Improving Compliance with a Nurse-Driven Protocol for Unfractionated Heparin Infusions in Patients with Venous Thromboembolism.

BACKGROUND: Unfractionated heparin (UFH) is a high-risk medication that can cause bleeding and/or thrombotic complications if not managed appropriately. Between January and July 2019, our institution experienced a high number of patient safety events related to UFH infusion for the treatment of venous thromboembolism (VTE). PURPOSE: The aim of this quality improvement (QI) initiative was to prevent these safety events by improving compliance with our institution's nurse-driven VTE UFH infusion protocol. METHODS: Baseline data for patients on the VTE UFH protocol were collected to identify improvement opportunities. Compliance with eight standards of care related to the VTE UFH infusion protocol was measured. Time to first therapeutic activated partial thromboplastin time (aPTT) was recorded to assess the benefit of improved compliance. INTERVENTIONS: Institutional policy updates were made to clarify the management of UFH infusions and documentation in the electronic health record. A multidisciplinary workgroup implemented order set changes, nursing communication orders, UFH infusion reports, and a nursing education module to promote compliance with the protocol. RESULTS: The overall rate of compliance with the VTE UFH infusion protocol increased from 79.4% at baseline to 85.2% following implementation of the QI initiative, and the median time to first therapeutic aPTT decreased from 831.5 minutes to 808 minutes over the same period. CONCLUSIONS: A multidisciplinary initiative to address improvement opportunities in a nurse-driven UFH protocol for VTE treatment increased compliance with the protocol and decreased the time to first therapeutic aPTT.

A multifaceted quality improvement intervention on venous thromboembolism prophylaxis compliance in hospitalized medical patients at a comprehensive cancer center.

INTRODUCTION: Previous studies suggest that quality improvement initiatives focused on hospital-acquired venous thromboembolism have a positive impact on prescribing rates of venous thromboembolism prophylaxis, especially those that incorporate computerized changes. METHODS: We conducted a quality improvement project to determine whether education and computerized prescriber order entry system changes affect venous thromboembolism prophylaxis compliance rates in hospitalized medical patients at a Comprehensive Cancer Center. Between 1 January 2021 and 31 January 2023, 37,739 non-surgical, adult patient encounters with a length of stay > 48 h were analyzed in our study. From 18 December 2021 to 8 March 2022, provider education was delivered to the three largest admitting services, and computerized prescriber order entry changes were implemented incorporating a mandatory requirement to either order venous thromboembolism prophylaxis or document a contraindication for all patients at moderate venous thromboembolism risk. RESULTS: Monthly venous thromboembolism prophylaxis compliance rates, as defined by the Centers for Medicare and Medicaid Services VTE-1 metric, increased from a mean of 74% to 93% after the interventions. This change was driven primarily by an increased utilization of mechanical venous thromboembolism prophylaxis from 37% to 53%. CONCLUSION: Our study demonstrated that a multi-faceted intervention incorporating provider education and computerized prescriber order entry system changes can significantly increase venous thromboembolism prophylaxis compliance rates in cancer patients.

Safety and Effectiveness of Direct Oral Anticoagulants for the Treatment of Gastrointestinal Cancer-Associated Venous Thromboembolism.

BACKGROUND: Patients with gastrointestinal cancer (GICA) are at high risk for venous thromboembolism (VTE). Data from randomized clinical trials in cancer-associated VTE suggest that direct oral anticoagulants (DOACs) conferred similar or superior efficacy but a heterogeneous safety profile in patients with GICA. We compared the safety and effectiveness of DOACs in patients with GICA and VTE at MD Anderson Cancer Center. MATERIALS AND METHODS: This was a retrospective chart review of patients with GICA and VTE receiving treatment with DOACs for a minimum of 6 months. Primary outcomes were the proportion of patients experiencing major bleeding (MB), clinically relevant non-major bleeding (CRNMB), and recurrent VTE. Secondary outcomes were time to bleeding and recurrent VTE. RESULTS: A cohort of 433 patients with GICA who were prescribed apixaban (n = 300), or rivaroxaban (n = 133) were included. MB occurred in 3.7% (95% confidence interval [CI] 2.1-5.9), CRNMB in 5.3% (95% CI 3.4-7.9), and recurrent VTE in 7.4% (95% CI 5.1-10.3). The cumulative incidence rates of CRNMB and recurrent VTE were not significantly different when comparing apixaban to rivaroxaban. CONCLUSION: Apixaban and rivaroxaban had a similar risk of recurrent VTE and bleeding and could be considered as anticoagulant options in selected patients with GICA and VTE.

External validation of a novel electronic risk score for cancer-associated thrombosis in a comprehensive cancer center.

Venous thromboembolism (VTE) is a significant complication for cancer patients undergoing systemic therapy. We performed an independent external validation for a recently derived and validated a novel electronic health record (EHR) VTE risk score in a comprehensive cancer center. Adult patients with incident cancer diagnoses were identified from MD Anderson Cancer Center Tumor Registry 1/2017-1/2021. Baseline covariates extracted at the time of first-line systemic therapy included demographics, cancer site/histology, stage, treatment, complete blood count, body mass index, recent prolonged hospitalization, and history of VTE or paralysis. VTE was ascertained using an institution-specific natural language processing radiology algorithm (positive predictive value of 94.8%). The median follow-up for 21 142 cancer patients was 8.1 months. There were 1067 (5.7%) VTE within 6 months after systemic therapy. The distribution of the novel score for 0-, 1, 2, 3, 4, 5+ was 5661, 3558, 3462, 3489, 2918, and 2054; while the corresponding 6-month VTE incidence was 1.3%, 3.1%, 5.4%, 7.3%, 9.3%, and 13.8%, respectively (c statistic 0.71 [95% CI 0.69-0.72] with excellent calibration). In comparison, the Khorana score had a c statistic of 0.64 [95% CI 0.62-0.65]. The two risk scores had 80% concordance; the novel score reclassified 20% of Khorana score (3530 low-to-high with 9.0% VTE; 734 high-to-low with 3.4% VTE) and led to a 25% increment in VTEs captured in the high-risk group. In conclusion, the novel score demonstrated consistent discrimination and calibration across cohorts with heterogenous demographics. It could become a new standard to select high-risk populations for clinical trials and VTE monitoring.

Diagnosis and management of immune-related adverse effects of immune checkpoint therapy in the emergency department.

Rapid advances in cancer immunotherapy using immune checkpoint inhibitors have led to significantly improved survival. Rapid identification of the toxicity syndromes associated with these therapeutic agents is very important for emergency physicians because the population of patients diagnosed with cancer is increasing and cancer therapies including immune checkpoint inhibitors have become the first-line treatment for more and more types of cancer. The emergency medicine literature lags behind rapid advances in oncology, and oncology guidelines for rapid recognition and management of these emerging toxicity syndromes are not familiar to emergency physicians. In this review article, we discuss the clinical presentation and management of immune-related adverse effects during the critical first hours of emergency care. We also suggest a workflow for the recognition and treatment of emergencies arising from serious immune-related adverse effects, including but not limited to colitis, adrenal crisis, myocarditis, pneumonitis, myasthenic crisis, diabetic ketoacidosis, bullous pemphigus, and hemophagocytic lymphohistiocytosis. Rapid advances in cancer therapy are bringing new diagnostic and therapeutic challenges to emergency providers, and therefore it is crucial to raise awareness and provide guidelines for the management of new treatment-related toxicities.

Timing to antibiotic therapy in septic oncologic patients presenting without hypotension.

PURPOSE: Sepsis accounts for only 2% of the hospitalizations worldwide but more than 17% of total in-hospital mortality. Inappropriate antimicrobial selection and delays in appropriate therapy have been associated with reduced survival in severe sepsis and septic shock. No studies to date have exclusively targeted septic oncologic patients without hypotension. METHODS: This study was a retrospective chart review of 100 adult cancer patients presenting to the emergency department with sepsis without hypotension. We investigated the effect of time to appropriate antibiotics on in-hospital mortality and hospital length of stay. It was hypothesized that increased time to antibiotic administration would worsen patient outcomes including in-hospital mortality and length of stay. RESULTS: Each 1-h delay in administration of appropriate antibiotic therapy increased the odds of in-hospital mortality by 16% (adjusted OR 1.16. 95% CI 1.04-1.34, p = 0.04). Time to appropriate antibiotics had no effect on hospital length of stay. CONCLUSIONS: Time to appropriate antibiotics and in-hospital mortality were associated in this population of adult oncologic patients with sepsis without hypotension. Clinicians in the emergency department should strive to ensure the timely administration of a complete and appropriate empiric antibiotic regimen in septic patients with active cancer even in the absence of hypotension.

Once daily versus twice daily enoxaparin for acute pulmonary embolism in cancer patients.

BACKGROUND: Venous thromboembolism (VTE) is a condition in which a thrombus occludes the vasculature. The incidence of VTE in cancer patients is three times higher than that of the general population. Enoxaparin 1 mg/kg subcutaneously (SC) twice daily and enoxaparin 1.5 mg/kg SC once daily are both FDA-approved dosing regimens for the treatment of pulmonary embolism (PE). The objectives of this study were to assess outcomes of cancer patients treated with once or twice daily enoxaparin for acute PE. Primary outcomes included recurrent or worsening PE and secondary outcomes included mortality or signs of clinically overt, major bleeding. METHODS: This study was a retrospective chart review of adult cancer patients treated at The University of Texas MD Anderson Cancer Center from 2011 to 2013 who received either 1 mg/kg twice daily or 1.5 mg/kg once daily enoxaparin for acute PE upon discharge. RESULTS: Among 48 patients in each the twice daily and once daily group, six recurrent PEs occurred. The incidence of recurrent PE was higher in the once daily group (n = 4) versus twice daily group (n = 2). More major bleeding events occurred in the once daily group than the twice daily group (15% vs. 6%). Mortality at 6 months was higher in the twice daily group versus once daily group (13% vs. 6%). CONCLUSION: Cancer patients receiving once daily enoxaparin for the treatment of acute PE may be at increased risk of recurrent PE and clinically overt bleeding. Larger randomized trials are needed to confirm the results of this study.

Low tissue oxygen saturation at emergency center triage is predictive of intensive care unit admission.

PURPOSE: Timely recognition of critical patients by emergency center triage is an ongoing challenge. Peripheral tissue oxygen saturation (StO2) measurement has been used to monitor shock patients' responses to resuscitation. Interest has developed in evaluating StO2 as a triage tool, but limited studies have addressed critically ill patients. MATERIAL AND METHODS: This is a single-center, retrospective study of 158 emergent cancer patients with hypotension and/or modified systemic inflammatory response syndrome who underwent StO2 spot measurement at triage. RESULTS: Of the 57 patients with StO2 less than 70%, 17 went to the intensive care unit (ICU), whereas only 14 of the 101 patients with StO2 of 70% to 89% (P = .01) went to the ICU. There was no significant difference in non-ICU hospital admission or mortality between the 2 groups. The odds ratio of ICU admission for patients with StO2 less than 70% relative to those with StO2 of 70% to 89% was 2.64 (95% confidence interval, 1.18-5.87) and 2.87 (95% confidence interval, 1.23-6.66) when adjusted for mean arterial pressure, pulse, and temperature. CONCLUSIONS: In this patient population, an StO2 less than 70% significantly increased the risk of ICU admission. Tissue oxygen saturation at triage identifies critical patients who may not be recognized by vital signs alone. Tissue oxygen saturation measurement could help providers make earlier decisions regarding hospital resource allocation.

Management of anticoagulation in the critically ill patient.

This article presents a review of the most commonly used anticoagulants in the intensive care unit setting. The difference between agents as well as the advantages and disadvantages are reviewed. For each agent, the mechanism of action, dosing, monitoring, adverse effects, and reversal strategies are discussed.