Evaluation of surrogacy in the multi-trial setting based on information theory: an extension to ordinal outcomes.

In clinical trials, surrogate outcomes are early measures of treatment effect that are used to predict treatment effect on a later primary outcome of interest: the primary outcome therefore does not need to be observed and trials can be shortened. Evaluating surrogates is a complex area as a given treatment can act through multiple pathways, some of which may circumvent the surrogate. One of the best established and practically sound approaches to surrogacy evaluation is based on information theory. We have extended this approach to the case of ordinal outcomes, which are used as primary outcomes in many medical areas. This extension provides researchers with the means of evaluating surrogates in this setting, which expands the usefulness of the information theory approach while also demonstrating its versatility.

Multicenter Review of Current Practices Associated With Venous Thromboembolism Prophylaxis in Pediatric Patients After Trauma.

OBJECTIVES: Frequency of venous thromboembolism in pediatric trauma patients admitted to PICUs is not insignificant, ranging up to 6%. Risk factors have been identified in this population. However, there is little consensus of actual venous thromboembolism prophylaxis practice. We examined factors associated with venous thromboembolism prophylaxis in PICUs. DESIGN: A retrospective study evaluating associations with mechanical venous thromboembolism prophylaxis, pharmacologic venous thromboembolism prophylaxis, or dual therapy (DUAL) prophylaxis compared with no venous thromboembolism prophylaxis. Multivariable logistic regression explored the relationship between prophylaxis type and selected covariates with stepwise selection method to identify the independent predictors of venous thromboembolism prophylaxis utilization. SETTING: Five level I/II pediatric trauma centers in the United States. PATIENTS: Children less than 18 years from January 1, 2013, to December 31, 2013, admitted to the PICU after a trauma, identified through combined trauma registry and Virtual Pediatric Systems database. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Six hundred ninety-two patients were included in the database, with 55 excluded for missing data. Of the remaining 637 patients, 538 (84.5%) had no venous thromboembolism prophylaxis by 48 hours, 77 (12.1%) had only mechanical venous thromboembolism prophylaxis, 11 (1.7%) had DUAL, and 11 (1.7%) had pharmacologic venous thromboembolism prophylaxis alone. Multivariable analysis showed increased age, and orthopedic procedure was associated with all forms of prophylaxis. Orthopedic procedures were associated with higher utilization of dual prophylaxis use (odds ratio, 5.2; 95% CI, 1.2-21.8), pharmacologic venous thromboembolism prophylaxis (odds ratio, 8.5; 95% CI, 2.3-31.7), and mechanical venous thromboembolism prophylaxis (odds ratio, 2.2; 95% CI, 1.1-4.2) alone. Brain/spinal cord procedures (odds ratio, 3.7; 95% CI, 1.9-7.3) and abdominal procedures (odds ratio, 6.6; 95% CI, 2.5-17.1) were associated with mechanical venous thromboembolism prophylaxis. Head injury was associated with a decreased use of any prophylaxis (odds ratio, 0.5; 95% CI, 0.3-0.9). Patient comorbidities were associated with decreased use of mechanical venous thromboembolism prophylaxis (odds ratio, 0.5; 95% CI, 0.3-1.0). CONCLUSIONS: Pharmacologic venous thromboembolism prophylaxis is not common in critically ill children after trauma. Patient age, orthopedic and vascular procedures, and higher injury severity are associated with pharmacologic venous thromboembolism prophylaxis.

Postpartum Thromboembolism Prophylaxis during Delivery Hospitalizations.

OBJECTIVE: This article evaluates trends in venous thromboembolism (VTE) prophylaxis during delivery hospitalizations in the United States. METHODS: We utilized an administrative database to determine if women hospitalized for vaginal or cesarean delivery received pharmacologic VTE prophylaxis, mechanical VTE prophylaxis, or both from January 2011 through March 2015. Mechanical prophylaxis included sequential compression devices, graduated compression stockings, and other pneumatic devices. Pharmacologic prophylaxis included unfractionated heparin, low molecular weight heparin, or fondaparinux. Probability of use of thromboprophylaxis for individual hospitals was estimated in an adjusted model. RESULTS: A total of 956,428 women who underwent cesarean and 1,914,142 women who underwent vaginal delivery were included in the analysis. Cesarean VTE prophylaxis declined between 2011 (50.3%) and 2015 (47.7%; p < 0.01). Of women undergoing vaginal delivery, 2.9% received prophylaxis. Delivery hospital was an important determinant of cesarean prophylaxis: in the adjusted model, one-third of hospitals used prophylaxis for less than 20% of deliveries, one-third of hospitals used prophylaxis for 20 to 80% of deliveries, and the final third of hospitals used prophylaxis in greater than 80% of deliveries. CONCLUSION: While many hospitals appear to be following best clinical practices, some do not provide routine cesarean VTE prophylaxis. Minimizing care quality variation may improve maternal safety.

What Factors Influence Compliance With Sequential Compression Devices in an Orthopaedic Unit: A Quality Assurance Observational Study.

The purpose of this study was to determine the compliance rate with sequential suppression devices (SCDs) of patients admitted to an orthopaedic unit of a level I trauma center. A quality assurance observational study was conducted over a 4-week period (June/July 2015). Three observations were performed per 24-hour period (0700, 1300, 1900 hours). ``Full SCD compliance'' was defined as the SCD ordered, on and functioning properly at the time of observation. Of the 1356 observations in 109 patients, 434 (32%) were fully compliant with SCD prophylaxis. SCD compliance in trauma patients was higher (21%) as compared with elective surgical patients (10%) (p < .0001). Morning observations had the highest compliance rate (38.3%), whereas the afternoon (23.5%) and evening observations (33.1%) had less compliance rates (p < .0001). There was a significantly higher compliance rate on weekdays (33.9%) as compared with weekends (28%) (p < .03). The overall low compliance level (32%) indicates compliance challenges and not the modality of the prophylaxis as the cause (Journal of Surgical Orthopaedic Advances 27(4):307-311, 2018).

Effect of Intermittent Pneumatic Compression on Preventing Deep Vein Thrombosis Among Stroke Patients: A Systematic Review and Meta-Analysis.

BACKGROUND: Deep vein thrombosis (DVT) and subsequent pulmonary embolism (PE) are common complications of stroke. However, the effect of intermittent pneumatic compression (IPC) for patients after stroke is uncertain. OBJECTIVES: To assess the effectiveness and safety of IPC in reducing the risk of DVT, PE, and mortality in stroke patients. METHODS: We searched leading medical databases including Medline, EMBASE, Cochrane Library, Wanfang, CNKI, and CBM, from inception to June 2, 2017. Studies comparing IPC with no IPC in stroke patients were included. Agreement was measured using simple agreement and kappa statistics. The rates of PE, DVT, and mortality were compared. The results were pooled using a fixed effects model to evaluate the differences between the IPC and control groups. If there was significant heterogeneity in the pooled result, a random effect model was used. RESULTS: We identified seven randomized controlled trials that included 3,551 stroke patients. The average calculated κ for the various parameters was κ = 0.96 (0.70-1). Overall, IPC significantly reduced the incidence of DVT in stroke patients (risk ratio [RR] = 0.50; 95% confidence interval [CI 0.27, 0.94]). At the same time, IPC increased IPC-related adverse events (RR = 5.71; 95% CI [3.40, 9.58]). Though IPC was associated with a significant increase in survival by 4.5 days during 6 months of follow-up (148-152 days; 95% CI [-0.2, 9.1]), there was a mean gain of only 0.9 days (26.7-27.6 days; 95% CI [2.1, 3.9]) in quality-adjusted survival during the 6-month follow-up. Overall, sensitivity analyses did not alter these findings. LINKING EVIDENCE TO ACTION: This review provides an important basis for preventing DVT in stroke patients, especially in hemorrhagic stroke patients. IPC significantly reduces the risk of DVT and significantly improves survival in a wide variety of patients who are immobile after stroke. However, IPC does not significantly improve quality-adjusted survival. Clinicians should take functional status and quality of life into consideration when making decisions for stroke patients.

Intermittent pneumatic compression in combination with low-molecular weight heparin in the prevention of venous thromboembolic events in esophageal cancer surgery.

INTRODUCTION: Aim of this study was to evaluate the use of Intermittent Pneumatic Compression (IPC) in the prevention of symptomatic venous thromboembolic events (VTE) in patients undergoing esophagectomy for cancer. METHODS: From a prospective database, all patients operated between 2010 and 2014 received IPC in addition to LMWH and were compared to a historical cohort of patients treated LMWH only (2004-2009). RESULTS: Of the 313 included patients, 195 (62%) received IPC. Patients with IPC received neoadjuvant chemoradiation more often (45% vs. 3%, P < 0.001), whereas, neoadjuvant chemotherapy was equally distributed (31% vs. 34%, P = 0.631). There were no differences with regard to surgical approach, operative time, blood loss, and ICU stay. Patients treated without IPC had a longer hospital stay (18 vs. 15 days, P = 0.014). Overall, 12 clinical VTE's occurred in 11 patients, which consisted of two deep venous thromboses and 10 pulmonary embolisms. In the group of patients, who received IPC 1.5% developed a symptomatic VTE compared to 6.8% in patients without IPC (OR = 0.215; 95% CI = 0.06-0.83). Multivariate analysis identified IPC as the only independent prognostic factor correlated with a reduction in postoperative VTE's (OR = 0.225; 95% CI = 0.06-0.88). CONCLUSION: The addition of IPC in patients undergoing esophagectomy for cancer was associated with a reduction in symptomatic VTE's. J. Surg. Oncol. 2017;115:181-185. © 2017 Wiley Periodicals, Inc.

Mechanical Prophylaxis after Lower Extremity Total Joint Arthroplasty: A Review.

Venous thromboembolism (VTE) is a serious complication that can occur after total hip and knee arthroplasty, and can potentially lead to significant morbidity and even mortality. While various modalities have been used to prevent VTE development, the medications can be associated with a number of adverse events. Therefore, mechanical prophylaxis with pumps and compressive devices has been used more frequently alone, or in combination, with medications. Therefore, the purpose of this study was to review the current literature on mechanical prophylaxis for VTEs after lower extremity total joint arthroplasty. Specifically, we reviewed mechanical prophylaxis after: 1) total hip arthroplasty and 2) total knee arthroplasty.

The Use of Intermittent Pneumatic Compression in Orthopedic and Neurosurgical Postoperative Patients: A Systematic Review and Meta-analysis.

OBJECTIVE: The objective of this systematic review and meta-analysis was to carry out an up-to-date evaluation on the use of compression devices as deep vein thrombosis (DVT) prophylaxis methods in orthopedic and neurological patients. SUMMARY OF BACKGROUND DATA: There is an increased risk of DVT with surgery, particularly in patients who are not expected to mobilize soon after their procedures, such as orthopedic and neurosurgical patients. Compression devices are often employed for DVT prophylaxis in these patients. However, the true efficacy of these devices and the standardization of use with these devices are yet to be established. METHODS: Medline, CINAHL, Embase, Google Scholar, and the Cochrane library electronic databases were searched to identify randomized controlled trials and observational studies reporting on the use of compression devices for DVT prevention. RESULTS: Nine studies were included for review and meta-analysis. Use of an intermittent pneumatic compression device alone is neither superior nor inferior to chemoprophylaxis. CONCLUSIONS: In the absence of large randomized multicenter trials comparing the use of intermittent pneumatic compression or chemoprophylaxis alone to a combination of both treatments, the current evidence supports the use of a combined approach in high-risk surgical patients.

Development of a Novel Composite Process Measure for Venous Thromboembolism Prophylaxis.

BACKGROUND: Postoperative venous thromboembolism (VTE) is important clinically, and VTE quality metrics are used in public reporting and pay-for-performance programs. However, current VTE outcome measures are not valid due to surveillance bias, and the Surgical Care Improvement Project (SCIP-VTE-2) process measure only requires prophylaxis within 24 hours of surgery. OBJECTIVES: We sought to (1) develop a novel measure of VTE prophylaxis that requires early ambulation, mechanical prophylaxis, and chemoprophylaxis throughout the hospitalization, and (2) compare hospital performance on the SCIP-VTE-2 process measure to this novel measure. RESEARCH DESIGN: A new composite measure of ambulation, sequential compression device (SCD), and chemoprophylaxis component measures was developed. The ambulation component required daily ambulation, the SCD component required documentation of continuous use, and the chemoprophylaxis component required patient-appropriate and medication-appropriate dosing and administration. Requirements could also be met with component-specific exceptions. Surgical patients at an academic center from 2012 to 2013 were assessed for SCIP-VTE-2 and composite measure adherence. RESULTS: Of 786 patients, 589 (74.9%) passed the ambulation measure, 494 (62.8%) passed the SCD measure, and 678 (86.3%) passed the chemoprophylaxis measure. A total of 268 (91.8%) SCD failures and 46 (42.6%) chemoprophylaxis failures were ordered but not administered. When comparing the 2 measures, 784 (99.7%) passed SCIP-VTE-2, whereas only 364 (46.3%) passed the composite measure (P<0.001). CONCLUSIONS: This new measure incorporates the critical aspects of VTE prevention to ensure defect-free care. After additional evaluation, this composite VTE prophylaxis measure with appropriate exclusion criteria may be a better alternative to existing VTE process and outcome measures.

Venous thromboembolism prophylaxis during and following caesarean section: a survey of clinical practice.

BACKGROUND: Caesarean section (CS) is a significant risk factor for venous thromboembolism; however, the optimal method of thromboprophylaxis around the time of CS is unknown. AIMS: To examine current thromboprophylaxis practice during and following CS in Australia and New Zealand, and the willingness of obstetricians to participate in a randomised controlled trial (RCT) comparing different methods of thromboprophylaxis after CS. MATERIALS AND METHODS: An online survey was sent to fellows and trainees of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. RESULTS: There were 488 responses from currently practising obstetricians (response rate 23.4%). During CS, 48% and 80% of obstetricians recommended intermittent pneumatic compression (IPC) and elastic stockings (ES), respectively. Following CS, 96-97% of obstetricians recommended early ambulation, 87-90% recommended ES, 23-36% recommended IPC, and 42-65% recommended low molecular weight heparin (LMWH) depending on clinical factors. Increased BMI (OR 3.42; 95% CI 2.87-4.06), emergency CS (OR 1.88; 95% CI 1.67-2.16) and older maternal age (OR 1.37; 95% CI 1.26-1.49) were associated with more frequent LMWH use. Of obstetricians who prescribed LMWH, 70% adjusted the dose depending on maternal weight. LMWH therapy was most commonly recommended until discharge from hospital (31%), <5 days (24%) and 5-7 days (15%). Most obstetricians (58-79%) were willing to enrol women in a RCT, but less likely if the woman had an increased BMI or emergency CS. CONCLUSIONS: There is considerable variation in clinical practice regarding thromboprophylaxis during and following CS. Obstetricians support a RCT to assess different methods of thromboprophylaxis following CS.

Compression therapy - current practice of care: level of knowledge in patients with venous leg ulcers.

BACKGROUND AND OBJECTIVES: Compression therapy is a mainstay in the causal treatment of patients with venous leg ulcers. It facilitates healing, reduces pain and recurrences, and increases quality of life. Up until now, there is a scarcity of scientific data with respect to the level of care and the specific knowledge of patients with venous leg ulcers. PATIENTS AND METHODS: At first presentation, patients with venous leg ulcers anonymously answered a standardized questionnaire. Participating facilities nationwide included 55 outpatient care services, 32 medical practices, four wound centers, and one specialized care center. RESULTS: Overall, 177 patients (mean age of 69.4; 75.1 % women) participated in the study. The average duration of florid venous leg ulcers was 17 months. With regard to compression therapy, 31.1 % of patients received none; 40.1 % used bandages; 28.8 % used stockings. Of the latter, 13.7 % were treated with compression class III; 67.4 %, with compression class II; and 19.6 %; with compression class I. While 70.6 % put on their stockings after getting out of bed in the morning, 21.1 % wore them day and night. In 39.2 % of individuals, the stockings caused them discomfort. Merely 11.7 % owned a donning device. On average, bandages were worn for 40.7 weeks, and 69 % were used without underpadding. In 2.8 % of patients, ankle and calf circumference was measured to monitor therapeutic success. 45.9 % reported doing leg exercises. CONCLUSIONS: Although it is considered a basic therapeutic measure in venous leg ulcers, one-third of all patients received no compression treatment. Moreover, given the long duration of ulcers, adequate product selection and correct use have to be questioned, too. Our findings indicate that improvements in the level of knowledge among users and prescribers as well as patient training are required.

Venous thromboembolism after lower limb arthroplasty: is chemical prophylaxis still needed?

BACKGROUND: Venous thromboembolism (VTE) is a significant complication of lower limb arthroplasty. The National Institute for Health and Care Excellence recommends routine use of chemical and mechanical prophylaxis to prevent VTE. Our high-volume, elective, arthroplasty unit adopted this guidance in 2008. PURPOSE: We examined our incidence of VTE before and after introduction of chemical thromboprophylaxis to determine whether the incidence of VTE reduced. METHODS: We retrospectively gathered data on 2 cohorts of patients-from January 2004 to August 2007 (Group 1) and January 2010 to December 2012 (Group 2). Patients in Group 1 received mechanical prophylaxis only (unless particularly high risk for VTE), and patients in Group 2 received mechanical and chemical prophylaxis. We recorded VTE occurring within 6 months of surgery. Patients in Group 1 receiving chemical prophylaxis were excluded. RESULTS: Group 1 had 2320 cases of primary and revision lower limb arthroplasty, and Group 2 had 1430 cases. VTE occurred in 37 cases in Group 1 (1.6 %), and in 17 cases in Group 2 (1.2 %). This difference was not statistically significant (p = 0.26). In Group 1, 1 patient died within 6 months due to pulmonary embolism (0.04 %); there were no VTE-related deaths in Group 2 (0 %). This was also not statistically significant (p = 0.06). CONCLUSIONS: Although our VTE rate reduced by 0.4 % and our VTE-related mortality reduced by 0.04 % after introduction of chemical thromboprophylaxis, these differences were not statistically significant. Chemical thromboprophylaxis may not be required in all patients undergoing arthroplasty providing appropriate mechanical prophylaxis is used.

Thromboembolism incidence and prophylaxis during vaginal delivery hospitalizations.

OBJECTIVE: Although major international guidelines recommend venous thromboembolism (VTE) prophylaxis during vaginal delivery hospitalization for women with additional risk factors, US guidelines recommend prophylaxis for a very small number of women who are at particularly high risk for an event. The purpose of this study was to characterize practice patterns of VTE prophylaxis in the United States during vaginal delivery hospitalizations and to determine VTE incidence in this population. STUDY DESIGN: A population-level database was used to analyze VTE incidence and use of VTE prophylaxis during vaginal delivery hospitalizations in the United States between 2006 and 2012 (n = 2,673,986). We evaluated whether patients received either pharmacologic or mechanical prophylaxis. Hospital-level factors and patient characteristics were included in multivariable regression analysis that evaluated prophylaxis administration. RESULTS: We identified 2,673,986 women who underwent vaginal delivery. Incidence of VTE increased during the study period from 15.6-29.8 events per 100,000 delivery hospitalizations. Within the cohort, 2.6% of patients (n = 68,835) received VTE prophylaxis. Pharmacologic prophylaxis was rare; <1% of women received unfractionated or low-molecular-weight heparin. Although patients with thrombophilia or a previous VTE event were likely to receive prophylaxis (60.8% and 72.8%, respectively), patients with risk factors for VTE such as obesity, smoking, and heart disease were unlikely to receive prophylaxis (rates of 5.9%, 3.3%, and 6.2%, respectively). CONCLUSION: Our findings demonstrate that the administration of VTE prophylaxis outside a small group of women at extremely high risk for VTE is rare during vaginal delivery hospitalization. Given that VTE incidence is rising in this population, further research to determine whether broadening prophylaxis for VTE may reduce severe maternal morbidity and death is indicated.

Sequential compression devices in postoperative urologic patients: an observational trial and survey study on the influence of patient and hospital factors on compliance.

BACKGROUND: Sequential compression devices (SCDs) are commonly used for thromboprophylaxis in postoperative patients but compliance is often poor. We investigated causes for noncompliance, examining both hospital and patient related factors. METHODS: 100 patients undergoing inpatient urologic surgery were enrolled. All patient had SCD sleeves placed preoperatively. Postoperative observations determined SCD compliance and reasons for non-compliance. Patient demographics, length of stay, inpatient unit type, and surgery type were recorded. At discharge, a patient survey gauged knowledge and attitudes regarding SCDs and bother with SCDs. Statistical analysis was performed to correlate SCD compliance with patient demographics; patient knowledge and attitudes regarding SCDs; and patient self-reported bother with SCDs. RESULTS: Observed overall compliance was 78.6%. The most commonly observed reasons for non-compliance were SCD machines not being initially available on the ward (71% of non-compliant observations on post-operative day 1) and SCD use not being restarted promptly after return to bed (50% of non-compliant observations for entire hospital stay). Mean self-reported bother scores related to SCDs were low, ranging from 1-3 out of 10 for all 12 categories of bother assessed. Patient demographics, knowledge, attitudes and bother with SCD devices were not significantly associated with non-compliance. CONCLUSIONS: Patient self-reported bother with SCD devices was low. Hospital factors, including SCD machine availability and timely restarting of devices by nursing staff when a patient returns to bed, played a greater role in SCD non-compliance than patient factors. Identifying and addressing hospital related causes for poor SCD compliance may improve postoperative urologic patient safety.

A randomized controlled trial comparing two types of pneumatic compression for breast cancer-related lymphedema treatment in the home.

PURPOSE: Pneumatic compression devices (PCDs) are used in the home setting as adjunctive treatment for lymphedema after acute treatment in a clinical setting. PCDs range in complexity from simple to technologically advanced. The objective of this prospective, randomized study was to determine whether an advanced PCD (APCD) provides better outcomes as measured by arm edema and tissue water reductions compared to a standard PCD (SPCD) in patients with arm lymphedema after breast cancer treatment. METHODS: Subjects were randomized to an APCD (Flexitouch system, HCPCS E0652) or SPCD (Bio Compression 2004, HCPCS E0651) used for home treatment 1 h/day for 12 weeks. Pressure settings were 30 mmHg for the SPCD and upper extremity treatment program (UE01) with standard pressure for the APCD. Thirty-six subjects (18 per group) with unilateral upper extremity lymphedema with at least 5% arm edema volume at the time of enrollment, completed treatments over the 12-week period. Arm volumes were determined from arm girth measurements and suitable model calculations, and tissue water was determined based on measurements of the arm tissue dielectric constant (TDC). RESULTS: The APCD-treated group experienced an average of 29% reduction in edema compared to a 16% increase in the SPCD group. Mean changes in TDC values were a 5.8% reduction for the APCD group and a 1.9% increase for the SPCD group. CONCLUSION: This study suggests that for the home maintenance phase of treatment of arm lymphedema secondary to breast cancer therapy, the adjuvant treatment with an APCD provides better outcomes than with a SPCD.

Venous thromboembolism prophylaxis in surgical patients: identifying a patient group to maximize performance improvement.

BACKGROUND: Venous thromboembolism (VTE) in surgical patients is a cause of increased morbidity, mortality, and cost of care. Deep vein thrombosis (DVT) prophylaxis reduces the risk of DVT or pulmonary embolism (PE), but not to zero, which is concerning because DVT/PE is being considered a serious reportable event. A study was conducted in January-June 2009 to test the hypothesis that most surgical VTEs occur despite the patient's receiving appropriate prophylaxis. METHODS: All patients with a surgical diagnosis-related group (DRG) who had a documented DVT/PE in 2008 were retrospectively reviewed. Each VTE episode was characterized as occurring during the index admission for surgery or being present on admission (POA). DVT prophylaxis compliance was measured in all patients who had a procedure at the institution, a 454-bed university teaching hospital, and those patients were classified in terms of compliance with our VTE protocols. Class 1 patients had VTE protocols followed; Class 2 patients had contraindications to VTE protocols documented; Class 3 patients should have received VTE prophylaxis but did not; and Class 4 patients had contraindications to VTE prophylaxis that were not documented. RESULTS: Some 156 (6.3%) of 2,474 surgical patients had a DVT/PE in 2008; for the 144 patients with complete records for review, 89 were candidates for VTE prophylaxis. Some 77 of the 89 patients had received appropriate VTE prophylaxis or had documented contraindications to prophylaxis. Eleven (12.4%) patients who should have received VTE prophylaxis did not. CONCLUSIONS: Compliance with VTE protocols continues to be less than 100%, and even when patients adhere to existing protocols VTE events continue to occur.

Prevention of thromboembolic events in surgical patients through the creation and implementation of a computerized risk assessment program.

OBJECTIVES: Deep vein thrombosis (DVT) is a major source of postoperative morbidity and mortality and is currently a major quality improvement initiative. Mechanical and pharmacological prophylaxis is effective in preventing postoperative thromboembolic events, yet it remains underutilized in the clinical setting. Thus, the objective of this study was to develop and implement a computerized DVT risk assessment program in the electronic medical record and determine its effect on compliance with DVT prophylaxis guidelines. METHODS: A standardized DVT risk assessment program was developed and incorporated into the Computerized Patient Record System for all surgical patients at the Jesse Brown Veterans Affairs Medical Center. Four hundred consecutive surgical patients before and after implementation were evaluated for DVT risk, the prescription of pharmacological and mechanical DVT prophylaxis, and the development of thromboembolic events. RESULTS: With implementation of the DVT risk assessment program, the number of patients receiving the recommended pharmacological prophylaxis preoperatively more than doubled (14% to 36%) (P < .001), and use of sequential compression devices (SCD) increased 40% (P < .001). Overall, the percentage of at-risk patients receiving the recommended combined DVT prophylaxis of SCD and pharmacological prophylaxis increased nearly seven-fold (5% to 32%) (P < .001). The assessment also improved use of prophylaxis postoperatively, increasing SCD use by 27% (P < .001). With respect to DVT occurrence, there was an 80% decrease in the incidence of postoperative DVT at 30 days and a 36% decrease at 90 days; however, this did not reach statistical significance due to the low event rate. CONCLUSIONS: The creation and implementation of a standardized DVT risk assessment program in the electronic medical record significantly increased use of pharmacological and mechanical DVT prophylaxis before surgery in a Veterans Affairs Medical Center setting.

Compliance with a perinatal prophylaxis policy for prevention of venous thromboembolism after caesarean section.

OBJECTIVE: To assess physician compliance, before and after a quality improvement intervention, with a regional policy on postpartum thromboprophylaxis following Caesarean section (CS), and to compare clinical outcomes (reduction of venous thromboembolism or increase in postpartum bleeding) between groups. METHODS: We performed a retrospective chart review of deliveries by CS, 404 prior to and 451 subsequent to a quality improvement intervention. All subjects were classified as being at either moderate or high risk for venous thromboembolism based on a risk-factor assessment, and warranted postpartum thromboprophylaxis according to the regional policy. Data regarding thromboembolism risk factors, postpartum thromboprophylaxis received, and clinical outcomes were recorded. RESULTS: Initial compliance with the regional policy was poor, but improved following the intervention. The use of intermittent pneumatic compression devices increased from 32% to 84% (P < 0.001), use of anticoagulation increased from 6.2% to 46% (P < 0.001), and full compliance with the policy increased from 1.7% to 30% (P < 0.001). Clinical outcomes were not significantly different between the groups. CONCLUSION: A quality improvement intervention markedly increased physician compliance with a regional policy on postpartum thromboprophylaxis among women at moderate to high risk of venous thromboembolism after CS. Adverse clinical outcomes were infrequent in this small study population.

"Keep Calm and Stop the Clot".

The impact of a nurse-driven change project.