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Improving venous thromboembolism (VTE) prophylaxis in acute urological admissions during out of hours through the introduction of a urological admission proforma.

ABSTRACT: Venous thromboembolism (VTE) kills more people than breast cancer, road traffic accidents, and AIDS combined, accounting for approximately 25,000 in-hospital deaths in England annually. The cost to the NHS is estimated at £640 million/annum. The most important element of VTE risk assessment strategy in England is to risk assess all patients for VTE on admission. The aim of our quality improvement programme (QIP) was to monitor our practice regarding VTE prophylaxis of the patients' admitted urgently in our department, and then implement a measure to increase compliance if found to be poor. Our standards were based on the National Institute for Health and Care Excellence (NICE) guidelines which state that all urgently admitted patients must have a completed VTE assessment form within 24 hours of admission and receive appropriate VTE prophylaxis including low molecular weight heparin (LMWH) and/or TED stockings. Our initial audit was conducted over a period of five weeks. All adult patients acutely admitted out of hours (5pm to 8am) were included. We then introduced a specially designed urological admissions proforma and organised several teaching sessions for junior doctors who facilitated acute admissions. Re-audit was performed using the same methods and timescale measuring improvement. Second re-audit six months after the introduction of the proforma, following the induction of the new cohort of junior doctors. - Primary audit: n=44. Proportion of: completed VTE form=56%, LMWH appropriately prescribed=65%,TEDS=35%. VTE related complications=3 - 1st re-audit: n=42. Proportion of: completed VTE form=93%, LMWH appropriately prescribed=83%,TEDS=64%. VTE related complications=0 - 2nd re-audit:n=43. Proportion of: completed VTE form=92%, LMWH prescribed=84%, TEDS=76%. VTE related complications=1 There has been a significant increase of compliance with the NICE guidelines regarding VTE prophylaxis within our department through introducing the specially designed urological admissions proforma and delivering teaching sessions for junior doctors. The implementation of the proforma also led to decreased prevalence of VTE related complications and their subsequent morbidity and mortality.

SUBMITTER: Gerakopoulos E

PROVIDER: S-EPMC4645822 | biostudies-other | 2015

REPOSITORIES: biostudies-other

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Improving venous thromboembolism (VTE) prophylaxis in acute urological admissions during out of hours through the introduction of a urological admission proforma.

Gerakopoulos Efstratios E

BMJ quality improvement reports 20150210 1

Venous thromboembolism (VTE) kills more people than breast cancer, road traffic accidents, and AIDS combined, accounting for approximately 25,000 in-hospital deaths in England annually. The cost to the NHS is estimated at £640 million/annum. The most important element of VTE risk assessment strategy in England is to risk assess all patients for VTE on admission. The aim of our quality improvement programme (QIP) was to monitor our practice regarding VTE prophylaxis of the patients' admitted urge ...[more]

PMID: 26734329

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Project description:Hospital-Acquired venous thromboembolism (VTE) is a common cause of morbidity and mortality in older adults. In psychiatric patients these risks are increased due to multiple factors including poor mobility, restraint, catatonia, sedation, and conventional antipsychotic use. Diagnosis and treatment of psychiatric patients presenting with signs and symptoms of a VTE can be delayed due to a patient's communication difficulties, non-compliance, or attribution of symptoms to a psychosomatic cause. However, despite the increased risk, approved VTE prophylaxis protocols are infrequently used on Psychiatric wards. On one Older Adult Psychiatric Ward, two patients presented with VTE (a fatal pulmonary embolism and a symptomatic deep vein thrombosis) over a 6 month period demonstrating the necessity for prophylactic assessment. A baseline audit over 3 months showed that 63-83% of patients on the ward had received no assessment of VTE risk, on any given week, although this improved slightly following the critical incidents. A VTE prophylaxis protocol, based on NICE guidance for VTE risk assessment in Medical and Surgical patients, was developed with consideration given to additional Psychiatric risk factors. This took the form of a pro-forma with a tick-box design that included mobility assessment, VTE risk factors, bleeding risk factors, and guidance on prescribing decisions. This was implemented on an Older Adult Psychiatric ward and prophylaxis was provided to those meeting the threshold. Weekly audit of all pro-formas (including assessments completed within 48 hours of admission and prophylaxis prescription) was conducted after the pro-forma introduction from 1st February 2013 to 24th May 2013. Frequency of assessments increased after protocol implementation with between 36% and 85% of all patients being assessed for VTE risk post intervention. Fluctuations in numbers assessed may have related to ward pressures, staff changes, and practicalities of pro-forma use. After completion of the PDSA cycles the initiative was handed over to a specialist registrar for implementation across the other trust Older Adult Psychiatry wards, and further audit was planned to be conducted via junior doctors and established Quality Assurance systems. Discussion of integration of a condensed pro-forma into the trust electronic notes system is ongoing.

Project description:OBJECTIVES:To review studies developing or validating a prognostic model for individual venous thromboembolism (VTE) recurrence risk following cessation of therapy for a first unprovoked VTE. Prediction of recurrence risk is crucial to informing patient prognosis and treatment decisions. The review aims to determine whether reliable prognostic models exist and, if not, what further research is needed within the field. DESIGN:Bibliographic databases (including MEDLINE, EMBASE and the Cochrane Library) were searched using index terms relating to the clinical field and prognosis. Screening of titles, abstracts and subsequently full texts was conducted by 2 reviewers independently using predefined criteria. Quality assessment and critical appraisal of included full texts was based on an early version of the PROBAST (Prediction study Risk Of Bias Assessment Tool) for risk of bias and applicability in prognostic model studies. SETTING:Studies in any setting were included. PRIMARY AND SECONDARY OUTCOME MEASURES:The primary outcome for the review was the predictive accuracy of identified prognostic models in relation to VTE recurrence risk. RESULTS:3 unique prognostic models were identified including the HERDOO2 score, Vienna prediction model and DASH score. Quality assessment highlighted the Vienna, and DASH models were developed with generally strong methodology, but the HERDOO2 model had many methodological concerns. Further, all models were considered at least at moderate risk of bias, primarily due to the need for further external validation before use in practice. CONCLUSIONS:Although the Vienna model shows the most promise (based on strong development methodology, applicability and having some external validation), none of the models can be considered ready for use until further, external and robust validation is performed in new data. Any new models should consider the inclusion of predictors found to be consistently important in existing models (sex, site of index event, D-dimer), and take heed of several methodological issues identified through this review. PROSPERO REGISTRATION NUMBER:CRD42013003494.

Project description:IntroductionThe risk of mortality in patients with COVID-19 was found to be significantly higher in patients who experienced thromboembolic events. Thus, several guidelines recommend using prophylactic anticoagulants in all COVID-19 hospitalized patients. However, there is uncertainty about the appropriate dosing regimen and safety of anticoagulation in critically ill patients with COVID-19. Thus, this study aims to compare the effectiveness and safety of standard versus escalated dose pharmacological venous thromboembolism (VTE) prophylaxis in critically ill patients with COVID-19.MethodsA two-center retrospective cohort study including critically ill patients aged ≥ 18-years with confirmed COVID-19 admitted to the intensive care unit (ICU) at two tertiary hospitals in Saudi Arabia from March 1st, 2020, until January 31st, 2021. Patients who received either Enoxaparin 40 mg daily or Unfractionated heparin 5000 Units three times daily were grouped under the "standard dose VTE prophylaxis and patients who received higher than the standard dose but not as treatment dose were grouped under "escalated VTE prophylaxis dose". The primary outcome was the occurance of thrombotic events, and the secondary outcomes were bleeding, mortality, and other ICU-related complications.ResultsA total of 758 patients were screened; 565 patients were included in the study. We matched 352 patients using propensity score matching (1:1). In patients who received escalated dose pharmacological VTE prophylaxis, any case of thrombosis and VTE were similar between the two groups (OR 1.22;95 %CI 0.52-2.86; P = 0.64 and OR 0.75; 95% CI 0.16-3.38; P = 0.70 respectively). However, the odds of minor bleeding was higher in patients who received escalated VTE prophylaxis dose (OR 3.39; 95% CI 1.08-10.61; P = 0.04). There was no difference in the 30-day mortality nor in-hospital mortality between the two groups (HR 1.17;95 %CI0.79-1.73; P = 0.43 and HR 1.08;95 %CI 0.76-1.53; P = 0.83, respectively).ConclusionEscalated-dose pharmacological VTE prophylaxis in critically ill patients with COVID-19 was not associated with thrombosis, or mortality benefits but led to an increased risk of minor bleeding. This study supports previous evidence regarding the optimal dosing VTE pharmacological prophylaxis regimen for critically ill patients with COVID-19.

Dataset Information

Improving venous thromboembolism (VTE) prophylaxis in acute urological admissions during out of hours through the introduction of a urological admission proforma.

Publications

Improving venous thromboembolism (VTE) prophylaxis in acute urological admissions during out of hours through the introduction of a urological admission proforma.

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