Venous thromboprophylaxis in general surgery ward admissions: strategies for improvement.

OBJECTIVE: To estimate the adherence to institutional venous thromboprophylaxis clinical practice guidelines (CPGs) in general surgery patients and to assess the effectiveness of a multi-strategy improvement intervention. DESIGN: A prospective before-after study. SETTING: Two teaching hospitals located in the city of Buenos Aires, Argentina. PARTICIPANTS: Prescriptions belonging to patients admitted to the general surgery wards were evaluated. INTERVENTION: A multi-strategy intervention that included (i) simplification of institutional CPGs for venous thromboprophylaxis using a single drug at a single dose, based on the American College of Chest Physicians recommendations, (ii) distribution of pocket cards with an algorithm for the implementation of new recommendations to both, physicians and nurses, working in the general surgery units, (iii) educational talks, (iv) paper-based reminders and (v) audit and feedback. MAIN OUTCOME MEASURE: The adherence of the venous thromboprophylaxis prescription to the institutional recommendations. RESULTS: The prescriptions of 100 admitted patients before and 90 after the intervention were included in the analysis. The initial rate of adherence was 31%. After the intervention this rate rose to 71.1% (P< 0.001). The major improvement observed was the reduction in omitted prophylaxis in patients at risk of venous thromboembolism from 45 to 13.3% (P< 0.001). In the adjusted model, prescribing compliance with CPGs was five times more likely during the second stage than during the first stage (OR = 5.60, 95% CI = 2.92-10.74). CONCLUSIONS: Simple and economical interventions such as those described in this study can improve general surgeons compliance with the institutional and international guidelines, thus assuring patient safety and quality of health care.

Adherence to local guidelines for venous thromboprophylaxis: a cross-sectional study of medical inpatients in Argentina.

BACKGROUND: Venous thromboembolism prophylaxis has been shown to safely and cost-effectively reduce the incidence of thromboembolic events in medical inpatients. However, there is a gap between evidence and medical practice. The aim of this study was evaluate the appropriateness of prescribing venous thromboembolism prophylaxis in accordance with local recommendations for medical inpatients. METHODS: This cross-sectional study included 310 prescriptions of medical general-ward admitted patients of two university hospitals of Buenos Aires, Argentina.Data was collected using filled-out prescriptions, medical records and interviews with the head attending physician. Information was gathered at different times during 16 days randomly selected over September 2007 and January 2008. RESULTS: One hundred eighty eight patients' prescriptions (60.6%) were appropriate according to the institutional guidelines. Inappropriateness was due to excessive (14.2%), insufficient (15.8%) and absent (9.4%) prescribing. According to the recommendations of the American College of Chest Physicians, 256 (82.6%) patients received appropriate prophylaxis. Twenty-nine patients (9.4%) were considered at low risk for thromboembolism and did not need pharmacologic or mechanical prophylaxis. One hundred three patients (33.2%) had at least one major risk factor for venous thromboembolism. Compliance with the institutional guidelines was more frequently in the case of high risk patients. Complex preventive measures and low risk patients were related to lower adherence to recommendations. In the multivariate analysis, predictors of inappropriateness were the requirement of a surgical procedure and absence of prophylaxis prescribing at admission. In contrast, patients with a diagnosis of gastrointestinal disorders had lower odds of inappropriateness than those with an infectious disease. CONCLUSIONS: Most medical inpatients received some thromboprophylaxis measure, but the compliance with recommendations was less frequent. Efforts should be made to improve the appropriate prescription.

Clinical Usefulness of Bronchoalveolar Lavage in the Management of Pulmonary Infiltrates in Adults with Hematological Malignancies and Stem Cell Transplantation.

INTRODUCTION: Pulmonary complications are frequent in patients with hematologic malignancies and stem cell transplantation. Regardless of the microbiological usefulness of bronchoalveolar lavage (BAL), little information exists on both its benefits as a guide for therapeutic decisions and its impact on patients' clinical outcome. METHODS: A prospective observational single-center study was performed between July 2011 and July 2016. Consecutive episodes of pulmonary infiltrates were analyzed in subjects over 18 years of age who presented hematologic malignancies and underwent chemotherapy or stem cell transplantation. RESULTS: Ninety-six episodes of pulmonary infiltrates were analyzed. Acute leukemia was the most frequent underlying condition. Thirty-seven patients (38.5%) received a stem cell transplant. Sixty-one (62.9%) were neutropenic at the moment of inclusion in the study. A definitive etiologic diagnosis was obtained in 41 cases (42.7%), where infection accounted for the vast majority of cases (33 cases, 80.5%). Definitive diagnosis was reached by non-invasive methods in 13 cases (13.5%). BAL was performed in 47 cases and led to a diagnosis in 40.4% of the cases. BAL results led to therapeutic changes in 27 cases (57.4%), including the addition of new antimicrobials to empiric treatments in 10. Regarding BAL's safety, two patients experienced minor adverse events and one a severe adverse event; no procedure-related deaths were observed. CONCLUSIONS: Infection was the leading cause of pulmonary infiltrates in patients with hematologic malignancies and stem cell transplantation. BAL was a useful decision-making diagnostic tool, with minor adverse events.

Hemoglobin concentration variations over time in general medical inpatients.

BACKGROUND: A decrease in hemoglobin concentration [Hb] with no apparent cause is frequently observed in critically ill patients. Scarce information is available about this situation in general ward-admitted patients (GWAP). OBJECTIVES: To describe [Hb] variation with no obvious cause in GWAP, and to estimate the prevalence and predictors of patients with [Hb] decreases > or =1.5 g/dL. DESIGN, SETTING AND PATIENTS: Prospective, observational study in internal medicine GWAP, carried out at two teaching hospitals in Buenos Aires, Argentina. Patients with a history of, or admitted for diseases associated with decreases in [Hb], as well as those with length of stay less than three days, were excluded. MEASUREMENTS: Upon hospitalization, complete personal and clinical data were recorded. Furthermore, Katz index, APACHE II acute physiology score (APS) and Charlson score were calculated. [Hb] and hematocrit (HCT) were also assessed during hospitalization. RESULTS: A total of 338 patients were evaluated, 131 were included. A mean [Hb] decrease of 0.71 g/dL was observed between admission and discharge (P < 0.001; 95% CI, 0.47-0.97). Forty-five percent of the included patients had decreases in [Hb] > or = 1.5 g/dL. This was associated with a higher APS, a higher [Hb] at admission, and a discharge diagnosis of infectious or gastrointestinal disease. No bleeding episodes were observed. CONCLUSIONS: An [Hb] decrease was frequently observed during GWAP hospitalization with no evident blood loss. Even though this decrease has multiple causes, the severity of the acute illness seems to play a major role.