Dauryne L. Shaffer

Nurse-Perceived Barriers to Effective Communication Regarding Prognosis and Optimal End-of-Life Care for Surgical ICU Patients: A Qualitative Exploration

BACKGROUND Integration of palliative care for intensive care unit (ICU) patients is important but often challenging, especially in surgical ICUs (SICUs), in part because many surgeons equate palliative care with terminal care and failure of restorative care. SICU nurses, who are key front-line clinicians, can provide insights into barriers for delivery of optimal palliative care in their setting. METHODS We developed a focus group guide to identify barriers to two key components of palliative care-optimal communication regarding prognosis and optimal end-of-life care-and used the tool to conduct focus groups of nurses providing bedside care in three SICUs at a tertiary care, academic, inner city hospital. Using content analysis technique, responses were organized into thematic domains that were validated by independent observers and a subset of participating nurses. RESULTS Four focus groups included a total of 32 SICU nurses. They identified 34 barriers to optimal communication regarding prognosis, which were summarized into four domains: logistics, clinician discomfort with discussing prognosis, inadequate skill and training, and fear of conflict. For optimal end-of-life care, the groups identified 24 barriers in four domains: logistics, inability to acknowledge an end-of-life situation, inadequate skill and training, and cultural differences relating to end-of-life care. CONCLUSIONS Nurses providing bedside care in SICUs identify barriers in several domains that may impede optimal discussions of prognoses and end-of-life care for patients with surgical critical illness. Consideration of these perceived barriers and the underlying SICU culture is relevant for designing interventions to improve palliative care in this setting.

Patient Preferences for Receiving Education on Venous Thromboembolism Prevention – A Survey of Stakeholder Organizations

Importance Venous thromboembolism (VTE) is a major cause of morbidity and mortality among hospitalized patients and is largely preventable. Strategies to decrease the burden of VTE have focused on improving clinicians’ prescribing of prophylaxis with relatively less emphasis on patient education. Objective To develop a patient-centered approach to education of patients and their families on VTE: including importance, risk factors, and benefit/harm of VTE prophylaxis in hospital settings. Design, Setting and Participants The objective of this study was to develop a patient-centered approach to education of patients and their families on VTE: including importance, risk factors, and benefit/harm of VTE prophylaxis in hospital settings. We implemented a three-phase, web-based survey (SurveyMonkey) between March 2014 and September 2014 and analyzed survey data using descriptive statistics. Four hundred twenty one members of several national stakeholder organizations and a single local patient and family advisory board were invited to participate via email. We assessed participants’ preferences for VTE education topics and methods of delivery. Participants wanted to learn about VTE symptoms, risk factors, prevention, and complications in a context that emphasized harm. Although participants were willing to learn using a variety of methods, most preferred to receive education in the context of a doctor-patient encounter. The next most common preferences were for video and paper educational materials. Conclusions Patients want to learn about the harm associated with VTE through a variety of methods. Efforts to improve VTE prophylaxis and decrease preventable harm from VTE should target the entire continuum of care and a variety of stakeholders including patients and their families.

The Johns Hopkins Venous Thromboembolism Collaborative: Multidisciplinary team approach to achieve perfect prophylaxis.

Venous thromboembolism (VTE) is an important cause of preventable harm in hospitalized patients. The critical steps in delivery of optimal VTE prevention care include (1) assessment of VTE and bleeding risk for each patient, (2) prescription of risk-appropriate VTE prophylaxis, (3) administration of risk-appropriate VTE prophylaxis in a patient-centered manner, and (4) continuously monitoring outcomes to identify new opportunities for learning and performance improvement. To ensure that every hospitalized patient receives VTE prophylaxis consistent with their individual risk level and personal care preferences, we organized a multidisciplinary task force, the Johns Hopkins VTE Collaborative. To achieve the goal of perfect prophylaxis for every patient, we developed evidence-based, specialty-specific computerized clinical decision support VTE prophylaxis order sets that assist providers in ordering risk-appropriate VTE prevention. We developed novel strategies to improve provider VTE prevention ordering practices including face-to-face performance reviews, pay for performance, and provider VTE scorecards. When we discovered that prescription of risk-appropriate VTE prophylaxis does not ensure its administration, our multidisciplinary research team conducted in-depth surveys of patients, nurses, and physicians to design a multidisciplinary patient-centered educational intervention to eliminate missed doses of pharmacologic VTE prophylaxis that has been funded by the Patient Centered Outcomes Research Institute. We expect that the studies currently underway will bring us closer to the goal of perfect VTE prevention care for every patient. Our learning journey to eliminate harm from VTE can be applied to other types of harm. Journal of Hospital Medicine 2016;11:S8-S14.

No Evidence to Support Ambulation for Reducing Postoperative Venous Thromboembolism

in an updated examination of the national data during the MELD era. 2 However, the inference that waitlist time alone is the factor contributing to the reduced survival in the MGH-migrated cohort has yet to be validated. As we mentioned in our discussion, the lack of complete data from the secondary center, including date of evaluation and listing, was a limitation of the study. The latter data, as well as other contributing factors potentially involved (donor type, operative course, immunosuppression, transplant center/provider practices, fragmentation of care, etc) all warrant further investigation to help ascertain the observed increased mortality in the MGHmigrated group. A mirror analysis by Dr Lee and his colleagues may help better define the complete picture. Third, we agree that a further understanding of the waitlisted population is important. Indeed, our practice now focuses on identifying those waitlisted candidates who fit the demographics of the migrated candidate for discussions regarding the aggressive pursuit of expanded criteria liver allografts or living donor liver transplantation in order to achieve transplant without relocating. In addition, we believe that we must broaden the discussion to consider the at-large population with end-stage liver disease (ESLD). Are there low MELD candidates within our region not referred for evaluation given the high MELD scores required to obtain a transplant? One cannot assume that the entire ESLD population consists only of those referred or listed for liver transplantation. Finally, we disagree with Dr Lee and his colleagues on their interpretation of our data. The geographic disparity that continues to persist across regional lines is irrespective of exception point listing. Indeed, the match MELD score for the MGH-transplanted cohort with HCC exception points was 28, and for non-HCC patients it was 32. In contrast, in a recent report of 966 liver transplants performed at Mayo Clinic, Jacksonville, FL from 2005 to 2010, 96% of the recipients had a median MELD score of 20. 3 We believe our data demonstrate that a privileged few who are unable to achieve transplant in Region 1, dueto lowMELD scores, migrate in order toreceive a liver transplant, but do so at the cost of a reduced 5-year overall survival. Furthermore, although we agree with Dr Lee and his colleagues that the MGH-migrated cohort, with a match MELD of 19.6, have the potential to benefit from liver transplantation, we do not believe that they should havetotravelacrosstheUnitedStatestoobtainthatbenefit. A geographic inequity for the distribution of livers continues to exist. We applaud the efforts put forth by the

Exploring the impact of route of administration on medication acceptance in hospitalized patients: Implications for venous thromboembolism prevention

BACKGROUND Non-administration of venous thromboembolism (VTE) prophylaxis contributes to preventable patient harm. We hypothesized that non-administration would be more common for parenteral VTE prophylaxis than oral infectious disease or cardiac prophylaxis or for treatment medications. The primary study goal was to determine if non-administration of parenteral VTE prophylaxis is more frequent than other prophylactic or treatment medications. METHODS In this retrospective cohort study of consecutive admissions we used descriptive statistics and risk ratios (RR) to compare the number of non-administered doses of VTE prophylaxis, oral infectious disease and cardiovascular prophylaxis and treatment medications. To quantify the influence of demographic and clinical characteristics on non-administration, we estimated incidence rate ratios from Poisson regression models. RESULTS 645 patients were admitted from July 1, 2014 through March 31, 2015. Median age was 52years (Interquartile range 43-57) and 365 (56.6%) were male. Subcutaneous VTE prophylaxis doses were not administered nearly 4-fold more frequently than oral infectious disease and cardiovascular prophylaxis (RR=3.93; 95% CI 3.36-4.59) and 3-fold more frequently than treatment medications (RR=3.06; 95% CI 2.91-3.22). Ninety percent of non-administered doses of VTE prophylaxis were refused. Risk factors for non-administration included younger age (age 18-35years), male sex, uninsured status, HIV-positivity and high VTE risk status. CONCLUSIONS Subcutaneous VTE prophylaxis is not administered more frequently than oral infectious diseases or cardiac prophylaxis and treatment medications. These data suggest that availability of an oral medication could improve the effectiveness of VTE prophylaxis in real world settings.

Venous Thromboembolism in Patients Hospitalized for Lung Transplantation

BACKGROUND Venous thromboembolism (VTE) is an important complication after solid organ transplantation. We sought to evaluate any association between VTE and in-hospital death, length of hospitalization, and total hospital charges for patients hospitalized for lung transplantation (LT). METHODS We retrospectively reviewed the Nationwide Inpatient Sample to identify patients hospitalized for LT from 2000 to 2011. We evaluated the incidence of VTE during hospitalization for LT, risk factors for VTE, and the association between VTE and in-hospital death, length of hospitalization, and total hospital charges. RESULTS Of the 16,318 adults hospitalized for LT during the study period, VTE developed in 1,029 (6.3%), including 854 (5.4%) with deep vein thrombosis alone and 175 (1.1%) with pulmonary embolism. The factors associated with VTE included age older than 60 years (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.03 to 1.94), female sex (OR, 0.61; 95% CI, 0.44 to 0.86), and receiving mechanical ventilation support for 96 hours or more (OR, 3.38; 95% CI, 2.49 to 4.58). The adjusted odds of in-hospital death in patients with pulmonary embolism was thrice as high as those without any VTE (OR, 3.40; 95% CI, 1.29 to 8.99). Among LT patients with VTE, the average length of hospitalization was 38% (95% CI, 27% to 48%) longer, and the total cost of hospitalization was 23% (95% CI, 16% to 30%) higher compared with LT patients without VTE. CONCLUSIONS VTE is a relatively frequent complication among LT recipients and is associated with increased death, total hospital length of stay, and hospital charges. These data indicate that prophylaxis practices should be reexamined to reduce this preventable complication.

Nonadministration of medication doses for venous thromboembolism prophylaxis in a cohort of hospitalized patients

Purpose. Results of a study to characterize patterns of nonadministration of medication doses for venous thromboembolism (VTE) prevention among hospitalized patients are presented. Methods. The electronic records of all patients admitted to 4 floors of a medical center during a 1‐month period were examined to identify patients whose records indicated at least 1 nonadministered dose of medication for VTE prophylaxis. Proportions of nonadministered doses by medication type, intended route of administration, and VTE risk categorization were compared; reasons for nonadministration were evaluated. Results. Overall, 12.7% of all medication doses prescribed to patients in the study cohort (n = 75) during the study period (857 of 6,758 doses in total) were not administered. Nonadministration of 1 or more doses of VTE prophylaxis medication was nearly twice as likely for subcutaneous anticoagulants than for all other medication types (231 of 1,112 doses [20.8%] versus 626 of 5,646 doses [11.2%], p < 0.001). For all medications prescribed, the most common reason for nonadministration was patient refusal (559 of 857 doses [65.2%]); the refusal rate was higher for subcutaneous anticoagulants than for all other medication categories (82.7% versus 58.8%, p < 0.001). Doses of antiretrovirals, immunosuppressives, antihypertensives, psychiatric medications, analgesics, and antiepileptics were less commonly missed than doses of electrolytes, vitamins, and gastrointestinal medications. Conclusion. Scheduled doses of subcutaneous anticoagulants for hospitalized patients were more likely to be missed than doses of all other medication types.

Effectiveness of two distinct web-based education tools for bedside nurses on medication administration practice for venous thromboembolism prevention: A randomized clinical trial

Background Venous thromboembolism (VTE) is a common cause of preventable harm in hospitalized patients. While numerous successful interventions have been implemented to improve prescription of VTE prophylaxis, a substantial proportion of doses of prescribed preventive medications are not administered to hospitalized patients. The purpose of this trial was to evaluate the effectiveness of nurse education on medication administration practice. Methods This was a double-blinded, cluster randomized trial in 21 medical or surgical floors of 933 nurses at The Johns Hopkins Hospital, an academic medical center, from April 1, 2014 –March 31, 2015. Nurses were cluster-randomized by hospital floor to receive either a linear static education (Static) module with voiceover or an interactive learner-centric dynamic scenario-based education (Dynamic) module. The primary and secondary outcomes were non-administration of prescribed VTE prophylaxis medication and nurse-reported satisfaction with education modules, respectively. Results Overall, non-administration improved significantly following education (12.4% vs. 11.1%, conditional OR: 0.87, 95% CI: 0.80–0.95, p = 0.002) achieving our primary objective. The reduction in non-administration was greater for those randomized to the Dynamic arm (10.8% vs. 9.2%, conditional OR: 0.83, 95% CI: 0.72–0.95) versus the Static arm (14.5% vs. 13.5%, conditional OR: 0.92, 95% CI: 0.81–1.03), although the difference between arms was not statistically significant (p = 0.26). Satisfaction scores were significantly higher (p<0.05) for all survey items for nurses in the Dynamic arm. Conclusions Education for nurses significantly improves medication administration practice. Dynamic learner-centered education is more effective at engaging nurses. These findings suggest that education should be tailored to the learner. Trial registration ClinicalTrials.gov NCT02301793