management of anticoagulation and identify bleeding or thromboembolic events during perioperative management of anticoagulation. METHODS: This is a retrospective study of patients who required perioperative management of anticoagulation for an invasive procedure from May 2009 to March 2014. Individualized perioperative anticoagulation management plans were prospectively developed for each patient according to the standardized Johns Hopkins perioperative bridging recommendations and documented in the medical record. Adherence to these standardized Johns Hopkins clinic guidelines, the incidence of thromboembolic events, and bleeding and adverse events during perioperative management were retrieved from the medical record. RESULTS: In 294 perioperative management cases, there was 1 (0.3%) thromboembolism, 3 (1%) major bleeds, and 21 (7%) minor bleeds. One patient experienced facial swelling after starting enoxaparin. There was no difference in thromboembolic (0 vs 1, P = 1.00), major (1 vs 2, P = 1.00), or minor bleeding (14 vs 7, P = 1.00) events in patients managed by providers who were adherent to guidelines when compared with providers who were nonadherent. CONCLUSION: Our study shows that using a standardized guideline for perioperative management of anticoagulation to inform but not to dictate clinical practice leads to low rates of both thromboembolism and bleeding.

A retrospective analysis of the impact of disabling item review on item performance on computerized fixed-item tests in a doctor of pharmacy program.

OBJECTIVE: The decision to disable item review, or 'backward navigation,' during computerized-fixed item tests proved controversial among faculty at our institution. We sought to determine the effect of disabling backward navigation on performance of individual exam items and overall exam performance across multiple courses within a doctor of pharmacy program. METHODS: Exam items that were administered unchanged and without error or adjustment of scoring between 2016 and 2017 were eligible for inclusion. Included items were evaluated for change in difficulty index, point biserial, and discrimination index for the year when backward navigation was enabled to the year after the function was disabled. Performance on matching exam pairs in each time frame was compared for any changes. RESULTS: We screened 2033 items and identified 576 which met study inclusion criteria. There were no significant differences in overall item difficulty index, point biserial, discrimination index or performance of the 27% lowest-scoring students. There was a decrease of 0.95% for the highest-scoring students (z = -2.93, p = 0.003). We identified 15 pairs of exams that contained at least 30% identical items from 2016 to 2017. No difference was found in the percent score minimum, maximum, mean, median, or standard deviation. CONCLUSIONS: Although there was a statistically significant decrease in item performance for students with the highest scores on the exam, we were unable to demonstrate that disabling backward navigation had a significant impact on overall item performance or exam results.