Franklin A. Michota

Bridging the Gap Between Evidence and Practice in Venous Thromboembolism Prophylaxis: The Quality Improvement Process

Venous thromboembolism (VTE) is considered to be the most common preventable cause of hospital-related death. Hospitalized patients undergoing major Surgery and hospitalized patients with acute medical illness have an increased risk of VTE. Although there is overwhelming evidence for the need and efficacy of VTE prophylaxis in patients at risk, only about a third of those who are at risk of VTE receive appropriate prophylaxis. To address the shortfall in VTE prophylaxis, the US Joint Commission and the National Quality Forum (NQF) endorse standardized VTE prophylaxis practices, and are identifying and testing measures to monitor these standards. Hospitals in the USA accredited by Centers for Medicare and Medicaid Services to receive medicare patients will need VTE prophylaxis programs in place to conform to these national consensus standards. This review aims to give background information on initiatives to improve the prevention of VTE and to identify key features of a successful quality improvement strategy for prevention of VTE in the hospital. A literature review shows that the key features of effective quality improvement strategies includes an active strategy, a multifaceted approach, and a continuous iterative process of audit and feedback. Risk assessment models may be helpful for deciding which patients should receive prophylaxis and for matching VTE risk with the appropriate intensity of prophylaxis. This approach should assist in implementing the NQF/Joint Commission-endorsed standards, as well as increase the use of appropriate VTE prophylaxis.

Managing diabetes in hemodialysis patients: observations and recommendations.

Diabetes is challenging to manage in patients who have end-stage renal disease (ESRD), as both uremia and dialysis can complicate glycemic control by affecting the secretion, clearance, and peripheral tissue sensitivity of insulin. The authors summarize the available evidence and make practical recommendations. Both uremia and dialysis can complicate glycemic control by affecting the secretion, clearance, and peripheral tissue activity of insulin.

Outcomes of patients with stable heart failure undergoing elective noncardiac surgery.

OBJECTIVEnTo evaluate modern surgical outcomes in patients with stable heart failure undergoing elective major noncardiac surgery and to compare the experience of patients with heart failure who have reduced vs preserved left ventricular ejection fraction (EF).nnnPATIENTS AND METHODSnWe retrospectively studied 557 consecutive patients with heart failure (192 EF less than or equal to 40% and 365 EF greater than 40%) and 10,583 controls who underwent systematic evaluation by hospitalists in a preoperative clinic before having major elective noncardiac surgery between January 1, 2003, and March 31, 2006. We examined outcomes in the entire cohort and in propensity-matched case-control groups.nnnRESULTSnUnadjusted 1-month postoperative mortality in patients with both types of heart failure vs controls was 1.3% vs 0.4% (P equals .009), but this difference was not significant in propensity-matched groups (P equals .09). Unadjusted differences in mean hospital length of stay among heart failure patients vs controls (5.7 vs 4.3 days; P less than .001) and 1-month readmission (17.8% vs 8.5%; P less than .001) were also markedly attenuated in propensity-matched groups. Crude 1-year hazard ratios for mortality were 1.71 (95% confidence interval [CI], 1.5-2.0) for both types of heart failure, 2.1 (95% CI, 1.7-2.6) in patients with heart failure who had EF less than or equal to 40%, and 1.4 (95% CI, 1.2-1.8) in those who had EF greater than 40% (P less than .01 for all 3 comparisons); however, the differences were not significant in propensity-matched groups (P equals .43).nnnCONCLUSIONnPatients with clinically stable heart failure did not have high perioperative mortality rates in association with elective major noncardiac surgery, but they were more likely than patients without heart failure to have longer hospital stays, were more likely to require hospital readmission, and had a substantial long-term mortality rate.

Rational Use of D-Dimer Measurement to Exclude Acute Venous Thromboembolic Disease

Clinical diagnosis of venous thromboembolic (VTE) disease is often inaccurate because signs and symptoms are nonspecific. Testing for the absence of D-dimer levels in the blood of patients with suspected deep venous thrombosis and pulmonary embolism can assist in ruling out these illnesses. Some highly sensitive D-dimer assays have sufficient specificity to assist in the exclusion of VTE disease. Numerous clinical management trials using D-dimer measurement in association with additional diagnostic tests have shown that it is safe to withhold anticoagulant therapy in selected patients with suspected VTE disease who have negative D-dimer assay results. Applying these diagnostic strategies can potentially decrease the need for radiological testing. The simplicity of measuring D-dimer levels creates the potential for misuse. For safe patient management, clinicians must understand the indications for and limitations of D-dimer measurement in the diagnosis of VTE disease.

Venous thromboembolism: Epidemiology, characteristics, and consequences

Venous thromboembolism (VTE) and its manifestations, including deep vein thrombosis (DVT) and pulmonary embolism (PE), pose a life-threatening health problem for thousands of people each year. The diagnosis of VTE is frequently missed, however, because few signs and symptoms are recognized. Symptoms of DVT may include pain, erythema, tenderness, and swelling of the affected limb, whereas PE often presents as sudden breathlessness with chest pain, or collapse with shock in the absence of other causes. Greater awareness of the epidemiology of VTE, the consequences of VTE, and the risk factors for VTE can help health care providers take appropriate preventive measures to reduce the incidence of VTE.

Transitions of care in anticoagulated patients

Anticoagulation is an effective therapeutic means of reducing thrombotic risk in patients with various conditions, including atrial fibrillation, mechanical heart valves, and major surgery. By its nature, anticoagulation increases the risk of bleeding; this risk is particularly high during transitions of care. Established anticoagulants are not ideal, due to requirements for parenteral administration, narrow therapeutic indices, and/or a need for frequent therapeutic monitoring. The development of effective oral anticoagulants that are administered as a fixed dose, have low potential for drug-drug and drug-food interactions, do not require regular anticoagulation monitoring, and are suitable for both inpatient and outpatient use is to be welcomed. Three new oral anticoagulants, the direct thrombin inhibitor, dabigatran etexilate, and the factor Xa inhibitors, rivaroxaban and apixaban, have been approved in the US for reducing the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation; rivaroxaban is also approved for prophylaxis and treatment of deep vein thrombosis, which may lead to pulmonary embolism in patients undergoing knee or hip replacement surgery. This review examines current options for anticoagulant therapy, with a focus on maintaining efficacy and safety during transitions of care. The characteristics of dabigatran etexilate, rivaroxaban, and apixaban are discussed in the context of traditional anticoagulant therapy.

Venous thromboembolism prophylaxis in the medically ill patient

All general medical patients should be assessed for clinical risk factors for VTE. The ACCP has recommended that general medical patients with clinical risk factors receive either LDUH twice or three times daily or once-daily LMWH. Current evidence suggests that twice-daily LDUH may not be efficacious enough in the acutely ill medical inpatient. LDUH three times daily may be efficacious in most medical patients; however, it is associated with an increased risk for bleeding. The preferred strategy for prevention in the medically ill population at high to very high risk for VTE is LMWH. For patients who have a high to very high risk for bleeding, nonpharmacologic strategies such as ES or IPC devices are recommended.

Update in Hospital Medicine

The boundaries of hospital medicine are not defined by specific organs and their associated diseases but rather by the severity of the patients condition, the subsequent risk for morbidity and death, and the intensity and monitoring of treatment necessary to provide care. Four content areas relevant to the care of hospitalized patients are the focus of this Update: nosocomial illness, community-acquired pneumonia, venous thromboembolic disease, and prognostic variables. Nosocomial Illness Physicians take an oath to do no harm, but the hospital environment itself carries its own risk. This disparity is addressed in the following section through a discussion of antibiotic resistance, stress ulceration and upper gastrointestinal bleeding, hospital-acquired pressure ulcers, and adverse drug reactions. Vancomycin Resistance Has a Negative Effect on Survival and Leads to Higher Health Care Costs Stosor V, Peterson LR, Postelnick M, et al. Enterococcus faecium bacteremia: does vancomycin resistance make a difference? Arch Intern Med. 1998; 158:522-7. Stosor and colleagues retrospectively analyzed the clinical features and outcomes of 53 patients with Enterococcus faecium bacteremia to better understand the epidemiologic characteristics of vancomycin-resistant enterococcus (VRE) bacteremia and to determine the clinical effect of vancomycin resistance on the outcome of patients with this infection. In the records reviewed, there were 32 episodes of vancomycin-susceptible enterococcus (VSE) bacteremia and 21 episodes of VRE bacteremia. All cases of VRE bacteremia were nosocomially acquired. Previous administration of vancomycin was associated with VRE bacteremia (16 [80%] cases of VRE compared with 10 [34%] cases of VSE; P<0.002), as were indwelling bladder catheters (13 [62%] cases of VRE compared with 9 [28%] cases of VSE; P=0.01). Survival rates for patients with VSE and VRE bacteremia were 59% and 24%, respectively (P=0.009), despite similar severity-of-illness scores. Patients infected with VRE had longer hospitalizations and were more likely to be on the medical service. On average, they had hospitalization costs that were about

Stroke Prevention in Atrial Fibrillation

27 000 more per episode than those of patients with VSE infection (

Intracerebral hemorrhage: Pick your poison

83 897 compared with