Effectiveness of Healthcare Delivery, Quality, and Safety a Patient Education Bundle on Venous Thromboembolism Prophylaxis Administration by Sex.

INTRODUCTION: Venous thromboembolism (VTE) is a frequent cause of preventable harm among hospitalized patients. Many prescribed prophylaxis doses are not administered despite supporting evidence. We previously demonstrated a patient-centered education bundle improved VTE prophylaxis administration broadly; however, patient-specific factors driving nonadministration are unclear. We examine the effects of the education bundle on missed doses of VTE prophylaxis by sex. METHODS: We performed a post-hoc analysis of a nonrandomized controlled trial to evaluate the differences in missed doses by sex. Pre-intervention and intervention periods for patients admitted to 16 surgical and medical floors between 10/2014-03/2015 (pre-intervention) and 04/2015-12/2015 (intervention) were compared. We examined the conditional odds of (1) overall missed doses, (2) missed doses due to patient refusal, and (3) missed doses for other reasons. RESULTS: Overall, 16,865 patients were included (pre-intervention 6853, intervention 10,012), with 2350 male and 2460 female patients (intervention), and 6373 male and 5682 female patients (control). Any missed dose significantly reduced on the intervention floors among male (odds ratio OR 0.55; 95% confidence interval CI, 0.44-0.70, P < 0.001) and female (OR 0.59; 95% CI, 0.47-0.73, P < 0.001) patients. Similar significant reductions ensued for missed doses due to patient refusal (P < 0.001). Overall, there were no sex-specific differences (P-interaction >0.05). CONCLUSIONS: Our intervention increased VTE prophylaxis administration for both female and male patients, driven by decreased patient refusal. Patient education should be applicable to a wide range of patient demographics representative of the target group. To improve future interventions, quality improvement efforts should be evaluated based on patient demographics and drivers of differences in care.

Hypertension, overweight/obesity, and diabetes among immigrants in the United States: an analysis of the 2010-2016 National Health Interview Survey.

BACKGROUND: Ethnic minority populations in the United States (US) are disproportionately affected by cardiovascular disease (CVD) risk factors, including hypertension, overweight/obesity, and diabetes. The size and diversity of ethnic minority immigrant populations in the US have increased substantially over the past three decades. However, most studies on immigrants in the US are limited to Asians and Hispanics; only a few have examined the prevalence of CVD risk factors across diverse immigrant populations. The prevalence of diagnosed hypertension, overweight/obesity, and diagnosed diabetes was examined and contrasted among a socioeconomically diverse sample of immigrants. It was hypothesized that considerable variability would exist in the prevalence of hypertension, overweight and diabetes. METHODS: A cross-sectional analysis of the 2010-2016 National Health Interview Survey (NHIS) was conducted among 41,717 immigrants born in Europe, South America, Mexico/Central America/Caribbean, Russia, Africa, Middle East, Indian subcontinent, Asia and Southeast Asia. The outcomes were the prevalence of diagnosed hypertension, overweight/obesity, and diagnosed diabetes. RESULTS: The highest multivariable adjusted prevalence of diagnosed hypertension was observed in Russian (24.2%) and Southeast Asian immigrants (23.5%). Immigrants from Mexico/Central America/Caribbean and the Indian subcontinent had the highest prevalence of overweight/obesity (71.5 and 73.4%, respectively) and diagnosed diabetes (9.6 and 10.1%, respectively). Compared to European immigrants, immigrants from Mexico/Central America/Caribbean and the Indian subcontinent respectively had higher prevalence of overweight/obesity (Prevalence Ratio (PR): 1.19[95% CI, 1.13-1.24]) and (PR: 1.22[95% CI, 1.14-1.29]), and diabetes (PR: 1.70[95% CI, 1.42-2.03]) and (PR: 1.78[95% CI, 1.36-2.32]). African immigrants and Middle Eastern immigrants had a higher prevalence of diabetes (PR: 1.41[95% CI, 1.01-1.96]) and PR: 1.57(95% CI: 1.09-2.25), respectively, than European immigrants -without a corresponding higher prevalence of overweight/obesity. CONCLUSIONS: Immigrants from Mexico/Central America/Caribbean and the Indian subcontinent bore the highest burden of overweight/obesity and diabetes while those from Southeast Asia and Russia bore the highest burden of hypertension.

Characterizing the relationship between age and venous thromboembolism in adult trauma patients: findings from the National Trauma Data Bank and the National Inpatient Sample.

BACKGROUND: Venous thromboembolism (VTE) is a tremendous burden in health care. However, current guidelines lack recommendations regarding the prevention of VTE in older adult trauma patients. Furthermore, the appropriate method of modeling of age in VTE models is currently unclear. METHODS: Patients included in the National Trauma Data Bank (NTDB) between the years 2008 and 2014 and patients included in the National Inpatient Sample (NIS) between 2009 and 2013 were analyzed. Multiple logistic regression of VTE on age was performed. RESULTS: Of 3,598,881 patients in the NTDB, 34,202 (1.0%) were diagnosed with VTE compared to 5405 (1.1%) of the 505,231 patients in NIS. In both the fully adjusted NTDB and NIS model, age was positively associated with odds of VTE diagnosis under 65 years (NTDB, adjusted odds ratio [aOR]: 1.018, 95% confidence interval [CI]: 1.017-1.019, P < 0.001; NIS, aOR: 1.025, 95% CI 1.022-1.027, P < 0.001). In patients aged ≥65 years, age was negatively associated with odds of VTE diagnosis in the NTDB (aOR: 0.995, 95% CI: 0.992-0.999, P = 0.006) but not in the NIS (aOR: 0.998, 95% CI 0.994-1.002, P = 0.26). CONCLUSIONS: Incidence of VTE among adult trauma patients steadily increases with age until 65 years, after which the odds of VTE appear to level off or even slightly decrease. These findings should be applied for improved modeling of VTE in trauma patients. The mechanism behind these findings should be explored before using them to update guidelines for standardized VTE prevention in older adults.

Effectiveness of Prevention Strategies for Contrast-Induced Nephropathy: A Systematic Review and Meta-analysis.

BACKGROUND: N-acetylcysteine, sodium bicarbonate, statins, and ascorbic acid have been studied for reducing contrast-induced nephropathy (CIN). PURPOSE: To evaluate the comparative effectiveness of interventions to reduce CIN in adults receiving contrast media. DATA SOURCES: MEDLINE, EMBASE, Cochrane Library, ClinicalTrials.gov, and Scopus databases through June 2015. Risk of bias and overall strength of evidence (SOE) of studies were assessed. STUDY SELECTION: Randomized, controlled trials of N-acetylcysteine, sodium bicarbonate, statins, or ascorbic acid that used intravenous (IV) or intra-arterial contrast media and defined CIN with enough data for meta-analysis. DATA EXTRACTION: Two reviewers independently extracted data and assessed study quality. DATA SYNTHESIS: Low-dose N-acetylcysteine plus IV saline compared with IV saline (risk ratio [RR], 0.75 [95% CI, 0.63 to 0.89]; low SOE), N-acetylcysteine plus IV saline compared with IV saline in patients receiving low-osmolar contrast media (RR, 0.69 [CI, 0.58 to 0.84]; moderate SOE), and statins plus N-acetylcysteine plus IV saline versus N-acetylcysteine plus IV saline (RR, 0.52 [CI, 0.29 to 0.93]; low SOE) had clinically important and statistically significant benefits. The following 3 comparisons suggested a clinically important difference that was not statistically significant: sodium bicarbonate versus IV saline in patients receiving low-osmolar contrast media (RR, 0.65 [CI, 0.33 to 1.25]; low SOE), statins plus IV saline versus IV saline (RR, 0.68 [CI, 0.39 to 1.20]; low SOE), and ascorbic acid versus IV saline (RR, 0.72 [CI, 0.48 to 1.01]; low SOE). Strength of evidence was generally insufficient for comparisons of the need for renal replacement, cardiac events, and mortality. LIMITATION: Too few studies were done in patients receiving IV contrast media. CONCLUSION: The greatest reduction in CIN was seen with N-acetylcysteine plus IV saline in patients receiving LOCM and with statins plus N-acetylcysteine plus IV saline. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

The Impact of Obesity on Early Complications Following Tracheostomy: An Evaluation of a Nationwide Registry.

INTRODUCTION: The obesity epidemic is an important public health problem in the United States. Previous studies have revealed the association between obesity and various surgical complications. Tracheostomy which is an important lifesaving procedure may prove technically challenging in an obese patient. This study sought to evaluate the association between obesity and early complications following standard tracheostomy using a national registry. METHODS: Adult patients who underwent tracheostomy from 2007 to 2017 were analyzed using the Nationwide Inpatient Sample (NIS). The population was stratified into obese and non-obese groups. Early complications following standard tracheostomy were identified and compared between the two groups. Multivariable logistic regression analyses were performed to assess the association between obesity and early complications following tracheostomy. RESULTS: Data pertaining to 205 032 adult patients were evaluated. Obese patients accounted for 12.1% (n = 21 816) of the entire cohort. The most common complication in the cohort was perioperative bleeding (4316 [2.1%]). A total of 1382 (0.67%), 949 (0.46%), and 134 (0.07%) patients developed pneumothorax/pneumomediastinum, stoma/surgical site infection, and tracheal injury following standard tracheostomy, respectively. There was no difference in the odds of tracheal injury, perioperative bleeding, and pneumomediastinum/pneumothorax following standard tracheostomy in the obese and non-obese group in multivariable analysis. However, obesity was associated with 60% increased odds of developing stoma/surgical site infection following standard tracheostomy (OR 1.60 [1.33-1.92], P < 0.01). CONCLUSION: Obesity is associated with an increased risk of developing stoma/surgical site infection following standard tracheostomy. This adds to the growing need for measures to help curb the obesity epidemic in a bid to improve surgical outcomes.

Alert-Triggered Patient Education Versus Nurse Feedback for Nonadministered Venous Thromboembolism Prophylaxis Doses: A Cluster-Randomized Controlled Trial.

Background Many hospitalized patients are not administered prescribed doses of pharmacologic venous thromboembolism prophylaxis. Methods and Results In this cluster-randomized controlled trial, all adult non-intensive care units (10 medical, 6 surgical) in 1 academic hospital were randomized to either a real-time, electronic alert-triggered, patient-centered education bundle intervention or nurse feedback intervention to evaluate their effectiveness for reducing nonadministration of venous thromboembolism prophylaxis. Primary outcome was the proportion of nonadministered doses of prescribed pharmacologic prophylaxis. Secondary outcomes were proportions of nonadministered doses stratified by nonadministration reasons (patient refusal, other). To test our primary hypothesis that both interventions would reduce nonadministration, we compared outcomes pre- versus postintervention within each cohort. Secondary hypotheses were tested comparing the effectiveness between cohorts. Of 11 098 patient visits, overall dose nonadministration declined significantly after the interventions (13.4% versus 9.2%; odds ratio [OR], 0.64 [95% CI, 0.57-0.71]). Nonadministration decreased significantly (P<0.001) in both arms: patient-centered education bundle, 12.2% versus 7.4% (OR, 0.56 [95% CI, 0.48-0.66]), and nurse feedback, 14.7% versus 11.2% (OR, 0.72 [95% CI, 0.62-0.84]). Patient refusal decreased significantly in both arms: patient-centered education bundle, 7.3% versus 3.7% (OR, 0.46 [95% CI, 0.37-0.58]), and nurse feedback, 9.5% versus 7.1% (OR, 0.71 [95% CI, 0.59-0.86]). No differential effect occurred on medical versus surgical units. The patient-centered education bundle was significantly more effective in reducing all nonadministered (P=0.03) and refused doses (P=0.003) compared with nurse feedback (OR, 1.28 [95% CI, 1.0-1.61]; P=0.03 for interaction). Conclusions Information technology strategies like the alert-triggered, targeted patient-centered education bundle, and nurse-focused audit and feedback can improve venous thromboembolism prophylaxis administration. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03367364.

Audit and Feedback to Surgery Interns and Residents on Prescribing Risk-Appropriate Venous Thromboembolism Prophylaxis.

OBJECTIVE: To evaluate the effectiveness of feedback using an emailed scorecard and a web-based dashboard on risk-appropriate VTE prophylaxis prescribing practices among general surgery interns and residents. DESIGN: Prospective cohort study. SETTING: The Johns Hopkins Hospital, an urban academic medical center. PARTICIPANTS: All 45 trainees (19 post-graduate year [PGY] 1 interns and 26 PGY-2 to PGY-5 residents) in our general surgery program. INTERVENTION: Feedback implementation encompassed three sequential periods: (1) scorecard (July 1, 2014 through June 30, 2015); (2) no feedback/wash-in (July 1 through October 31, 2015); and (3) web-based dashboard (November 1, 2015 through June 30, 2016). No feedback served as the baseline period for the intern cohort. The scorecard was a static document showing an individual's compliance with risk-appropriate VTE prophylaxis prescription compared to compliance of their de-identified peers. The web-based dashboard included other information (e.g., patient details for suboptimal prophylaxis orders) besides individual compliance compared to their de-identified peers. Trainees could access the dashboard anytime to view current and historic performance. We sent monthly emails to all trainees for both feedback mechanisms. Main outcome was proportion of patients prescribed risk-appropriate VTE prophylaxis, and mean percentages reported. RESULTS: During this study, 4088 VTE prophylaxis orders were placed. Among residents, mean prescription of risk-appropriate prophylaxis was higher in the wash-in (98.4% vs 95.6%, p < 0.001) and dashboard (98.4 vs 95.6%, p < 0.001) periods compared to the scorecard period. There was no difference in mean compliance between the wash-in and dashboard periods (98.4% vs 98.4%, p = 0.99). Among interns, mean prescription of risk-appropriate VTE prophylaxis improved between the wash-in and dashboard periods (91.5% vs 96.4%, p < 0.001). CONCLUSIONS AND RELEVANCE: Using audit and individualized performance feedback to general surgery trainees through a web-based dashboard improved prescribing of appropriate VTE prophylaxis to a near-perfect performance.

Effectiveness of ambulation to prevent venous thromboembolism in patients admitted to hospital: a systematic review.

BACKGROUND: Patient ambulation is frequently recommended to help prevent venous thromboembolism during hospital admission. Our objective was to synthesize the evidence for ambulation as a prophylaxis for venous thromboembolism in hospital. METHODS: We conducted a systematic review. We searched MEDLINE, Embase, Scopus, Web of Science and Cochrane Central Register of Controlled Trials indexed from their inception through April 2020 for studies of adult patients admitted to hospital, in which ambulation or mobilization alone or concomitant with prophylaxis was indicated for prevention of venous thromboembolism. We searched ClinicalTrials.gov for unpublished trials. We included randomized controlled trials (RCTs) and observational studies. Two reviewers independently screened articles and assessed risk of bias using 2 validated tools. We scored studies on quality of reporting, internal and external validity and study power; combined scores determined the overall quality. RESULTS: Eighteen articles met the inclusion criteria: 8 retrospective and 2 prospective cohorts, 7 RCTs and 1 secondary analysis of an RCT. The intervention (ambulation or mobilized) groups varied across studies. Five studies examined exercise as a therapeutic prophylaxis for thrombosis and 9 described an ambulation protocol. Five studies attempted to quantify amount and duration of patient ambulation and 3 reported ambulation distance. In the 5 studies rated as good or excellent statistical quality, findings were mixed. Incidence of venous thromboembolism was lowest when pharmacologic anticoagulants were added as part of the prescribed prophylaxis regimen. INTERPRETATION: We did not find high-quality evidence supporting ambulation alone as an effective prophylaxis for venous thromboembolism. Ambulation should not be considered an adequate prophylaxis for venous thromboembolism, nor as an adequate reason to discontinue pharmacologic prophylaxis for venous thromboembolism during a patient's hospital admission.

Contemporary analysis of charges and mortality in the use of extracorporeal membrane oxygenation: A cautionary tale.

Objective: The use of extracorporeal membrane oxygenation (ECMO) has increased exponentially. Costs and outcomes, however, vary considerably by indication. We sought to elucidate and quantify these differences. Methods: Adult patients supported on ECMO between 2008 and 2016 were analyzed using the Nationwide Inpatient Sample. We divided the study period into an early (2008-2013) and late period (2013-2016). The primary outcome was hospital charges, and the secondary outcomes were mortality, length of stay (LOS), and duration of ECMO support. These were stratified by the 5 most common indications: postcardiotomy shock (PCS), cardiogenic shock (CS), severe acute respiratory failure (SARF), heart (HT), and lung transplantation (LT). Both patient and hospital characteristics were assessed. Charges were adjusted for inflation and analyzed using a generalized linear model with gamma distribution. Pairwise comparison with Bonferroni correction was used to evaluate the cost and multivariate logistic regression to assess the risk of mortality. Results: Data pertaining to 15,829 adult patients were evaluated. Mean age of the entire cohort was 52.8 years, 8895 (56%) were white, and 10,278 (65%) were male. PCS was the predominant indication for ECMO (39%), followed by CS (37%). SARF accounted for 15% and HT and LT accounted for 3.9% and 5.4%, respectively. Mean LOS and duration of ECMO support were 23.4 days and 5.3 days respectively. Mean hospital charges per hospitalization for the entire cohort were USD 731,914 per patient. Charges per patient pertaining to hospitalizations in which ECMO was used in transplant patients were the highest: USD 1,448,931 and USD 1,574,378 (P = .99) for HT and LT, respectively. Charges were lower for the other indications: PCS USD 798,909, CS USD 655,099, and SARF USD 824,852. Overall mortality for the entire cohort was 55%. PCS and CS (53% vs 58%, P = .34) had similar survival, whereas SARF was 45%, LT was 39% and HT 32%. There were no differences in survival in these latter indications (SARF, LT and HT). The cumulative charges (proportion × hospital charges) reveal that PCS and CS (39% and 37%) account for both the majority of charges as well as the greatest mortality. Conversely, SARF and transplantation accounted for the smaller proportion of charges and the lower mortality. Patients undergoing HT had the longest LOS (51.7 days) and duration on ECMO (15.9 days), followed by LT (35.4 and 8.8 days respectively), and patients with SARF (28.6 and 6.6 respectively). LOS and duration of ECMO for those with PCS were 18.7 days and 4.8 days, respectively. Those on ECMO for CS were hospitalized for 19.7 days and spent an average of 3.8 days on ECMO. Mortality decreased, whereas charges increased in the late era. Conclusions: The use of ECMO is associated with high hospital charges and a wide variation in outcomes. Hospitalizations, in which ECMO is used to support patients with cardiogenic shock (PCS and CS), are individually associated with lower LOS and charges. Cumulatively, however, these account for greater charges and greater mortality. Although mortality may be decreasing, overall charges are increasing with time. These variations may influence reimbursement decisions in value-based healthcare.

Using electronic health record system triggers to target delivery of a patient-centered intervention to improve venous thromboembolism prevention for hospitalized patients: Is there a differential effect by race?

BACKGROUND: Racial disparities are common in healthcare. Venous thromboembolism (VTE) is a leading cause of preventable harm, and disparities observed in prevention practices. We examined the impact of a patient-centered VTE education bundle on the non-administration of preventive prophylaxis by race. METHODS: A post-hoc, subset analysis (stratified by race) of a larger nonrandomized trial. Pre-post comparisons analysis were conducted on 16 inpatient units; study periods were October 2014 through March 2015 (baseline) and April through December 2015 (post-intervention). Patients on 4 intervention units received the patient-centered, nurse educator-led intervention if the electronic health record alerted a non-administered dose of VTE prophylaxis. Patients on 12 control units received no intervention. We compared the conditional odds of non-administered doses of VTE prophylaxis when patient refusal was a reason for non-administration, stratified by race. RESULTS: Of 272 patient interventions, 123 (45.2%) were white, 126 (46.3%) were black, and 23 (8.5%) were other races. A significant reduction was observed in the odds of non-administration of prophylaxis on intervention units compared to control units among patients who were black (OR 0.61; 95% CI, 0.46-0.81, p<0.001), white (OR 0.57; 95% CI, 0.44-0.75, p<0.001), and other races (OR 0.50; 95% CI, 0.29-0.88, p = 0.015). CONCLUSION: Our finding suggests that the patient education materials, developed collaboratively with a diverse group of patients, improved patient's understanding and the importance of VTE prevention through prophylaxis. Quality improvement interventions should examine any differential effects by patient characteristics to ensure disparities are addressed and all patients experience the same benefits.

Anti-Xa activity by weight in critically ill patients receiving unfractionated heparin for venous thromboembolism prophylaxis.

PURPOSE: This study compared anti-Xa activity in critically ill patients receiving UFH for VTE prophylaxis between two weight groups (<100 kg vs ≥100 kg). METHODS: This prospective, observational study included critically ill patients on UFH 5000 or 7500 units every 8 h. A peak and trough anti-Xa activity assay was ordered for each patient at steady state. Goal peak anti-Xa activity was 0.1-0.3 units/mL. RESULTS: From March 2017 to June 2018, 75 patients were enrolled with 44 in the <100 kg group and 31 in the ≥100 kg group. There was no significant difference in the percentage of patients with peak anti-Xa activity within goal range between patients <100 kg and ≥ 100 kg (55.3% vs 35.7%, p = 0.12). The odds ratio for achieving peak anti-Xa activity within goal range as weight-based dose increased was 1.03 (95% CI 0.99-1.07). No differences were found in trough anti-Xa activity, VTE, bleeding, length of stay, or death. CONCLUSIONS: Though only one-third of patients ≥100 kg had peak anti-Xa activity within goal range, no significant difference was found between the weight groups. Additional prospective studies with adequate sample sizes are warranted to further investigate appropriate weight-based dosing of UFH in critically ill patients.

Venous Thromboembolism Prevention in Emergency General Surgery: A Review.

Importance: Venous thromboembolism (VTE) is the most preventable cause of morbidity and mortality in US hospitals, and approximately 2.5% of emergency general surgery (EGS) patients will be diagnosed with a VTE event. Emergency general surgery patients are at increased risk of morbidity and mortality because of the nature of acute surgical conditions and the challenges related to prophylaxis. Observations: MEDLINE, Embase, and the Cochrane Database of Collected Reviews were searched from January 1, 1990, through December 31, 2015. Nearly all operatively and nonoperatively treated EGS patients have a moderate to high risk of developing a VTE, and individual risk should be assessed at admission. Pharmacologic prophylaxis in the form of unfractionated or low-molecular-weight heparin should be considered unless an absolute contraindication, such as bleeding, exists. Patients should receive the first dose at admission to the hospital, and administration should continue until discharge without missed doses. Certain patient populations, such as those with malignant tumors, may benefit from prolonged VTE prophylaxis after discharge. Mechanical prophylaxis should be considered in all patients, particularly if pharmacologic prophylaxis is contraindicated. Studies that specifically target improved adherence with VTE prophylaxis in EGS patients suggest that efficacy and quality improvement initiatives should be undertaken from a system and institutional perspective. Conclusions and Relevance: Operatively and nonoperatively treated EGS patients are at a comparatively high risk of VTE. Despite gaps in existing literature with respect to this increasing patient population, successful best practices can be applied. Best practices include assessment of VTE risk, optimal prophylaxis, and physician, nurse, and patient education regarding the use of mechanical and pharmacologic VTE prophylaxis and institutional policies.

Nonadministration of medication doses for venous thromboembolism prophylaxis in a cohort of hospitalized patients.

PURPOSE: Results of a study to characterize patterns of nonadministration of medication doses for venous thromboembolism (VTE) prevention among hospitalized patients are presented. METHODS: The electronic records of all patients admitted to 4 floors of a medical center during a 1-month period were examined to identify patients whose records indicated at least 1 nonadministered dose of medication for VTE prophylaxis. Proportions of nonadministered doses by medication type, intended route of administration, and VTE risk categorization were compared; reasons for nonadministration were evaluated. RESULTS: Overall, 12.7% of all medication doses prescribed to patients in the study cohort (n = 75) during the study period (857 of 6,758 doses in total) were not administered. Nonadministration of 1 or more doses of VTE prophylaxis medication was nearly twice as likely for subcutaneous anticoagulants than for all other medication types (231 of 1,112 doses [20.8%] versus 626 of 5,646 doses [11.2%], p < 0.001). For all medications prescribed, the most common reason for nonadministration was patient refusal (559 of 857 doses [65.2%]); the refusal rate was higher for subcutaneous anticoagulants than for all other medication categories (82.7% versus 58.8%, p < 0.001). Doses of antiretrovirals, immunosuppressives, antihypertensives, psychiatric medications, analgesics, and antiepileptics were less commonly missed than doses of electrolytes, vitamins, and gastrointestinal medications. CONCLUSION: Scheduled doses of subcutaneous anticoagulants for hospitalized patients were more likely to be missed than doses of all other medication types.

Venous Thromboembolism in Patients Hospitalized for Lung Transplantation.

BACKGROUND: Venous thromboembolism (VTE) is an important complication after solid organ transplantation. We sought to evaluate any association between VTE and in-hospital death, length of hospitalization, and total hospital charges for patients hospitalized for lung transplantation (LT). METHODS: We retrospectively reviewed the Nationwide Inpatient Sample to identify patients hospitalized for LT from 2000 to 2011. We evaluated the incidence of VTE during hospitalization for LT, risk factors for VTE, and the association between VTE and in-hospital death, length of hospitalization, and total hospital charges. RESULTS: Of the 16,318 adults hospitalized for LT during the study period, VTE developed in 1,029 (6.3%), including 854 (5.4%) with deep vein thrombosis alone and 175 (1.1%) with pulmonary embolism. The factors associated with VTE included age older than 60 years (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.03 to 1.94), female sex (OR, 0.61; 95% CI, 0.44 to 0.86), and receiving mechanical ventilation support for 96 hours or more (OR, 3.38; 95% CI, 2.49 to 4.58). The adjusted odds of in-hospital death in patients with pulmonary embolism was thrice as high as those without any VTE (OR, 3.40; 95% CI, 1.29 to 8.99). Among LT patients with VTE, the average length of hospitalization was 38% (95% CI, 27% to 48%) longer, and the total cost of hospitalization was 23% (95% CI, 16% to 30%) higher compared with LT patients without VTE. CONCLUSIONS: VTE is a relatively frequent complication among LT recipients and is associated with increased death, total hospital length of stay, and hospital charges. These data indicate that prophylaxis practices should be reexamined to reduce this preventable complication.

Effect of Real-time Patient-Centered Education Bundle on Administration of Venous Thromboembolism Prevention in Hospitalized Patients.

Importance: Numerous interventions have improved prescription of venous thromboembolism (VTE) prophylaxis; however, many prescribed doses are not administered to hospitalized patients, primarily owing to patient refusal. Objective: To evaluate a real-time, targeted, patient-centered education bundle intervention to reduce nonadministration of VTE prophylaxis. Design, Setting, and Participants: This nonrandomized controlled, preintervention-postintervention comparison trial included 19 652 patient visits on 16 units at The Johns Hopkins Hospital, Baltimore, Maryland, from April 1 through December 31, 2015. Data analysis was performed from June 1, 2016, through November 30, 2017, on an intention-to-treat basis. Interventions: Patients on 4 intervention units received a patient-centered education bundle if a dose of VTE prophylaxis medication was not administered. Patients on 12 control units received no intervention. Main Outcomes and Measures: Conditional odds of nonadministration of doses of VTE prophylaxis (primary outcome) before and after the intervention on control vs intervention units. Reasons for nonadministration (ie, patient refusal and other) and VTE event rates (secondary outcomes) were compared. Results: A total of 19 652 patient visits where at least 1 dose of VTE prophylaxis was prescribed were included (51.7% men; mean [SD] age, 55.6 [17.1] years). Preintervention and postintervention groups were relatively similar in age, sex, race, and medical or surgery unit. From the preintervention period to the postintervention period, on intervention units, the conditional odds of VTE prophylaxis nonadministration declined significantly (9.1% [95% CI, 5.2%-16.2%] vs 5.6% [95% CI, 3.1%-9.9%]; odds ratio [OR], 0.57; 95% CI, 0.48-0.67) compared with no change on control units (13.6% [95% CI, 9.8%-18.7%] vs 13.3% [95% CI, 9.6%-18.5%]; OR, 0.98; 95% CI, 0.91-1.07; P < .001 for interaction). The conditional odds of nonadministration owing to patient refusal decreased significantly on intervention units (5.9% [95% CI, 2.6%-13.6%] vs 3.4% [95% CI, 1.5%-7.8%]; OR, 0.53; 95% CI ,0.43-0.65) compared with no change on control units (8.7% [95% CI, 5.4%-14.0%] vs 8.5% [95% CI, 5.3%-13.8%]; OR, 0.98; 95% CI, 0.89-1.08; P < .001 for interaction). On intervention units, the conditional odds of nonadministration owing to reasons other than patient refusal decreased (2.3% [95% CI, 1.5%-3.4%] vs 1.7% [95% CI, 1.1%-2.6%]; OR, 0.74; 95% CI, 0.58-0.94), with no change on control units (3.4% [95% CI, 2.7%-4.4%] vs 3.3% [95% CI, 2.6%-4.2%]; OR, 0.98; 95% CI, 0.87-1.10; P = .04 for interaction). No differential effect occurred on medical vs surgical units (OR, 0.86; 95% CI, 0.60-1.23; P = .41 for interaction). There was no statistical difference in the proportion of VTE events among patients on intervention vs control units (0.30% vs 0.18%; OR, 0.60; 95% CI, 0.16-2.23). Conclusions and Relevance: In this study, a targeted patient-centered education bundle significantly reduced nonadministration of pharmacologic VTE prophylaxis in hospitalized patients. This novel strategy improves health care quality by leveraging electronic data to target interventions in real time for at-risk patients. Trial Registration: ClinicalTrials.gov Identifier: NCT02402881.

ECMO Support in Lung Transplantation: A Contemporary Analysis of Hospital Charges in the United States.

BACKGROUND: There is little in the literature pertaining to cost associated with the use of extracorporeal membrane oxygenation (ECMO) in lung transplantation. We sought to evaluate charges associated with the index hospitalization among recipients of a lung transplant who required ECMO to identify factors that increase hospital charges in these patients. METHODS: With the use of the Nationwide Inpatient Sample, we reviewed data pertaining to patients who received a lung transplant between 2000 and 2011 and stratified them into ECMO and non-ECMO groups based on use of ECMO. Regression modeling was used to identify differences in charges. RESULTS: Data pertaining to 15,596 recipients of a lung transplant were evaluated, 658 (4.2%) of whom required ECMO. ECMO recipients were more likely to have a diagnosis of idiopathic pulmonary fibrosis (3.5% versus 1.3%, p = 0.007) or pulmonary hypertension (PH) (9.1% versus 3.0%, p < 0.001). Patients who received a bilateral lung transplant had 32.1% (95% confidence interval [CI]: 26.2% to 37.9%, p < 0.001) higher charges. Recipients with PH had 28.7% (95% CI: 14.9% to 42.4%, p = 0.001) higher charges. Median charges for recipients of a lung transplant who required ECMO were $780,391.50 versus $324,279.80 for non-ECMO recipients of a lung transplant and were 50.3% (95% CI: 33.0% to 67.5%, p < 0.001) higher. Hospital charges among Medicare enrollees were 6.6% (95% CI: 0.7% to 12.5%, p = 0.028) higher than privately insured recipients of a lung transplant. Black recipients had approximately 34.2% (95% CI: 3.2% to 65.0%, p = 0.030) higher charges. The ECMO group had longer median length of stay (LOS) (25 versus 15 days, p < 0.001). CONCLUSIONS: Recipients of a lung transplant who required ECMO support had longer LOS and higher hospital charges, specifically among black recipients, recipients with PH, and Medicare enrollees.

Exploring the impact of route of administration on medication acceptance in hospitalized patients: Implications for venous thromboembolism prevention.

BACKGROUND: Non-administration of venous thromboembolism (VTE) prophylaxis contributes to preventable patient harm. We hypothesized that non-administration would be more common for parenteral VTE prophylaxis than oral infectious disease or cardiac prophylaxis or for treatment medications. The primary study goal was to determine if non-administration of parenteral VTE prophylaxis is more frequent than other prophylactic or treatment medications. METHODS: In this retrospective cohort study of consecutive admissions we used descriptive statistics and risk ratios (RR) to compare the number of non-administered doses of VTE prophylaxis, oral infectious disease and cardiovascular prophylaxis and treatment medications. To quantify the influence of demographic and clinical characteristics on non-administration, we estimated incidence rate ratios from Poisson regression models. RESULTS: 645 patients were admitted from July 1, 2014 through March 31, 2015. Median age was 52years (Interquartile range 43-57) and 365 (56.6%) were male. Subcutaneous VTE prophylaxis doses were not administered nearly 4-fold more frequently than oral infectious disease and cardiovascular prophylaxis (RR=3.93; 95% CI 3.36-4.59) and 3-fold more frequently than treatment medications (RR=3.06; 95% CI 2.91-3.22). Ninety percent of non-administered doses of VTE prophylaxis were refused. Risk factors for non-administration included younger age (age 18-35years), male sex, uninsured status, HIV-positivity and high VTE risk status. CONCLUSIONS: Subcutaneous VTE prophylaxis is not administered more frequently than oral infectious diseases or cardiac prophylaxis and treatment medications. These data suggest that availability of an oral medication could improve the effectiveness of VTE prophylaxis in real world settings.

Effectiveness of two distinct web-based education tools for bedside nurses on medication administration practice for venous thromboembolism prevention: A randomized clinical trial.

BACKGROUND: Venous thromboembolism (VTE) is a common cause of preventable harm in hospitalized patients. While numerous successful interventions have been implemented to improve prescription of VTE prophylaxis, a substantial proportion of doses of prescribed preventive medications are not administered to hospitalized patients. The purpose of this trial was to evaluate the effectiveness of nurse education on medication administration practice. METHODS: This was a double-blinded, cluster randomized trial in 21 medical or surgical floors of 933 nurses at The Johns Hopkins Hospital, an academic medical center, from April 1, 2014 -March 31, 2015. Nurses were cluster-randomized by hospital floor to receive either a linear static education (Static) module with voiceover or an interactive learner-centric dynamic scenario-based education (Dynamic) module. The primary and secondary outcomes were non-administration of prescribed VTE prophylaxis medication and nurse-reported satisfaction with education modules, respectively. RESULTS: Overall, non-administration improved significantly following education (12.4% vs. 11.1%, conditional OR: 0.87, 95% CI: 0.80-0.95, p = 0.002) achieving our primary objective. The reduction in non-administration was greater for those randomized to the Dynamic arm (10.8% vs. 9.2%, conditional OR: 0.83, 95% CI: 0.72-0.95) versus the Static arm (14.5% vs. 13.5%, conditional OR: 0.92, 95% CI: 0.81-1.03), although the difference between arms was not statistically significant (p = 0.26). Satisfaction scores were significantly higher (p<0.05) for all survey items for nurses in the Dynamic arm. CONCLUSIONS: Education for nurses significantly improves medication administration practice. Dynamic learner-centered education is more effective at engaging nurses. These findings suggest that education should be tailored to the learner. TRIAL REGISTRATION: ClinicalTrials.gov NCT02301793.

Prevalence of graduated compression stocking-associated pressure injuries in surgical intensive care units.

PURPOSE: This study aimed to determine the prevalence of static graduated compression stocking (sGCS)-associated pressure injury among patients in surgical intensive care units (ICUs). METHODS: We retrospectively reviewed data from wound care rounds between April 2011 and June 2012 at 3 surgical ICUs at an urban, tertiary care hospital. Patients with sGCS-associated pressure injury were identified and descriptive analysis was performed on their demographic, perioperative, and postoperative characteristics. RESULTS: We examined 1787 individual patients during 2391 patient encounters. A total of 129 (7.2%) of patients developed pressure injuries. Forty patients (2.2%) developed sGCS-associated pressure injury. Static GCS-associated pressure injury accounted for 31% (40/129) of all pressure injuries and 74% (40/54) of all medical device-related pressure injury. Eighteen (45%) and 6 (15%) developed stage 1 and 2 pressure injury, respectively, and 16 (40%) developed deep tissue injuries. The mean age of our patients was 64.7 years, about half (47.5%) were male, and their mean Acute Physiology and Chronic Health Evaluation II score was 18.8. Many had comorbid conditions, including obesity (44.5%) and diabetes (42.5%), and required mechanical ventilation (45%). CONCLUSIONS: Pressure injuries are a notable complication of sGCS in surgical ICU patients. Appropriate measures are required to help avoid this potentially preventable harm.