Lynda Bonner

Comprehensive VTE Prevention Program Incorporating Mandatory Risk Assessment Reduces the Incidence of Hospital-Associated Thrombosis

BACKGROUND VTE is a common complication of hospitalization and is associated with significant morbidity and mortality. The use of appropriate thromboprophylaxis can significantly reduce the risk of VTE but remains underutilized. In England, a comprehensive approach to VTE prevention was launched in 2010. This study aimed to evaluate the impact of the implementation of the national program in a single center. METHODS A prospective quality improvement program was established at Kings College Hospital NHS Foundation Trust in 2010. The multidisciplinary thrombosis team launched mandatory documented VTE risk assessment and updated thromboprophylaxis guidance. Root cause analysis of hospital-associated thrombosis (HAT) was implemented to identify system failures, enable outcome measurement, and facilitate learning to improve VTE prevention practice. The key outcomes were the incidence of HAT and the proportion of events preventable with appropriate thromboprophylaxis. RESULTS Documented VTE risk assessment improved from <40% to > 90% in the first 9 months. Four hundred twenty-five episodes of HAT were identified over 2 years. A significant reduction in the incidence of HAT was observed following sustained achievement of 90% risk assessment (risk ratio, 0.88; 95% CI, 0.74-0.98; P = .014). The proportion of HAT attributable to inadequate thromboprophylaxis fell significantly from 37.5% to 22.4% (P = .005). CONCLUSIONS Mandatory VTE risk assessment can significantly reduce preventable HAT and thereby improve patient safety.

Presenting D-dimer and early symptom severity are independent predictors for post-thrombotic syndrome following a first deep vein thrombosis.

Post‐thrombotic syndrome (PTS) is the most common complication of deep vein thrombosis (DVT). Current preventative strategies are limited to the daily wear of graduated compression stockings (GCS). The aim of this study was to evaluate early predictors of PTS. One hundred and twenty‐two consecutive patients with a first DVT were prospectively recruited from diagnosis and followed for up to 6 months post‐end of anticoagulation. D‐dimer was measured in 107 participants at presentation and Villalta scale was evaluated in 70 participants at a median of 2 weeks following diagnosis. PTS developed in 51·6% of participants. GCS were obtained by 78·1% of participants, with 33·7% reporting daily wear at the end of follow‐up. Mean early Villalta scale was significantly higher in those with PTS (8·1 ± 3·7) compared to those without (2·6 ± 2·7, P < 0·001). Median D‐dimer was significantly higher in those with PTS [3260 ng/ml, interquartile range (IQR) 820–8000 ng/ml] compared to those without (1540 ng/ml, IQR 810–2520 ng/ml, P < 0·001). The adjusted odds ratio for every one point increase in early Villalta scale was 1·78 [95% confidence interval (CI), 1·19–2·64; P = 0·005] and for D‐dimer >1910 ng/ml it was 2·71 (95% CI, 1·05–7·03; P = 0·04). These markers could enable targeted counselling regarding GCS for those at high risk of PTS.

Post-thrombotic syndrome is an independent determinant of health-related quality of life following both first proximal and distal deep vein thrombosis

Post-thrombotic syndrome (PTS) is a common complication of deep vein thrombosis (DVT), affecting between 20 and 50%.[1][1] DVT and PTS have been demonstrated to adversely impact on disease-specific and generic measures of health-related quality of life (QOL).[2][2],[3][3] We sought to establish

African-Caribbean ethnicity is associated with a hypercoagulable state as measured by thrombin generation.

African–Caribbean ethnicity is associated with an increased risk of both first and recurrent venous thromboembolism (VTE). The aim of this study was to evaluate thrombin generation in African–Caribbeans compared with whites in patients with deep vein thrombosis (DVT) and healthy volunteers. Thrombin generation was measured in a case–control study of 80 patients who had completed anticoagulation therapy for a first DVT (50 white and 30 African–Caribbean) and 66 controls. Peak thrombin with and without thrombomodulin was significantly higher in African–Caribbeans with DVT compared with whites with DVT (P < 0.001 for both comparisons) and African–Caribbean controls (P < 0.001, 0.003, respectively). Endogenous thrombin potential (ETP) with and without thrombomodulin was significantly higher in African–Caribbeans with DVT than whites with DVT (P ⩽ 0.001 for both comparisons). Maximum velocity and ETP ratio were increased in African–Caribbeans with DVT compared with whites with DVT (P < 0.001 and 0.030, respectively) and African–Caribbean controls (P < 0.001 and 0.019, respectively). Within the control group, peak thrombin was significantly increased in African–Caribbeans compared with whites (P = 0.017). ETP, peak thrombin with thrombomodulin and maximum velocity were also increased in African–Caribbeans compared with white controls (P = 0.045 for all comparisons). African–Caribbeans with DVT had significantly higher factor VIII levels compared with whites with DVT and controls. African–Caribbean ethnicity confers a hypercoagulable state as measured by thrombin generation. This supports epidemiological findings of increased risk of first and recurrent VTE. Thrombin generation requires adjustment for ethnicity in studies undertaken in ethnically diverse populations.

A survey of work engagement and psychological capital levels

AIM To evaluate the relationship between work engagement and psychological capital (PsyCap) levels reported by registered nurses. BACKGROUND PsyCap is a developable human resource. Research on PsyCap as an antecedent to work engagement in nurses is needed. METHODS A convenience sample of 137 registered nurses participated in this quantitative cross-sectional survey. Questionnaires measured self-reported levels of work engagement and psychological capital. Descriptive and inferential statistics were used for data analysis. RESULTS There was a statistically significant correlation between work engagement and PsyCap scores (r=0.633, p<0.01). Nurses working at band 5 level reported statistically significantly lower PsyCap scores compared with nurses working at band 6 and 7 levels. CONCLUSION Nurses reporting high levels of work engagement also reported high levels of PsyCap. Band 5 nurses might benefit most from interventions to increase their PsyCap. This study supports PsyCap as an antecedent to work engagement.