Alan Karovitch

Do postal reminders increase postpartum screening of diabetes mellitus in women with gestational diabetes mellitus? A randomized controlled trial

OBJECTIVE Women with previous gestational diabetes mellitus rarely receive the recommended 2-hour oral glucose tolerance test (OGTT) after delivery. We sought to determine whether postal reminders to be sent after delivery to a patient, her physician, or both would increase screening rates. STUDY DESIGN Patients were assigned randomly to 4 groups: reminders sent to both physician and patient, to physician but not patient, or to patient but not physician or no reminders were sent. The primary outcome was the proportion of patients who underwent an OGTT within 1 year after delivery. The secondary outcome was the performance of other postpartum screening tests. RESULTS OGTT rates were significantly increased in the physician/patient reminder group (49/81 women; 60.5%), in the patient-only reminder group (42/76 women; 55.3%), and in the physician-only reminder group (16/31 women; 51.6%) compared with the no reminder group (5/35 women; 14.3%; P < .05). CONCLUSION Postpartum reminders greatly increased screening rates for women with gestational diabetes mellitus.

Improving physician hand hygiene compliance using behavioural theories: a study protocol

BackgroundHealthcare-associated infections affect 10% of patients in Canadian acute-care hospitals and are significant and preventable causes of morbidity and mortality among hospitalized patients. Hand hygiene is among the simplest and most effective preventive measures to reduce these infections. However, compliance with hand hygiene among healthcare workers, specifically among physicians, is consistently suboptimal. We aim to first identify the barriers and enablers to physician hand hygiene compliance, and then to develop and pilot a theory-based knowledge translation intervention to increase physicians’ compliance with best hand hygiene practice.DesignThe study consists of three phases. In Phase 1, we will identify barriers and enablers to hand hygiene compliance by physicians. This will include: key informant interviews with physicians and residents using a structured interview guide, informed by the Theoretical Domains Framework; nonparticipant observation of physician/resident hand hygiene audit sessions; and focus groups with hand hygiene experts. In Phase 2, we will conduct intervention mapping to develop a theory-based knowledge translation intervention to improve physician hand hygiene compliance. Finally, in Phase 3, we will pilot the knowledge translation intervention in four patient care units.DiscussionIn this study, we will use a behavioural theory approach to obtain a better understanding of the barriers and enablers to physician hand hygiene compliance. This will provide a comprehensive framework on which to develop knowledge translation interventions that may be more successful in improving hand hygiene practice. Upon completion of this study, we will refine the piloted knowledge translation intervention so it can be tested in a multi-site cluster randomized controlled trial.

The management of thrombophilia during pregnancy: a Canadian survey.

OBJECTIVE To determine current Canadian practice patterns in the management of pregnant women with thrombophilia. METHODS Physician members of the Society of Obstetricians and Gynaecologists of Canada (SOGC) who provide obstetrical care were invited to complete a closed-ended questionnaire in which they were presented 5 clinical scenarios involving thrombophilic pregnancies and asked to give their management recommendations. The 5 scenarios presented in the survey were of a pregnant woman with (1) asymptomatic factor V Leiden (FVL), (2) asymptomatic FVL and a family history of venous thromboembolism (VTE), (3) FVL and recurrent fetal loss, (4) FVL and a previous VTE, or (5) antiphospholipid antibody syndrome and recurrent fetal loss. RESULTS Of the 1448 eligible SOGC members invited, 18 had moved with no forwarding address, and 662 (46.3% of the remainder) responded. The majority (65%) of the respondents were obstetricians and 51% of them had a university-affiliated practice. In scenario 1, 26% of physicians indicated they would recommend some form of antepartum thromboprophylaxis, whereas in the remaining four scenarios, 58% to 84% would definitely recommend antepartum thromboprophylaxis. CONCLUSION Most clinicians favour intervening with thromboprophylaxis in pregnant thrombophilic women rather than observing without prophylaxis. This tendency spans a wide range of clinical scenarios, despite a lack of evidence to support such decisions. This survey highlights the need to provide clinicians and women with evidence for the safety and effectiveness of prophylaxis, before these interventions become the default recommendation by clinicians caring for this prevalent group of women.

Understanding practice: factors that influence physician hand hygiene compliance.

OBJECTIVE To identify the behavioral determinants--both barriers and enablers--that may impact physician hand hygiene compliance. DESIGN A qualitative study involving semistructured key informant interviews with staff physicians and residents. SETTING An urban, 1,100-bed multisite tertiary care Canadian hospital. PARTICIPANTS A total of 42 staff physicians and residents in internal medicine and surgery. METHODS Semistructured interviews were conducted using an interview guide that was based on the theoretical domains framework (TDF), a behavior change framework comprised of 14 theoretical domains that explain health-related behavior change. Interview transcripts were analyzed using thematic content analysis involving a systematic 3-step approach: coding, generation of specific beliefs, and identification of relevant TDF domains. RESULTS Similar determinants were reported by staff physicians and residents and between medicine and surgery. A total of 53 specific beliefs from 9 theoretical domains were identified as relevant to physician hand hygiene compliance. The 9 relevant domains were knowledge; skills; beliefs about capabilities; beliefs about consequences; goals; memory, attention, and decision processes; environmental context and resources; social professional role and identity; and social influences. CONCLUSIONS We identified several key determinants that physicians believe influence whether and when they practice hand hygiene at work. These beliefs identify potential individual, team, and organization targets for behavior change interventions to improve physician hand hygiene compliance.

Use of Low Molecular Weight Heparin in Acute Venous Thromboembolic Events in Pregnancy

OBJECTIVE To compare the maternal and neonatal outcomes arising from the use of low molecular weight heparin (LMWH) or unfractionated heparin (UFH) in the treatment of acute venous thromboembolism (VTE) in pregnancy. STUDY DESIGN A retrospective review of the charts of all women treated for acute VTE in pregnancy at the Ottawa Hospital from January 1990 to December 1999. RESULTS Twenty-three cases were identified, of which 11 were treated with LMWH and 12 with UFH. Maternal and fetal outcomes were similar between the two groups. Hospital length of stay was shorter in the LMWH group. There was no difference in delivery management between the two groups. There was minor bleeding in 2 women in the UFH group and none in the LMWH group. There was one recurrent VTE during treatment in each of the groups. CONCLUSION There is no difference in complication rate between LMWH and UFH in the treatment of acute VTE in pregnancy.

Guidance for the diagnosis of pulmonary embolism during pregnancy: Consensus and controversies

Pulmonary embolism (PE) is one of the leading causes of maternal mortality despite a low incidence of PE during pregnancy. Several challenges surround the diagnosis of PE in pregnant women and the existing clinical guidelines provide weak recommendations on selecting the appropriate investigations for suspected PE in pregnancy. The purpose of this narrative review is to compare and contrast the recommendations of current clinical guidelines and review the evidence underpinning the recommendations on the evaluation of suspected PE in pregnancy. Consensus and controversies, knowledge gaps and areas requiring further research will be highlighted.

Clinical predictors for diabetes screening in the first year postpartum after gestational diabetes

Background: Postpartum screening for diabetes in women with gestational diabetes (GDM) improves with use of reminder systems. Our primary objective was to identify predictors of diabetes screening in the first year after delivery. Methods: A retrospective study was performed of 556 women with GDM who received outpatient prenatal care between 2007 and 2009. A mailed reminder system was utilized at two sites. Rates of postpartum glucose testing at 6 and 12 months postpartum were measured. Results: Site of care and non-smoking status were identified as the only predictors of postpartum diabetes screening (p<0.001 and p = 0.02, respectively). Rates of OGTT completion at one year (38% vs. 19% p<0.001) were higher in women who attended clinics with postpartum reminders. Conclusions: The site of diabetes care in pregnancy is a major predictor of adherence to diabetes screening postpartum. Health care delivery should be considered in the development of strategies to increase screening rates.

Contemporary Management of the High-Risk Pulmonary Embolism: The Clot Thickens

Pulmonary embolism (PE) is a common disease process encountered in the acute care setting. It presents on a spectrum of severity with the most severe presentations carrying a substantial risk of morbidity and mortality. In recent years, a wide range of competing treatment strategies have been proposed for the high-risk PE including new catheter-based and extracorporeal techniques, and management has become more challenging. There is currently no consensus as to the optimal approach to treatment. Contemporary management decisions are informed by the balance between the risk of deterioration and the risk of harm from intervention, within the available resources. This review will summarize the current evidence to better inform clinical decision-making in high-risk PE and highlight future directions in management.

Development and Implementation of a DKA Protocol for Adults with Type 1 and Type 2 Diabetes at a Tertiary Care Multi-Campus Hospital

OBJECTIVES Diabetic ketoacidosis (DKA) is associated with significant morbidity and mortality. Using standardized protocols for DKA management improves outcomes and is recommended in Diabetes Canadas clinical practice guidelines. Audits of DKA care at our institution revealed inconsistent management. We developed, piloted and evaluated a standardized DKA protocol adapted into preprinted order sets for use in the emergency department and the acute monitoring area. METHODS The protocol was developed by an expert committee on the basis of Diabetes Canadas clinical practice guidelines, a literature review and an environmental survey. A before-and-after analysis was used. Uptake of the DKA protocol and clinical outcomes were monitored through statistical process control. RESULTS Patients admitted postprotocol (n=55, mean age 37.9 years [SD 17.5 years], 62% male, 85% type 1 diabetes) were compared to those admitted preprotocol (n=55, mean age 43.3 years [SD 17.5 years], 53% male, 67.2% type 1 diabetes). Postimplementation, 87% of patients were managed according to the protocol. Postprotocol ordering of appropriate laboratory investigations increased, appropriate intravenous (IV) fluid resuscitation improved, continuation of IV insulin until anion gap closure increased, mean time to anion gap closure decreased and mean length of stay was reduced. Of those surveyed, 85% of nurses and 74% of physicians felt that the protocol improved patient care, and 75% of patients rated their DKA management as being satisfactory. CONCLUSIONS Successful implementation of a standardized preprinted protocol for DKA management significantly improved best practices for DKA management and was valued by treating clinicians.

A 2 hr oral glucose tolerance test will identify more women at risk for type 2 diabetes when screening postpartum in gestational diabetics.

A 2 hr oral glucose tolerance test will identify more women at risk for type 2 diabetes when screening postpartum in gestational diabetics. Heather D. Clark*, Alan Karovitch, Erin J Keely, Departments of Medicine and Obstetrics/Gynecology, University of Ottawa, Ottawa ON The CDA 2003 Clinical Practice guidelines recommends screening women with gestational diabetes (GDM) in the first 6 months postpartum for type 2 Diabetes Mellitus (T2DM) with a 2 hour 75 g oral glucose tolerance test (2 hr GTT) as a fasting glucose may lead to under-diagnosis of T2DM (Grade D, consensus) and can not identify impaired glucose tolerance (IGT). We performed a randomized controlled trial evaluating the effect of postal reminders on screening rates in women with GDM. All women from this cohort who completed a 2 hr GTT were included. We determined the rates of impaired fasting glucose (IFG) and T2DM diagnosed by a fasting glucose and IGT and T2DM diagnosed by a 2 hr GTT. Of the 428 patients 156 women completed a 2 hr GTT. 20/156 (12.8%) were diagnosed with IFG, 27/156 (17.3%) were diagnosed with IGT and 4/156 (2.6%) were diagnosed with both. 3/156 (1.9%) women were diagnosed with T2DM by a fasting glucose and 8/156 (5.1%) were diagnosed based on the 2 hr glucose result only. If a two step testing strategy was utilized (i.e. only women with fasting glucose >5.6 mmol/L screened with 2 hr GTT ) 15/27 (56%) of women with IGT and 3/11 (27%) of women with T2DM would be missed. In summary, we found if women were screened postpartum with a fasting glucose alone or a two step screening strategy miss a substantial proportion of women with IGT and T2DM, were missed supporting the CDA recommendations.