Effect of a Physiotherapist-Guided Home-Based Exercise Intervention on Physical Capacity and Patient-Reported Outcomes Among Patients With Acute Pulmonary Embolism: A Randomized Clinical Trial.

Importance: Survivors of acute pulmonary embolism (PE) experience long-term negative physical and mental consequences, but the effects of rehabilitation on outcomes among these patients have not been investigated. Objective: To investigate the effect of a rehabilitation intervention, comprising an 8-week home-based exercise program and nurse consultations, on physical capacity and patient-reported outcomes among patients with acute PE. Design, Setting, and Participants: This multicenter randomized clinical superiority trial was conducted at 4 regional hospitals and 1 university hospital in Denmark. The 140 consecutively included participants had been diagnosed with an acute PE between April 2016 and February 2018 and had 6 months of follow-up. An intention-to-treat analysis was conducted. Intervention: Patients in the control group received a brief nurse consultation, while patients in the exercise group participated in an 8-week home-based exercise program in addition to receiving nurse consultations. Main Outcomes and Measures: The primary outcome was the Incremental Shuttle Walk Test, and secondary outcomes were the Pulmonary Embolism Quality of Life and the EuroQol-5 Dimensions-3 Levels questionnaires, self-reported number of sick-leave days, and self-reported use of psychotropic drugs. Results: A total of 140 patients (90 [64.3%] men) were included, with a mean (SD) age of 61 (11) years. Of 70 participants (50.0%) randomized to each group, 69 participants (49.3%) received the intervention and 68 (48.6%) received the control intervention. Both groups achieved improvements in all outcomes (eg, mean [SD] improvement on Incremental Shuttle Walk Test: control group, 78 (127) m; intervention group, 104 [106] m; median [interquartile range] improvement on Pulmonary Embolism Quality of Life: control group, -17 [-22 to -11] points; intervention group, -20 [-24 to -15] points). Between-group differences were nonsignificant. The mean differences between the intervention group and the control group were 25 m (95% CI, -20 to 70 m; P = .27) on the Incremental Shuttle Walk Test, 3.0 points (95% CI, -3.7 to 9.9 points; P = .39) on the Pulmonary Embolism Quality of Life questionnaire, and 0.017 point (95% CI, -0.032 to 0.065 point; P = .50) on the EuroQol-5 Dimensions-3 Levels questionnaire. Of the 27 patients in the intervention group on sick leave at baseline, 24 (88.9%) reported fit-for-duty at the 6-month follow-up, and of 18 patients in the control group on sick leave, 17 (94.4%) reported fit-for-duty at the 6-month follow up. The between-group risk difference was not significant (5.5 points; P = .49). Conclusions and Relevance: An 8-week rehabilitation intervention with exercise added to nurse consultations did not show significantly better outcomes than nurse consultations alone. However, because of a ceiling effect on the primary outcome of physical capacity and an inclusion of patients with a low comorbidity burden and low PE disease severity, definitive conclusions could not be drawn. Initiating an exercise intervention shortly after pulmonary embolism was safe and without adverse events. Trial Registration: ClinicalTrials.gov Identifier: NCT02684721.

Instrument for Assessing Knowledge of Oral Anticoagulant Therapy: Construction and Validation.

BACKGROUND AND PURPOSE: A valid and reliable assessment tool is fundamental for evaluating the knowledge of individuals about using oral anticoagulant therapy (OAT). The purpose of this study was to develop a tool to assess knowledge about OAT and provide evidence to support its use in people living in developing countries. METHODS: Construction and validation: development of items; assessment of face and content validity; pilot study; application of the instrument to a sample of 500 users of OAT to analyze dimensionality, convergent validation, and reliability. RESULTS: Analysis of dimensionality suggested a unidimensional instrument. Direct correlation between knowledge of OAT and educational level was confirmed (r = .61, p < .001) (validity of construct). Reliability measured by KR-20 was 0.86. CONCLUSIONS: The new instrument was shown to be valid and reliable for assessing knowledge of OAT in the population studied.

[Nursing care of pulmonary embolism in out-of-hospital emergencies]. / Cuidados de Enfermería en el tromboembolismo pulmonar en urgencias extrahospitalarias.

Pulmonary embolism is one of the most severe venous thromboembolic diseases, both in mortality and the high number of associated complications and their impact on quality of life. The early hours are critical and proper management during this period can determine future sequels. Therefore, in the outpatient setting, nurses must have adequate knowledge and tools to act quickly and efficiently. In this paper, we present a case of a 77 year-old male in his home that after being discharged from a knee replacement surgery starts with symptoms compatible with pulmonary thromboembolism. A Nursing Care Process is performed, according to the functional patterns of Margory Gordon and a care plan is developed based on NNN taxonomy (NANDA, NOC, NIC). As main nursing diagnosis 'ineffective breathing pattern' is selected and as possible potential complication of the pulmonary embolism the 'pulmonary infarction' is chosen. The results obtained after conducting the care plan are satisfactory, improving the signs and symptoms presented by the patient, hence why we believe it is useful for nurses when facing similar clinical situations.

Venous Thromboembolism: New Concepts in Perioperative Management.

Venous thromboembolism (VTE) is a serious pathophysiologic condition that is a major cause of morbidity and mortality, especially during the perioperative period. A collective term, VTE is used to describe a blood clot that develops inside the vasculature and results in a deep vein thrombosis (DVT) and/or a pulmonary embolism (PE). Deep vein thrombosis and PE are the third leading cause of cardiovascular mortality, superseded only by myocardial infarction and stroke. Patients who receive treatment for acute PE are 4 times more likely to die of a recurrent VTE within the next year. In hospitalized patients who have had surgery, the incidence of VTE and PE is estimated to be 100 times more prevalent than in the general population. The Joint Commission has established Surgical Care Improvement Project measures to address prophylactic interventions to minimize the incidence of VTE. This journal course will review the current approaches to pharmacologic and nonpharmacologic prevention and management of VTE during the perioperative period. Identification and treatment of deep vein thrombosis and acute PE are also described.

Care of the patient with an acute pulmonary embolism.

There are evidence-based prevention strategies known to reduce the risk of pulmonary embolism formation. However, pulmonary emboli remain a leading cause of death in critically ill patients with a 3-month mortality of 10% to 15%. This article addresses patients' risk factors, pulmonary embolism prevention strategies, clinical manifestations, and treatment modalities the interdisciplinary team should understand.

Proactivity in VTE prevention: a concept analysis.

Venous thromboembolism (VTE) prevention is an international patient safety issue. The author has observed gaps in prescription and provision of VTE prophylaxis, and that the attitude to VTE is often reactive rather than proactive. This concept analysis aims to explore proactivity and apply it to VTE prevention to address this. Ten databases were searched (1992-2012) using the keywords proactive, proactivity, nurse, nursing, VTE/venous thromboembolism, prevent/prevention/preventing, behaviour, DVT/PE (deep vein thrombosis, pulmonary embolism). The Walker and Avant (2010) method of concept analysis identified the defining attributes as personal initiative, taking charge and feedback-seeking behaviour. Antecedents and consequences have been identified, and empirical referents are demonstrated. Defining proactivity in VTE prevention has the potential to increase prescription and, crucially, provision of prophylaxis, thereby improving patient care, reducing avoidable harm and improving the patient experience.

[A tool for the management of patients with pulmonary embolism]. / Un outil pour la prise en charge d'un patient atteint d'une embolie pulmonaire.

In order to develop materials for the validation of skills in the pulmonology intensive care unit, a steering committee on 'Learning situations' was created in the University Hospitals Paris-West (Hupo-AP-HP). A tool was developed based on knowledge and skills to be validated by students in the event of pulmonary embolism.

Improving rates of intermittent pneumatic compression therapy utilization.

BACKGROUND: The most preventable causes of death in the hospitalized patient are deep vein thrombosis (DVT) and pulmonary embolism. Despite the long-term (> 15 years) availability of evidence-based consensus guidelines for prevention of venous thromboembolism, thromboprophylaxis remains underused. Improving staff and patient utilization of prophylactic treatment for postoperative patients reduces hospital-acquired venous thromboembolism and improves patient outcomes. Anecdotal evidence and observations of intermittent pneumatic compression (IPC) therapy utilization at the authors' institution suggested that ordered IPC therapy was not consistently in use with postsurgical patients. OBJECTIVES: We sought to increase the use of IPC devices by all staff on our hospital pilot units and to promote sustained use of IPC devices. METHODS: Multiple methodologies were employed to address this issue, including point prevalence audits, root-cause analyses, a nursing survey, and a pilot project on selected surgical units. RESULTS: Statistically significant improvements on the pilot units were achieved by implementing a 3-tier interventional plan. CONCLUSION: Our pilot project demonstrated that nurse education, patient education, and nurse attention to solving systems issues can significantly improve IPC use in surgical patients.

Alteplase treatment of acute pulmonary embolism in the intensive care unit.

Acute pulmonary embolism accounts for 50 000 to 100 000 deaths each year in the United States. Because of the wide spectrum of clinical manifestations, ranging from massive pulmonary embolism to small peripheral emboli, stratifying and treating patients according to their signs and symptoms is important when an acute embolism is suspected. Patients' clinical findings can range from no signs or symptoms to unstable hemodynamic status and shock. The 3-month mortality is 10% to 15%, but can be as high as 60% in patients with hemodynamic shock. This article reviews the classifications of acute peripheral emboli, explains the treatment of acute peripheral emboli, reviews the pharmacology of alteplase, and presents an assessment of the literature evaluating alteplase for the treatment of acute peripheral emboli. Clinical pearls for the administration, monitoring, and care of a patient receiving alteplase in an intensive care unit also are discussed.

Prevention of venous thromboembolism in hospitalized patients: analysis of reduced cost and improved clinical outcomes.

The impact of implementing a guideline on venous thromboembolism (VTE) prophylaxis was evaluated in a metropolitan private hospital with a before- and after-intervention study. This subsequent study aimed to identify if improved prophylaxis rates translated into cost savings and improved clinical outcomes. A conceptual decision-tree analytical model incorporating local treatment algorithms and clinical trial data was used to compare prophylaxis costs and clinical outcomes before and after the guideline implementation. The study analyzed data from 21,942 medical and surgical patients admitted to a 250-bed acute-care private hospital in Sydney, Australia. The modeled simulation estimated the incidence of symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE) as well as adverse events such as heparin-induced thrombocytopenia (HIT), post-thrombotic syndrome (PTS), major bleeding, and mortality. The costs of prophylaxis therapy and treating adverse events were also calculated. The improvement in prophylaxis rates following the implementation of the guideline was estimated to result in 13 fewer deaths, 84 fewer symptomatic DVTs, 19 fewer symptomatic PEs, and 512 fewer hospital-bed days. Improved adherence to evidence-based prophylaxis regimens was associated with overall cost savings of $245,439 over 12 months. We conclude that improved adherence to evidence-based guidelines for VTE prophylaxis is achievable and is likely to result in fewer deaths, fewer VTE events, and a significant overall cost saving.

Awareness of patients who undergo cesarean section about venous thromboembolism prophylaxis.

Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is a potentially life-threatening condition and the most well-known cause of postpartum maternal death, especially in patients undergoing cesarean section (CS). The aim of this study was to evaluate the level of awareness of VTE among patients who undergo CS. This study was cross-sectional, involving 230 patients who underwent CS at a major university hospital. A validated standardized questionnaire was used to determine the awareness of VTE among CS patients. Approximately 46% of the patients were aware of DVT, and 18.7% were aware of PE. Most patients recognized obesity or immobility as risk factors of DVT, and 22.6% of them recognized CS as a risk factor for DVT. Only 25.4% recognized pregnancy as a risk factor for DVT. The level of patient knowledge about both DVT and PE were not affected by parity. The study showed that most patients who underwent CS were not aware of VTE as a complication of CS and the factors that may increase its risk, which could reflect inadequate patient counseling/education on the part of healthcare professionals.

Acute pulmonary embolism.

Over the next 5 days, Mr. R continues to respond well to treatment. He'll continue on the prescribed warfarin regimen, with scheduled follow-up to evaluate his condition and adjust the dosage if necessary. He's instructed to continue wearing his GCS as an outpatient. Mr. R and his wife are given individualized instructions to prepare Mr. R for discharge. Mr. and Mrs. R participate in a thorough review of safe anticoagulation management, including the importance of taking warfarin exactly as prescribed. They're taught strategies to avoid missing a dose, and Mr. R is instructed not to take more than the prescribed dose. They're taught to recognize signs and symptoms of lower extremity DVT such as pain, redness, swelling, and warmth. Signs and symptoms of PE are also reviewed, including sudden onset of difficulty breathing, rapid respiratory rate, and pleuritic chest pain. If any of these symptoms occur, Mr. and Mrs. R are instructed to call emergency medical services immediately. The importance of postdischarge follow-up appointments with Mr. R's PCP is emphasized. Mr. R is advised to avoid eating foods or using supplements high in vitamin K. Mr. R is also encouraged to stay active, but to use caution to prevent injuries and avoid falls by engaging in activities such as walking and, when approved, swimming.

Baccalaureate education in nursing and patient outcomes.

OBJECTIVES: The aim of this study was to examine the effects of registered nurse (RN) education by determining whether nurse-sensitive patient outcomes were better in hospitals with a higher proportion of RNs with baccalaureate degrees. BACKGROUND: The Future of Nursing report recommends increasing the percentage of RNs with baccalaureate degrees from 50% to 80% by 2020. Research has linked RN education levels to hospital mortality rates but not with other nurse-sensitive outcomes. METHODS: This was a cross-sectional study that, with the use of data from 21 University HealthSystem Consortium hospitals, analyzed the association between RN education and patient outcomes (risk-adjusted patient safety and quality of care indicators), controlling for nurse staffing and hospital characteristics. RESULTS: Hospitals with a higher percentage of RNs with baccalaureate or higher degrees had lower congestive heart failure mortality, decubitus ulcers, failure to rescue, and postoperative deep vein thrombosis or pulmonary embolism and shorter length of stay. CONCLUSION: The recommendation of the Future of Nursing report to increase RN education levels is supported by these findings.

What NPs need to know about anticoagulation therapy.

Venous thromboembolism (VTE) refers to pulmonary embolism and deep venous thrombosis. Anticoagulation is the cornerstone of management for patients with VTE. This review will discuss current anticoagulation guidelines.

Acute pulmonary embolism.

Venous thromboembolism is the third leading cause of cardiovascular death in the United States and is the second leading cause of death among hospitalized cancer patients. Continued controversy exists regarding the role of thrombolytic therapy among patients with acute pulmonary embolism. Limited research exists on thrombolytic therapy in this setting, most of which has focused on symptoms, including right ventricular function, hemodynamic status, and electrocardiographic changes. However, these studies have excluded patients with a known malignancy. Presented is an interesting case of a patient, in remission from breast cancer, who presented to the emergency department with symptomatic pulmonary emboli. The presentation, medical management, and consequences of the treatment have been discussed. Also, a brief review of the literature is presented regarding the treatment of acute pulmonary embolism.