Paul J. Grant

Hospital Performance for Pharmacologic Venous Thromboembolism Prophylaxis and Rate of Venous Thromboembolism : A Cohort Study

IMPORTANCE Hospitalization for acute medical illness is associated with increased risk of venous thromboembolism (VTE). Although efforts designed to increase use of pharmacologic VTE prophylaxis are intended to reduce hospital-associated VTE, whether higher rates of prophylaxis reduce VTE in medical patients is unknown. OBJECTIVE To examine the association between pharmacologic VTE prophylaxis rates and hospital-associated VTE. DESIGN, SETTING, AND PARTICIPANTS Retrospective, multicenter cohort study conducted at 35 Michigan hospitals participating in a statewide quality collaborative from January 1, 2011, through September 13, 2012. Trained medical record abstractors at each hospital collected data from 31 260 general medical patients. Use of VTE prophylaxis on admission, VTE risk factors, and VTE events 90 days after hospital admission were recorded using a combination of medical record review and telephone follow-up. Hospitals were grouped into tertiles of performance based on rate of pharmacologic prophylaxis use on admission for at-risk patients. MAIN OUTCOMES AND MEASURES Association between hospital performance and time to development of VTE within 90 days of hospital admission. RESULTS A total of 14 563 of 20 794 patients (70.0%) eligible for pharmacologic prophylaxis received prophylaxis on admission. The rates of pharmacologic prophylaxis use at hospitals in the high-, moderate-, and low-performance tertiles were 85.8%, 72.6%, and 55.5%, respectively. A total of 226 VTE events occurred during 1 765 449 days of patient follow-up. Compared with patients at hospitals in the highest-performance tertile, the hazard of VTE in patients at hospitals in moderate-performance (hazard ratio, 1.10; 95% CI, 0.74-1.62) and low-performance (hazard ratio, 0.96, 95% CI, 0.63-1.45) tertiles did not differ after adjusting for potential confounders. Results remained robust when examining mechanical prophylaxis, prophylaxis use throughout the hospitalization, and subsequent inpatient stays after discharge from the index hospitalization. CONCLUSIONS AND RELEVANCE The occurrence of 90-day VTE in medical patients after hospitalization is low. Patients who receive care at hospitals that have lower rates of pharmacologic prophylaxis do not have higher adjusted hazards of VTE, even after accounting for individual receipt of pharmacologic prophylaxis. Efforts to increase rates of pharmacologic VTE prophylaxis in hospitalized medical patients may not substantively reduce this adverse outcome.

Update in Perioperative Medicine 2011

The field of perioperative medicine continues to mature as evidenced by the growing number of high-quality articles published each year. This is encouraging given the increasingly complex patient population that routinely undergoes major surgery. Furthermore, as surgeons have become more sub-specialized, there is increased reliance on the generalist to perform consultative medicine for the preoperative patient, as well as co-manage patients throughout the hospitalization.

Perioperative Medicine for the Hospitalized Patient

Given the increasing complexity of hospitalized patients and the increasing specialization among surgeons, there is greater reliance on hospitalists for preoperative assessment. Several institutions have developed surgery/medicine comanagement teams that jointly care for patients in the perioperative setting. Despite a growing body of evidence, it is important to recognize there are many gaps in the perioperative literature. This has led to considerable dependence on consensus statements and expert opinion when evaluating patients perioperatively. This review focuses on the preoperative cardiovascular and pulmonary evaluation of the hospitalized patient: the two systems responsible for the greatest morbidity and mortality. Prevention of postoperative venous thromboembolism and management of perioperative hyperglycemia are also discussed.

The Michigan Risk Score to predict peripherally inserted central catheter-associated thrombosis

Essentials How best to quantify thrombosis risk with peripherally inserted central catheters (PICC) is unknown. Data from a registry were used to develop the Michigan Risk Score (MRS) for PICC thrombosis. Five risk factors were associated with PICC thrombosis and used to develop a risk score. MRS was predictive of the risk of PICC thrombosis and can be useful in clinical practice.

Perioperative Medicine: Medical Consultation and Co-Management

Perioperative Medicine: Medical Consultation and Co-Management is the first comprehensive reference text developed specifically for hospitalists but envisioned also to help internists, anesthesiologists, allied health professionals, fellows, residents, and medical students manage various aspects of the medical care of the surgical patient. The book features both the preoperative and postoperative medical management of the surgical patient. It focuses on systems, operations, quality of perioperative care, and preoperative assessment of the patient, all in consideration with system-specific risk and evidence-based strategies that minimize risk. It places special emphasis on care of the older hospitalized surgical patient and offers a thorough discussion of post-operative conditions and their management.

Hospital medicine and perioperative care: A framework for high-quality, high-value collaborative care

BACKGROUND: Hospitalists have long been involved in optimizing perioperative care for medically complex patients. In 2015, the Society of Hospital Medicine organized the Perioperative Care Work Group to summarize this experience and to develop a framework for providing optimal perioperative care. METHODS: The work group, which consisted of perioperative care experts from institutions throughout the United States, reviewed current hospitalist‐based perioperative care programs, compiled key issues in each perioperative phase, and developed a framework to highlight essential elements to be considered. The framework was reviewed and approved by the board of the Society of Hospital Medicine. RESULTS: The Perioperative Care Matrix for Inpatient Surgeries was developed. This matrix characterizes perioperative phases, coordination, and metrics of success. Additionally, concerns and potential risks were tabulated. Key questions regarding program effectiveness were drafted, and examples of models of care were provided. CONCLUSIONS: The Perioperative Care Matrix for Inpatient Surgeries provides an essential collaborative framework hospitalists can use to develop and continually improve perioperative care programs.

Update in perioperative cardiac medicine

Recent studies have shed light on preoperative risk assessment, medical therapy to reduce postoperative cardiac complications (beta-blockers, statins, and angiotensin II receptor blockers [ARBs]), perioperative management of patients with coronary stents on antiplatelet therapy, and perioperative bridging anticoagulation. Risk assessment, risk reduction, antiplatelet therapy after stent placement, and bridging anticoagulation.

Venous thromboembolism prophylaxis: a path toward more appropriate use

Hospital-acquired venous thromboembolism (VTE) is a leading cause of preventable death in hospitalised patients and its prevention with pharmacological prophylaxis has been rated a top patient safety practice.1 Furthermore, the rate at which VTE prophylaxis is administered to ‘at-risk’ patients along with the rate of ‘potentially preventable’ VTE events are national performance measures for US hospitals.2 As a result, many hospitals have spent considerable time and effort implementing processes designed to increase rates of VTE prophylaxis. Missed doses due to patient refusal of VTE prophylaxis is a commonly encountered barrier. Strategies to minimise anticoagulant refusal in patients who would otherwise benefit from prophylaxis are needed. Baillie et al 3 describe a multifaceted approach designed to increase adherence to pharmacological VTE prophylaxis in hospitalised patients. By standardising the nursing response to patient refusal of heparin injections (which included a strong focus on patient education), assessing successful administration of VTE prophylaxis on a daily basis via a multidisciplinary rounding checklist, and receiving regular feedback on patient refusal rates, the authors were able to demonstrate a reduction in missed doses in over 20 000 patient admissions to medical and oncology units. Much of the improvement was due to reductions in patient refusal. The fact that the reduction in missed doses was not seen in several units serving as the control group further supports the effectiveness of the intervention. As the authors highlight, which aspects of the multifaceted intervention primarily …

Use of Venous Thromboembolism Prophylaxis in Hospitalized Patients

National guidelines1 recommend objective risk stratification for venous thromboembolism (VTE) in hospitalized medical patients. The Padua Prediction Score risk assessment model2 is recommended to categorize patients as high or low risk. The Michigan Hospital Medicine Safety Consortium (HMS), a statewide quality collaborative aimed at preventing adverse events in hospitalized medical patients, collects detailed data on VTE risk factors, prophylactic treatment, and outcomes. Using data from the HMS,3 we sought to determine whether patients in this cohort were receiving appropriate VTE prophylaxis.

Annals for Hospitalists Inpatient Notes - Perioperative Medicine—The Past, Present, and Future of Cardiovascular Risk Assessment and Risk Reduction Strategies

Perioperative medicine is an evolving field that has become increasingly collaborative. As surgical patients become older and their conditions more complex, surgeons routinely consult hospitalists for medical care. As the field of hospital medicine moves into its third decade, it is worthwhile to reflect on the evolution of cardiovascular risk stratification and risk reduction measures, and to look toward the future. Lessons From the Past Although the preoperative evaluation has always primarily focused on risk stratification and reduction, the science has continued to evolve. Early clinical risk prediction indices included the Goldman Multifactorial Cardiac Risk Index and the Detsky Cardiac Risk Index. The first formal perioperative guidelines were published in 1996 by the American College of Cardiology (ACC) and the American Heart Association (AHA) (1). The guidelines featured major, intermediate, and minor clinical predictors of cardiovascular risk and promoted noninvasive cardiac stress testing for patients considered to be at high risk for cardiac events. We have since learned that the positive predictive value of preoperative stress testing is very low. Perhaps more important, preoperative coronary revascularization does not seem to improve outcomes in stable patients. In the late 1990s, perioperative -blockers emerged as a strategy to decrease risk for cardiovascular events. In early studies, these agents seemed to confer significant cardiovascular protection. However, the study results were heterogeneous and based on a small number of cardiac events. In addition, a significant proportion of the randomized clinical trial data supporting -blocker use was later deemed to be fraudulent, leading to the retraction of these papers from the medical literature. Although a role for perioperative -blockade may still exist in some situations (for example, patients with systolic heart failure or recent myocardial infarction), these agents have the potential to cause significant hypotension, bradycardia, and even death (2). Routine use of these drugs to reduce cardiac risk is therefore no longer recommended. For many years, perioperative bridging anticoagulation was also a routine intervention. Although data were scant, bridging was viewed as the safer option for patients receiving anticoagulants, even if only for stroke prophylaxis with atrial fibrillation. However, the first randomized controlled trial addressing perioperative anticoagulation in patients with this disorder showed that not only does bridging therapy not decrease the risk for stroke, it significantly increases the risk for major bleeding for patients at moderate risk for stroke (3). Thus, bridging is now only recommended in specific clinical scenarios. Over the years, we also learned that low-dose aspirin in the perioperative setting does not protect against cardiovascular events but increases risk for major bleeding. Similarly, we determined that a restrictive strategy for red blood cell transfusion is safer than a more liberal approach in the postoperative setting. Current Practice: Less Is More The focus of todays perioperative risk assessment is the history and physical examination. Findings that suggest severe or decompensated heart disease warrant additional evaluation. However, in the absence of such findings, use of an objective clinical risk assessment tool is the cornerstone for risk stratification. The most recent ACC/AHA guidelines (4) endorse the following 3 tools: The Revised Cardiac Risk Index, the Myocardial Infarction and Cardiac Arrest (MICA) risk calculator, and the American College of Surgery risk calculator. Routine noninvasive cardiac stress testing is not recommended. Once risk has been determined, medical optimization should be the goal, although few interventions are proven to reduce risk. Perioperative use of statins is one of the few interventions that has consistently demonstrated a cardioprotective effect, and these agents should be continued or initiated in the perioperative setting for high-risk patients. -Blockers should not be started in the perioperative setting unless specific indications exist and there is adequate time for dose titration. Similarly, perioperative bridging is rarely necessary for patients with atrial fibrillation, with the possible exception of patients with exceedingly high risk for thrombosis. Aspirin is not recommended to reduce perioperative cardiac risk (although it is usually continued in patients with coronary stents), and restrictive blood transfusion protocols are the norm. Thus, less is now more in the perioperative setting. The Future There is great interest in the potential value of biomarkers to more accurately assess cardiovascular risk. Brain natriuretic peptide (BNP) and N-terminal fragment of proBNP are simple, inexpensive predictors of cardiac events. Further, elevated postoperative troponin levels in asymptomatic but high-risk patients are associated with increased 30-day mortality. Recent Canadian Cardiovascular Society guidelines (5) recommend measuring these biomarkers in high-risk patients. However, it remains unclear how the test results should affect patient management. Attempts to mitigate ischemic risk with -blockers, aspirin, nitrates, calcium-channel blockers, clonidine, and coronary revascularization have proven unhelpful (or even harmful) in stable patients. Future studies to better translate these assessments into therapeutic strategies and improved clinical outcomes are necessary. As surgical techniques and anesthesia care improve, larger numbers of frail patients with comorbid conditions will go under the knife. Although hospitalists remain well-suited to assess perioperative risk and implement risk reduction strategies, it may be equally important for them to recognize when surgery is not the best course of action, and when noninvasive treatments or palliative measures are more appropriate. After all, prevention remains the best cureeven for perioperative cardiac events.