P136: A quality improvement initiative to optimize appropriate testing for venous thromboembolism in the emergency department

Introduction: Venous thromboembolism (VTE) is a common diagnostic consideration among patients presenting to the emergency department (ED) and often requires the use of diagnostic testing. A normal d-dimer (DD) blood test can exclude VTE and eliminate the need for costly imaging and the associated contrast medium and radiation exposure. The purpose of this quality improvement initiative was to increase the use of DD testing for patients with a low and intermediate clinical pretest probability of VTE, increase the use of ventilation perfusion scans (VQ) as an alternative to CT pulmonary angiogram (CTPA) and decrease the use of CTPA and venous doppler ultrasound (VDUS) at St. Michael’s hospital. Methods: A multispecialty team developed an ED specific algorithm set for appropriate VTE testing that were posted on the ED online portal along with a poster in each zone of the ED after an ED launch campaign with request for feedback. A run chart was used to track DD, CTPA, VQ and VDUS utilization. Two-sided T-test comparison was conducted to compare pre- and post-implementation utilization. Results: Physician feedback was positive regarding the use of: DD in VTE intermediate risk patients and the VTE algorithm set. Feedback was negative for DD turnaround time. We found a significant increase in DD use (77 tests per month to 93; p=0.013), but no significant change in the use of CTPA (27.3 per month to 30; p=0.38), VDUS, or VQ. Number of monthly ED visits remained constant. Conclusion: This intervention increased DD utilization, but measuring appropriateness will require prospective collection of clinical pre-test probability. Integrated risk stratification and decision aids into computer physician order entry may be necessary to track and improve appropriateness.

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Improving the adoption of optimal venous thromboembolism prophylaxis in critically ill patients: A process evaluation of a complex quality improvement initiative

Journal of Critical Care ◽

10.1016/j.jcrc.2018.11.023 ◽

2019 ◽

Vol 50 ◽

pp. 111-117 ◽

Cited By ~ 3

Author(s):

Khara M. Sauro ◽

Rebecca Brundin-Mather ◽

Jeanna Parsons Leigh ◽

Daniel J. Niven ◽

Barry Kushner ◽

...

Keyword(s):

Quality Improvement ◽

Venous Thromboembolism ◽

Critically Ill ◽

Process Evaluation ◽

Critically Ill Patients ◽

Quality Improvement Initiative ◽

Thromboembolism Prophylaxis ◽

Venous Thromboembolism Prophylaxis

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P041 Successful Reduction in Opioid Prescription for IBD Flare in the Emergency Department: A Retrospective Study and Quality Improvement Initiative

The American Journal of Gastroenterology ◽

10.14309/01.ajg.0000798764.14625.6a ◽

2021 ◽

Vol 116 (1) ◽

pp. S10-S11

Author(s):

Park Steven ◽

Graziano Elliot ◽

Lee Edwin ◽

Bittner Krystle ◽

Acquisto Nicole ◽

...

Keyword(s):

Emergency Department ◽

Quality Improvement ◽

Retrospective Study ◽

Quality Improvement Initiative ◽

Opioid Prescription ◽

Successful Reduction

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Improving pediatric pharmacy services in a primarily adult emergency department

American Journal of Health-System Pharmacy ◽

10.1093/ajhp/zxab383 ◽

2021 ◽

Author(s):

Souheila N Hachem ◽

Julie M Thomson ◽

Melissa K Heigham ◽

Nancy C MacDonald

Keyword(s):

Emergency Department ◽

Quality Improvement ◽

Quality Improvement Initiative ◽

Pharmacy Services ◽

Compliance Assessment ◽

Practice Elements ◽

Full Compliance ◽

Institutional Review ◽

Improve Compliance ◽

American Society

Abstract Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose The American Society of Health-System Pharmacists (ASHP) and Pediatric Pharmacy Advocacy Group (PPAG) guidelines for providing pediatric pharmacy services in hospitals and health systems can be used to improve medication safety wherever pediatric patients receive care, including in the emergency department (ED). The purpose of this initiative was to improve compliance with these guidelines in a primarily adult ED. Methods This quality improvement initiative was conducted in a level 1 trauma center ED between October 2019 and March 2020. The ASHP-PPAG guidelines were used to create practice elements applicable to the ED. An initial compliance assessment defined elements as noncompliant, partially compliant, fully compliant, or not applicable. Investigators identified interventions to improve compliance for noncompliant or partially compliant elements and then reassessed compliance following implementation. Data were expressed using descriptive statistics. This initiative was exempt from institutional review board approval. Results Ninety-three ED practice elements were identified within the 9 standards of the ASHP-PPAG guidelines. At the initial compliance assessment, the majority (59.8%) of practice elements were fully compliant; however, various service gaps were identified in 8 of the standards, and 16 interventions were implemented to improve compliance. At the final compliance assessment, there was a 19.5% increase in full compliance. Barriers to achieving full compliance included technology restrictions, time constraints, financial limitations, and influences external to pharmacy. Conclusion This quality improvement initiative demonstrated that the ASHP-PPAG guidelines can be used to improve ED pediatric pharmacy services in a primarily adult institution. The initiative may serve as an example for other hospitals to improve compliance with the guidelines.

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Abstract WP237: Improved Thrombolysis Rates and Quality of Care for Stroke Patients Through a Provincial Emergency Department Quality Improvement Initiative

Stroke ◽

10.1161/str.44.suppl_1.awp237 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Devin R Harris ◽

Robert Stenstrom ◽

Eric Grafstein ◽

Mark Collison ◽

Grant Innes ◽

...

Keyword(s):

Emergency Department ◽

Quality Improvement ◽

Quality Of Care ◽

Performance Measures ◽

Large Scale ◽

Primary Outcome ◽

Baseline Data ◽

Quality Improvement Initiative ◽

Stroke Patients

Background: The care of stroke patients in the emergency department (ED) is time sensitive and complex. We sought to improve quality of care for stroke patients in British Columbia (B.C.), Canada, emergency departments. Objectives: To measure the outcomes of a large-scale quality improvement initiative on thrombolysis rates and other ED performance measures. Methods: This was an evaluation of a large-scale stroke quality improvement initiative, within ED’s in B.C., Canada, in a before-after design. Baseline data was derived from a medical records review study performed between December 1, 2005 to January 31, 2007. Adherence to best practice was determined by measuring selected performance indicators. The quality improvement initiative was a collaboration between multidisciplinary clinical leaders within ED’s throughout B.C. in 2007, with a focus on implementing clinical practice guidelines and pre-printed order sets. The post data was derived through an identical methodology as baseline, from March to December 2008. The primary outcome was the thrombolysis rate; secondary outcomes consisted of other ED stroke performance measures. Results: 48 / 81 (59%) eligible hospitals in B.C. were selected for audit in the baseline data; 1258 TIA and stroke charts were audited. For the post data, 46 / 81 (57%) acute care hospitals were selected: 1199 charts were audited. The primary outcome of the thrombolysis rate was 3.9% (23 / 564) before and 9.3% (63 / 676) after, an absolute difference of 5.4% (95% CI: 2.3% - 7.6%; p=0.0005). Other measures showed changes: administration of aspirin to stroke patients in the ED improved from 23.7% (127 / 535) to 77.1% (553 / 717), difference = 53.4% (95% CI: 48.3% - 58.1%; p=0.0005); and, door to imaging time improved from 2.25 hours (IQR = 3.81 hours) to 1.57 hours (IQR 3.0), difference = 0.68 hours (p=0.03). Differences were found in improvements between large and small institutions, and between health regions. Conclusions: Implementation of a provincial emergency department quality improvement initiative showed significant improvement in thrombolysis rates and adherence to other best practices for stroke patients. The specific factors that influenced improvement need to be further explored.

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Abstract 096: Association of Body Mass Index With Bleeding in Patients Taking Warfarin for Atrial Fibrillation or Venous Thromboembolism

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.10.suppl_3.096 ◽

2017 ◽

Vol 10 (suppl_3) ◽

Author(s):

Kyle Stahlbaum ◽

Eva Kline-Rogers ◽

Xiaowen Kong ◽

Geoffrey D Barnes ◽

Brian Haymart ◽

...

Keyword(s):

Atrial Fibrillation ◽

Body Mass Index ◽

Quality Improvement ◽

Venous Thromboembolism ◽

Body Mass ◽

Normal Weight ◽

Risk Scores ◽

Quality Improvement Initiative ◽

Minor Bleeding ◽

Life Threatening

Background: Most patients taking warfarin for atrial fibrillation (AF) and venous thromboembolism (VTE) have a target International Normalized Ratio (INR) between 2-3 to reduce risk of bleeding and thromboembolic events. Body Mass Index (BMI) is not included in traditional bleed risk scores, but may be an indicator of bleeding risk in warfarin patients. Methods: Using data from the multi-site Michigan Anticoagulation Quality Improvement Initiative (MAQI 2 ) Registry, we identified all AF/VTE patients , separated them into three cohorts: BMI < 20 (underweight), BMI 20-25 (normal weight) and BMI >25 (overweight). Bleeding events in these cohorts were identified and stratified into severity according to International Society of Thrombosis and Hemostasis criteria. Results: Of 6,054 patients, 4,766 (78.7%) had a BMI of > 25. These patients were generally younger, with higher prevalence of hypertension. The HAS-BLED scores were slightly lower in overweight AF patients (2.6 vs 2.8; p=0.04); otherwise no difference between groups. The overall minor, major, and life threatening bleeding rates were 22.8/27.7; 4.3/3.7; and 1.2/0.7 (per 100 patient years) in AF and VTE patients, respectively. A higher proportion of females were underweight for both indications, and AF patients were older. More underweight and normal weight AF and VTE patients had a bleeding history compared to overweight patients. Bleeding outcomes are listed in Table. Comparisons were made with Poisson regression analysis. Conclusion: In a large, unselected cohort of warfarin treated patient from a multi-site registry, minor bleeding was more common in underweight and normal weight AF patients; major and life-threatening bleeding was more common in underweight and normal weight VTE patients. Since the majority of patients were overweight, further studies are needed to determine if reasons for bleeding differ between patients based on BMI in order to guide quality improvement efforts.

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