Practice patterns surrounding referral to a specialty venous thromboembolism (VTE) clinic: a retrospective review.

This study audited prescribing practices for patients with acute venous thromboembolism (VTE) prior to and after being seen in an outpatient VTE clinic. This retrospective chart review conducted between June 2018 through May 2019 included patients with confirmed acute VTE, seen for an initial appointment. Exclusion criteria were patients with additional indications for anticoagulation, lack of information to determine primary outcome and active cancer. To assess practices, the time taken to be seen in clinic, anticoagulant therapies (prior to/following clinic) used and concordance of anticoagulant use with product monographs were assessed. Of the 325 (40.6%) patients included, the median age was 57.7 years, most were referred with pulmonary embolism (PE) (54.5%) and the majority of referrals came through the emergency department (45.2%). The median time to be seen in clinic was 13 days, with no differences in time between type of VTE or proximity of clot. Prior to being seen in VTE clinic, most were prescribed direct oral anticoagulants (DOACs) (81.9%), with a small portion receiving low molecular weight heparin (LMWH) (12.9%) and warfarin (5.2%). Most received anticoagulants concordant with product monographs (87.7%), with more discordance with warfarin (52.9%) and LMWH (14.3%) compared to DOACs (9.4%) (P < 0.001). At the initial VTE clinic visit, 70 (21.5%) patients had therapy changes, with most being from LMWH/warfarin to a DOAC (47.1%). Our data reflects high uptake of DOACs for acute VTE treatment with most prescribed in accordance with product monographs.

Mycobacterium chimaera Encephalitis Following Cardiac Surgery: A New Syndrome.

We report the cases of 3 patients with fatal, disseminated Mycobacterium chimaera infections following cardiac surgeries. Progressive neurocognitive decline and death were explained by active granulomatous encephalitis, with widespread involvement of other organs. This syndrome is clinically elusive and, thus, may have caused deaths in prior reported series.

Applying improvement science to establish a resident sustained quality improvement (QI) educational model.

BACKGROUND: Prior to 2017, internal medicine (IM) residents at the University of Alberta did not have a standardised quality improvement (QI) educational curriculum. Our goal was to use QI principles to develop a resident sustained curriculum using the Evidence-based Practice for Improving Quality (EPIQ) training course. METHODS: Three one-year Plan-Do-Study-Act (PDSA) cycles were conducted. The EPIQ course was delivered to postgraduate year (PGY) 1-3 residents (n=110, PDSA 1) in 2017, PGY-1 residents (n=27, PDSA 2) in 2018 and PGY-1 residents (n=28, PDSA 3) in 2019. Trained residents were recruited as facilitators for PDSA 2 and 3. Residents worked through potential QI projects that were later presented for evaluation. Precourse and postcourse surveys and tests were conducted to assess knowledge acquisition and curriculum satisfaction. Process, outcome and balancing measures were also evaluated. RESULTS: In PDSA 1, 98% felt they had acquired understanding of QI principles (56% increase), 94% of PGY-2 and PGY-3 residents preferred this QI curriculum compared with previous training, and 65% of residents expressed interest in pursuing a QI project (15% increase). In PDSA 2, tests scores of QI principles improved from 77.6% to 80%, and 40% of residents expressed interest in becoming a course facilitator. In PDSA 3, self-rated confidence with QI methodology improved from 53% to 75%. A total of 165 residents completed EPIQ training and 11 residents became course facilitators. CONCLUSIONS: Having a structured QI curriculum and working through practical QI projects provided valuable QI training for residents. Feedback was positive, and with each PDSA cycle there was increased resident interest in QI. Developing this curriculum using validated QI tools highlighted areas of change opportunity thereby enhancing acceptance. As more cycles of EPIQ are delivered and more residents become facilitators, it is our aim to have this curriculum sustained by future residents.

Comparability of Automated Office Blood Pressure to Daytime 24-Hour Ambulatory Blood Pressure.

BACKGROUND: Clinical practice guidelines endorse automated office blood pressure (AOBP) measurement as the preferred in-office measurement modality. However, recent data indicate that this method may underestimate daytime ambulatory BP. The objective of this study was to further assess the comparability of mean AOBP and daytime ambulatory BP in clinical practice. METHODS: A retrospective cross-sectional chart review was conducted of 96 consecutive patients referred from primary or specialty care practices to a tertiary care ambulatory BP monitoring service. Six AOBP readings were taken using an appropriately cuffed BpTRU (BpTRU Medical Devices, Coquitlam, Canada) device on the nondominant arm and no rest period (first reading discarded). Twenty-four-hour ambulatory BP monitoring was then performed. Between-group means were compared with paired t tests. The proportion of patients with differences of ≥ 5, 10, and 15 mm Hg was tabulated. RESULTS: Mean age was 52.6 ± 16.7 years, 60% were women, and 79% had previously diagnosed hypertension. Mean AOBPs were 130.8 ± 15.5/82.3 ± 10.7 mm Hg, and mean daytime ambulatory BPs were 142.8 ± 14.9/83.9 ± 11.2 mm Hg (difference of -11.9 ± 13.5/-1.6 ± 7.6; P < 0.001 for systolic BP and P < 0.04 for diastolic BP). Between-group differences were greater in patients with previous hypertension and in those with daytime ambulatory BP levels ≥ 135 mm Hg. The proportions of patients with systolic or diastolic BP differences of ≥ 5, 10 and 15 mm Hg were 89%, 52%, and 33%, respectively. CONCLUSIONS: Mean AOBP underestimates daytime ambulatory BP. Variability between the 2 methods is high. These findings do not support the premise that AOBP closely approximates daytime ambulatory BP.