scholarly journals P028: Implementation of an emergency department outpatient deep venous thrombosis treatment guideline: a quality improvement initiative

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S87-S88
Author(s):  
L. Costello ◽  
M. McGowan ◽  
V. Dounaevskai ◽  
A.H. Cheng
Keyword(s):  
Emergency Department ◽  
Quality Improvement ◽  
Venous Thrombosis ◽  
Deep Venous Thrombosis ◽  
Major Bleeding ◽  
Treatment Guideline ◽  
Quality Improvement Initiative ◽  
Warfarin Group ◽  
Ed Visits ◽  
One Year

Introduction: Deep venous thrombosis (DVT) is a common diagnosis in the Emergency Department (ED). Despite evidence that Rivaroxaban is non-inferior to the low molecular weight heparin (LMWH) bridge to Warfarin approach for anticoagulation, there is still variability in physician practice. A collaborative ED-Hematology quality improvement initiative, that included a treatment guideline and increased access to a thrombosis clinic, was introduced to guide anticoagulation. Methods: A retrospective chart review of ED patients with DVT one-year pre (April 1, 2013-March 31, 2014) and one-year post (April 1, 2014-March 31, 2015) implementation of an outpatient DVT treatment guideline was conducted. Primary outcomes were percentage of patients discharged from the ED on Rivaroxaban or LMWH/Warfarin. Secondary outcomes included mean ED length of stay (ED LOS), mean number of return ED visits per patient and percentage of thrombosis clinic referrals. Balance measures included percentage of return ED visits with pulmonary embolism (PE) within one month and percentage of return ED visits with bleeding (major bleeding or clinically relevant non-major bleeding) due to anticoagulation use. Clinical and administrative data was extracted with 15% independently reviewed for inter-rater reliability. Results: 95 patients met inclusion criteria (52 patients pre and 43 post guideline implementation). The prescribing of Rivaroxaban increased from 9.6% (5/52) to 62.7% (27/43). Mean ED LOS for the Rivaroxaban group was 7.5 hours (95% CI, 5.8-9.2) versus 10.0 hours in the Warfarin group (95% CI, 8.5-11.4) [p=0.04]. The mean return ED visits for the Rivaroxaban group was 0.2 (95% CI, 0-0.3) versus 3.9 in the Warfarin group (95% CI, 3.2-4.6) [p<0.001]. The thrombosis clinic referrals increased from 29.5% (13/44) to 86.0% (37/43). There was one PE diagnosed in the Warfarin group within one month of treatment and zero in the Rivaroxaban group. There were 7.9% (5/63) return visits for bleeding in the warfarin group and 3.1% (1/32) in the Rivaroxaban group. Conclusion: By implementing an outpatient DVT treatment guideline at our academic center, we increased the prescribing of Rivaroxaban. This significantly decreased both the ED LOS and return ED visits in the Rivaroxaban group. There was also a threefold increase in referrals to a thrombosis clinic. This was all achieved without increasing patient harm.

Decreasing Emergency Department Visits for Children with Epilepsy

2021 ◽  
pp. 10.1212/CPJ.0000000000001109
Author(s):  
Anup D. Patel ◽  
Andrea Debs ◽  
Debbie Terry ◽  
William Parker ◽  
Mary Burch ◽  
...  
Keyword(s):  
Emergency Department ◽  
Quality Improvement ◽  
Children And Adolescents ◽  
Multidisciplinary Team ◽  
Outcome Measure ◽  
Emergency Department Visits ◽  
Ed Visits ◽  
One Year ◽  
Patients With Epilepsy

AbstractObjectiveEpilepsy and seizures represent a frequent cause of emergency department (ED) visits for patients. By implementing quality improvement (QI) methodology, we planned to decrease ED visits for children and adolescents with epilepsy.MethodsIn 2016, a multidisciplinary team was created to implement QI methodology to address ED visits for patients with epilepsy. Based on previous successes, further ED visit reduction was deemed possible Our aim statement was to decrease the number of ED visits, per 1000 established epilepsy patients, from 13.03 to 11.6, by December 2019 and sustain for one year.ResultsWe successfully decreased ED visits for seizure related care in patients with epilepsy from 13.03% to 10.2% per 1000 patients which resulted in a centerline shift.ConclusionUsing QI methodology, we improved the outcome measure of decreasing ED visits for children with epilepsy. Implementations of these interventions can be considered at other institutions that may lead to similar results.

Efficacy of compression stockings in preventing post-thrombotic syndrome in patients with deep venous thrombosis: a systematic review and metaanalysis

VASA ◽  
2016 ◽  
Vol 45 (2) ◽  
pp. 141-147 ◽  
Author(s):  
Jakob Martin Burgstaller ◽  
Johann Steurer ◽  
Ulrike Held ◽  
Beatrice Amann-Vesti
Keyword(s):  
Systematic Review ◽  
Venous Thrombosis ◽  
Deep Venous Thrombosis ◽  
Cochrane Library ◽  
Compression Stockings ◽  
Post Thrombotic Syndrome ◽  
Study Results ◽  
Preventive Efficacy ◽  
One Year ◽  
The Cochrane Library

Abstract. Background: Here, we update an earlier systematic review on the preventive efficacy of active compression stockings in patients with diagnosed proximal deep venous thrombosis (DVT) by including the results of recently published trials. The aims are to synthesize the results of the original studies, and to identify details to explain heterogeneous results. Methods: We searched the Cochrane Library, PubMed, Scopus, and Medline for original studies that compared the preventive efficacy of active compression stockings with placebo or no compression stockings in patients with diagnosed proximal DVT. Only randomized controlled trials (RCTs) were included. Results: Five eligible RCTs with a total of 1393 patients (sample sizes ranged from 47 to 803 patients) were included. In three RCTs, patients started to wear compression stockings, placebo stockings or no stockings within the first three weeks after the diagnosis of DVT. The results of two RCTs indicate a statistically significant reduction in post-thrombotic syndrome (PTS) of 50% or more after two or more years. The result of one RCT shows no preventive effect of compression stockings at all. Due to the heterogeneity of the study results, we refrained from pooling the results of the RCTs. In a further RCT, randomization to groups with and without compression stockings took place six months after the diagnosis of DVT, and in another RCT, only patients with the absence of PTS one year after the diagnosis of DVT were analyzed. One RCT revealed a significant reduction in symptoms, whereas another RCT failed to show any benefit of using compression stockings. Conclusions: At this time, it does not seem to be justifiable to entirely abandon the recommendations regarding compression stockings to prevent PTS in patients with DVT. There is evidence favoring compression stockings, but there is also evidence showing no benefit of compression stockings.

Heparin Assays and Bleeding Complications in Treatment of Deep Venous Thrombosis with Particular Reference to Retroperitoneal Bleeding

1985 ◽  
Vol 53 (02) ◽  
pp. 278-281 ◽  
Author(s):  
H Asbjørn Holm ◽  
Ulrich Abildgaard ◽  
Sigmund Kalvenes
Keyword(s):  
Venous Thrombosis ◽  
Deep Venous Thrombosis ◽  
Major Bleeding ◽  
Bleeding Complications ◽  
Minor Bleeding ◽  
Thrombin Time ◽  
Heparin Infusion ◽  
Retroperitoneal Bleeding ◽  
Heparin Activity ◽  
The Difference

SummaryBleeding complications occurred in 30 (11%) out of 280 patients who received continuous heparin infusion for deep venous thrombosis (DVT). 22 (8%) had minor while 8 patients (3%) had major bleeding complications (1 intrathoracic [fatal], 2 gastrointestinal and 5 retroperitoneal). Heparin activity, in daily drawn blood samples, was determined by four assays (chromogenic substrate [CS] assay, activated partial thromboplastin time [APTT], thrombin time with citrated plasma [CiTT] and thrombin time with recalcified plasma [CaTT]). The differences in median heparin activity between patients with minor bleeding and patients with no bleeding did not reach significance for any of the tests. In patients with major bleeding, the differences were significant with the CS (p = .011) and the CaTT (p = .030) assays. Patients with retroperitoneal bleeding had significantly increased median activity judged by all four assays: CS (p = .002), CaTT (p = .003), APTT (p = .010), CiTT (p = .029). The difference was most pronounced after four days of heparin treatment, but there was a considerable overlap with patients without bleeding.

High incidence of patients lost to follow-up after venous thromboembolism diagnosis – Identifying an unmet need for targeted transition of care

Vascular ◽  
2021 ◽  
pp. 170853812110209
Author(s):  
Rae S Rokosh ◽  
Jack H Grazi ◽  
David Ruohoniemi ◽  
Eugene Yuriditsky ◽  
James Horowitz ◽  
...  
Keyword(s):  
Emergency Department ◽  
Pulmonary Embolism ◽  
Venous Thromboembolism ◽  
Venous Thrombosis ◽  
Deep Venous Thrombosis ◽  
Time Of Day ◽  
Transition Of Care ◽  
Initial Discharge ◽  
Significant Difference

Objectives Venous thromboembolism, including deep venous thrombosis and pulmonary embolism, is a major source of morbidity, mortality, and healthcare utilization. Given the prevalence of venous thromboembolism and its associated mortality, our study sought to identify factors associated with loss to follow-up in venous thromboembolism patients. Methods This is a single-center retrospective study of all consecutive admitted (inpatient) and emergency department patients diagnosed with acute venous thromboembolism via venous duplex examination and/or chest computed tomography from January 2018 to March 2019. Patients with chronic deep venous thrombosis and those diagnosed in the outpatient setting were excluded. Lost to venous thromboembolism-specific follow-up (LTFU) was defined as patients who did not follow up with vascular, cardiology, hematology, oncology, pulmonology, or primary care clinic for venous thromboembolism management at our institution within three months of initial discharge. Patients discharged to hospice or dead within 30 days of initial discharge were excluded from LTFU analysis. Statistical analysis was performed using STATA 16 (College Station, TX: StataCorp LLC) with a p-value of <0.05 set for significance. Results During the study period, 291 isolated deep venous thrombosis, 25 isolated pulmonary embolism, and 54 pulmonary embolism with associated deep venous thrombosis were identified in 370 patients. Of these patients, 129 (35%) were diagnosed in the emergency department and 241 (65%) in the inpatient setting. At discharge, 289 (78%) were on anticoagulation, 66 (18%) were not, and 15 (4%) were deceased. At the conclusion of the study, 120 patients (38%) had been LTFU, 85% of whom were discharged on anticoagulation. There was no statistically significant difference between those LTFU and those with follow-up with respect to age, gender, diagnosis time of day, venous thromboembolism anatomic location, discharge unit location, or anticoagulation choice at discharge. There was a non-significant trend toward longer inpatient length of stay among patients LTFU (16.2 days vs. 12.3 days, p = 0.07), and a significant increase in the proportion of LTFU patients discharged to a facility rather than home ( p = 0.02). On multivariate analysis, we found a 95% increase in the odds of being lost to venous thromboembolism-specific follow-up if discharged to a facility (OR 1.95, CI 1.1–3.6, p = 0.03) as opposed to home. Conclusions Our study demonstrates that over one-third of patients diagnosed with venous thromboembolism at our institution are lost to venous thromboembolism-specific follow-up, particularly those discharged to a facility. Our work suggests that significant improvement could be achieved by establishing a pathway for the targeted transition of care to a venous thromboembolism-specific follow-up clinic.

scholarly journals Improving pediatric pharmacy services in a primarily adult emergency department

2021 ◽  
Author(s):  
Souheila N Hachem ◽  
Julie M Thomson ◽  
Melissa K Heigham ◽  
Nancy C MacDonald
Keyword(s):  
Emergency Department ◽  
Quality Improvement ◽  
Quality Improvement Initiative ◽  
Pharmacy Services ◽  
Compliance Assessment ◽  
Practice Elements ◽  
Full Compliance ◽  
Institutional Review ◽  
Improve Compliance ◽  
American Society

Abstract Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose The American Society of Health-System Pharmacists (ASHP) and Pediatric Pharmacy Advocacy Group (PPAG) guidelines for providing pediatric pharmacy services in hospitals and health systems can be used to improve medication safety wherever pediatric patients receive care, including in the emergency department (ED). The purpose of this initiative was to improve compliance with these guidelines in a primarily adult ED. Methods This quality improvement initiative was conducted in a level 1 trauma center ED between October 2019 and March 2020. The ASHP-PPAG guidelines were used to create practice elements applicable to the ED. An initial compliance assessment defined elements as noncompliant, partially compliant, fully compliant, or not applicable. Investigators identified interventions to improve compliance for noncompliant or partially compliant elements and then reassessed compliance following implementation. Data were expressed using descriptive statistics. This initiative was exempt from institutional review board approval. Results Ninety-three ED practice elements were identified within the 9 standards of the ASHP-PPAG guidelines. At the initial compliance assessment, the majority (59.8%) of practice elements were fully compliant; however, various service gaps were identified in 8 of the standards, and 16 interventions were implemented to improve compliance. At the final compliance assessment, there was a 19.5% increase in full compliance. Barriers to achieving full compliance included technology restrictions, time constraints, financial limitations, and influences external to pharmacy. Conclusion This quality improvement initiative demonstrated that the ASHP-PPAG guidelines can be used to improve ED pediatric pharmacy services in a primarily adult institution. The initiative may serve as an example for other hospitals to improve compliance with the guidelines.

Abstract WP237: Improved Thrombolysis Rates and Quality of Care for Stroke Patients Through a Provincial Emergency Department Quality Improvement Initiative

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Devin R Harris ◽  
Robert Stenstrom ◽  
Eric Grafstein ◽  
Mark Collison ◽  
Grant Innes ◽  
...  
Keyword(s):  
Emergency Department ◽  
Quality Improvement ◽  
Quality Of Care ◽  
Performance Measures ◽  
Large Scale ◽  
Primary Outcome ◽  
Baseline Data ◽  
Quality Improvement Initiative ◽  
Stroke Patients

Background: The care of stroke patients in the emergency department (ED) is time sensitive and complex. We sought to improve quality of care for stroke patients in British Columbia (B.C.), Canada, emergency departments. Objectives: To measure the outcomes of a large-scale quality improvement initiative on thrombolysis rates and other ED performance measures. Methods: This was an evaluation of a large-scale stroke quality improvement initiative, within ED’s in B.C., Canada, in a before-after design. Baseline data was derived from a medical records review study performed between December 1, 2005 to January 31, 2007. Adherence to best practice was determined by measuring selected performance indicators. The quality improvement initiative was a collaboration between multidisciplinary clinical leaders within ED’s throughout B.C. in 2007, with a focus on implementing clinical practice guidelines and pre-printed order sets. The post data was derived through an identical methodology as baseline, from March to December 2008. The primary outcome was the thrombolysis rate; secondary outcomes consisted of other ED stroke performance measures. Results: 48 / 81 (59%) eligible hospitals in B.C. were selected for audit in the baseline data; 1258 TIA and stroke charts were audited. For the post data, 46 / 81 (57%) acute care hospitals were selected: 1199 charts were audited. The primary outcome of the thrombolysis rate was 3.9% (23 / 564) before and 9.3% (63 / 676) after, an absolute difference of 5.4% (95% CI: 2.3% - 7.6%; p=0.0005). Other measures showed changes: administration of aspirin to stroke patients in the ED improved from 23.7% (127 / 535) to 77.1% (553 / 717), difference = 53.4% (95% CI: 48.3% - 58.1%; p=0.0005); and, door to imaging time improved from 2.25 hours (IQR = 3.81 hours) to 1.57 hours (IQR 3.0), difference = 0.68 hours (p=0.03). Differences were found in improvements between large and small institutions, and between health regions. Conclusions: Implementation of a provincial emergency department quality improvement initiative showed significant improvement in thrombolysis rates and adherence to other best practices for stroke patients. The specific factors that influenced improvement need to be further explored.

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