Cirrhosis, Thrombosis, Finding FaXts about Doses: Dosing of Unfractionated Heparin for Venous Thromboembolism in Cirrhosis

2019 ◽  
Vol 54 (5) ◽  
pp. 450-456
Author(s):  
Nicholas D. Franz ◽  
Adamo Brancaccio ◽  
Adam C. Robinson ◽  
Randolph E. Regal
Keyword(s):  
Venous Thromboembolism ◽  
Unfractionated Heparin ◽  
Medical Center ◽  
Statistical Significance ◽  
Severe Disease ◽  
Academic Medical Center ◽  
The United States ◽  
Monitoring Methods ◽  
Heparin Infusion ◽  
Severe Cirrhosis

Background: Despite known disease-specific alterations to anti–factor Xa (AXA) levels, the physiological response of patients with cirrhosis to unfractionated heparin (UFH) infusions is not well established in clinical settings. Objective: The purpose of this study was to characterize the dosing and safety profile of UFH in patients with varying degrees of cirrhosis when treated for venous thromboembolism (VTE). Methods: This retrospective observational study was conducted at a single academic medical center in the United States. Patients with a diagnosis of cirrhosis who received UFH infusions for greater than 48 hours for treatment of VTE were included. Comparisons between heparin infusion rates, AXA levels, and safety outcomes based on severity of cirrhosis were made to define differences between those groups. Results: When compared by compensation status or by Child-Turcotte-Pugh (CTP) class, patients with more severe disease trended toward lower initial AXA levels on heparin initiation and higher heparin requirements to achieve therapeutic levels and were significantly less likely to achieve therapeutic levels than patients with less severe disease ( P = 0.001 for compensation, P = 0.017 for CTP). Additionally, bleeding rates were higher in patients with more severe disease, without reaching statistical significance. Conclusion and Relevance: Patients with severe cirrhosis required higher doses of heparin to achieve the same therapeutic AXA levels, but also tended to have higher rates of bleeding compared with less severe cirrhosis. These results represent further evidence of changes in heparin response as cirrhosis severity increases and may suggest that current monitoring methods are suboptimal in this patient population.

scholarly journals Incidence and Outcomes of Heparin-Induced Thrombocytopenia Associated with a Heparin Shortage at a Large Academic Medical Center

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 10-10
Author(s):  
Stephanie L. Seto ◽  
Megan E. Barra ◽  
Russel J. Roberts ◽  
Rachel P. Rosovsky
Keyword(s):  
Unfractionated Heparin ◽  
Massachusetts General Hospital ◽  
Medical Center ◽  
Academic Medical Center ◽  
The United States ◽  
Mitigation Strategies ◽  
Drug Shortage ◽  
Bleeding Events ◽  
Platelet Factor ◽  
Heparin Induced Thrombocytopenia

Heparin-induced thrombocytopenia (HIT) is a life-threatening complication associated with significant morbidity and mortality in hospitalized patients. The 2019 African swine fever outbreak in China resulted in a critical national shortage of porcine-derived heparin products in the United States. As a result, our institution implemented a multitude of mitigation strategies to reduce heparin utilization by >80% and optimize safe and effective alternative therapies. The aim of this study was to determine whether this change in clinical practice impacted the incidence of HIT and associated outcomes. A single-center, retrospective cohort study was performed on patients admitted to Massachusetts General Hospital who were ≥ 18 years of age and had a positive platelet factor 4 (PF4) drawn between February 2019 and January 2020. Patient demographics, comorbidities, baseline labs, serotonin release assay results, timing and magnitude of platelet count fall, and characteristics of heparinoid and non-heparinoid anticoagulant use were collected from the medical record. Thrombotic and hemorrhagic outcomes were characterized. Seventy-five patients were included in the final analysis, of which 56 (75%) were critically-ill. Baseline characteristics were similar between groups including median age 66.8 years, 49% male, 80% Caucasian. Forty-four (59%) patients underwent surgery, 23 (31%) required continuous renal replacement therapy, and 13 (17%) underwent extracorporeal membrane oxygenation. Incidence of HIT with any exposure to heparinoid product was 0.3% and 0.15% (p=0.002) in the pre-shortage and shortage periods, respectively. In those who received therapeutic dose unfractionated heparin, incidence of HIT was 1.26% and 1.05% (p=0.63) in the pre-shortage and shortage groups, respectively. Thrombotic complications were observed in 19 (41%) patients in the pre-shortage group and 11 (38%) in the post-shortage group (p=0.77). Bleeding events were observed in 8 (17%) and 5 (17%) (p=0.99). We observed a lower incidence of HIT resulting from our institution's efforts to conserve unfractionated heparin supply and utilize alternative anticoagulants during a critical national drug shortage. There were no significant differences in associated thrombotic and bleeding events. Disclosures Rosovsky: Bristol-Myers Squibb, Dova, Janssen, Portola: Consultancy; Bristol-Myers Squibb, Janssen: Research Funding.

Safety of High-Dose Unfractionated Heparin for Prophylaxis of Venous Thromboembolism in Hospitalized Obese Patients

2020 ◽  
pp. 106002802097456
Author(s):  
Teresa Regis ◽  
Pavel Goriacko ◽  
Nadia Ferguson
Keyword(s):  
Venous Thromboembolism ◽  
Unfractionated Heparin ◽  
Incidence Rate ◽  
Standard Dose ◽  
Medical Center ◽  
Academic Medical Center ◽  
Bleeding Event ◽  
High Dose ◽  
Obese Patients ◽  
Significant Difference

Background Optimal dosing of unfractionated heparin (UFH) for thromboprophylaxis in the obese patient population is uncertain because of their high-risk, prothrombotic state and a complexity of pharmacokinetic considerations. Literature on the appropriateness of the use of a higher dose UFH regimen remains unclear and inconsistent. Objective To evaluate the safety of the use of 7500 units every 8 hours ( high-dose) of subcutaneous UFH compared with the use of 5000 units every 8 hours ( standard-dose) of subcutaneous UFH for thromboprophylaxis in obese patients (defined as BMI ≥30 kg/m2). Methods In a retrospective cohort study, 326 adult patients were included, with a BMI ≥30 kg/m2, who were admitted to a large, urban academic medical center between September 1, 2015, and September 1, 2018. Patients received either high-dose or standard-dose UFH for at least 48 hours. The primary end point was the incidence rate of bleeding events, defined as a ≥2-g/dL fall in hemoglobin level or receipt of transfusion of 2 or more units of packed red blood cells (pRBCs) from the start of the UFH order. Results The incidence rate of bleeding was significantly higher in those who received high-dose UFH (43%) compared with those who received standard-dose UFH (29%; P = 0.008). No significant difference was found between venous thromboembolism event rates. Conclusion and Relevance High-dose UFH was associated with an increased bleeding event rate compared with standard-dose UFH in patients with a BMI ≥30 kg/m2. This raises safety concerns about the appropriateness of utilizing this regimen in this population.

scholarly journals Clinical Features and Outcomes of 105 Hospitalized Patients With COVID-19 in Seattle, Washington

2020 ◽  
Vol 71 (16) ◽  
pp. 2167-2173 ◽  
Author(s):  
Frederick S Buckner ◽  
Denise J McCulloch ◽  
Vidya Atluri ◽  
Michela Blain ◽  
Sarah A McGuffin ◽  
...  
Keyword(s):  
Medical Center ◽  
Severe Disease ◽  
Academic Medical Center ◽  
Skilled Nursing Facility ◽  
The United States ◽  
Washington State ◽  
Hospitalized Patients ◽  
Nursing Facility ◽  
Skilled Nursing ◽  
Academic Medical

Abstract Background Washington State served as the initial epicenter of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic in the United States. An understanding of the risk factors and clinical outcomes of hospitalized patients with coronavirus disease 2019 (COVID-19) may provide guidance for management. Methods All laboratory-confirmed COVID-19 cases in adults admitted to an academic medical center in Seattle, Washington, between 2 March and 26 March 2020 were included. We evaluated individuals with and without severe disease, defined as admission to the intensive care unit or death. Results One hundred five COVID-19 patients were hospitalized. Thirty-five percent were admitted from a senior home or skilled nursing facility. The median age was 69 years, and half were women. Three or more comorbidities were present in 55% of patients, with hypertension (59%), obesity (47%), cardiovascular disease (38%), and diabetes (33%) being the most prevalent. Most (63%) had symptoms for ≥5 days prior to admission. Only 39% had fever in the first 24 hours, whereas 41% had hypoxia at admission. Seventy-three percent of patients had lymphopenia. Of 50 samples available for additional testing, no viral coinfections were identified. Severe disease occurred in 49%. Eighteen percent of patients were placed on mechanical ventilation, and the overall mortality rate was 33%. Conclusions During the early days of the COVID-19 epidemic in Washington State, the disease had its greatest impact on elderly patients with medical comorbidities. We observed high rates of severe disease and mortality in our hospitalized patients.

scholarly journals Perinatal Mood and Anxiety Disorder Management in Multicenter Community Practices: Clinicians’ Training, Current Practices and Perceived Strategies to Improve Future Implementation

2021 ◽  
Vol 12 ◽  
pp. 215013272199688
Author(s):  
Ajeng J. Puspitasari ◽  
Dagoberto Heredia ◽  
Elise Weber ◽  
Hannah K Betcher ◽  
Brandon J. Coombes ◽  
...  
Keyword(s):  
Anxiety Disorder ◽  
Health Services ◽  
Behavioral Health ◽  
Psychiatric Symptoms ◽  
Medical Center ◽  
Academic Medical Center ◽  
Management Training ◽  
The United States ◽  
Behavioral Health Services ◽  
Perinatal Women

Background: This study aimed to explore clinicians’ perspectives on the current practice of perinatal mood and anxiety disorder (PMAD) management and strategies to improve future implementation. Methods: This study had a cross-sectional, descriptive design. A 35-item electronic survey was sent to clinicians (N = 118) who treated perinatal women and practiced at several community clinics at an academic medical center in the United States. Results: Among clinicians who provided care for perinatal women, 34.7% reported never receiving PMAD management training and 66.3% had less than 10 years of experience. Out of 10 patients who reported psychiatric symptoms, 47.8% of clinicians on average reported providing PMAD management to 1 to 3 patients and 40.7% noted that they conducted screening only when patient expresses PMAD symptoms. Suggested future improvements were providing training, developing a referral list, and establishing integrated behavioral health services. Conclusions: Results from this study indicated that while PMAD screening and management was implemented, improvements are warranted to meet established guidelines. Additionally, clinicians endorsed providing PMAD management to a small percentage of perinatal patients. Suggested strategies to increase adoption and implementation of PMAD management should be explored to improve access to behavioral health services for perinatal women.

scholarly journals Communications and Screening for 2019 Novel Coronavirus at a Tertiary-Care Medical Center

2020 ◽  
Vol 41 (S1) ◽  
pp. s84-s84
Author(s):  
Lorinda Sheeler ◽  
Mary Kukla ◽  
Oluchi Abosi ◽  
Holly Meacham ◽  
Stephanie Holley ◽  
...  
Keyword(s):  
Screening Tool ◽  
Medical Center ◽  
Academic Medical Center ◽  
Tertiary Care ◽  
The United States ◽  
World Health ◽  
Communication Campaign ◽  
Electronic Screening ◽  
Novel Coronavirus ◽  
The Impact

Background: In December of 2019, the World Health Organization reported a novel coronavirus (severe acute respiratory coronavirus virus 2 [SARS-CoV-2)]) causing severe respiratory illness originating in Wuhan, China. Since then, an increasing number of cases and the confirmation of human-to-human transmission has led to the need to develop a communication campaign at our institution. We describe the impact of the communication campaign on the number of calls received and describe patterns of calls during the early stages of our response to this emerging infection. Methods: The University of Iowa Hospitals & Clinics is an 811-bed academic medical center with >200 outpatient clinics. In response to the coronavirus disease 2019 (COVID-19) outbreak, we launched a communications campaign on January 17, 2020. Initial communications included email updates to staff and a dedicated COVID-19 webpage with up-to-date information. Subsequently, we developed an electronic screening tool to guide a risk assessment during patient check in. The screening tool identifies travel to China in the past 14 days and the presence of symptoms defined as fever >37.7°C plus cough or difficulty breathing. The screening tool was activated on January 24, 2020. In addition, university staff contacted each student whose primary residence record included Hubei Province, China. Students were provided with medical contact information, signs and symptoms to monitor for, and a thermometer. Results: During the first 5 days of the campaign, 3 calls were related to COVID-19. The number of calls increased to 18 in the 5 days following the implementation of the electronic screening tool. Of the 21 calls received to date, 8 calls (38%) were generated due to the electronic travel screen, 4 calls (19%) were due to a positive coronavirus result in a multiplex respiratory panel, 4 calls (19%) were related to provider assessment only (without an electronic screening trigger), and 2 calls (10%) sought additional information following the viewing of the web-based communication campaign. Moreover, 3 calls (14%) were for people without travel history but with respiratory symptoms and contact with a person with recent travel to China. Among those reporting symptoms after travel to China, mean time since arrival to the United States was 2.7 days (range, 0–11 days). Conclusion: The COVID-19 outbreak is evolving, and providing up to date information is challenging. Implementing an electronic screening tool helped providers assess patients and direct questions to infection prevention professionals. Analyzing the types of calls received helped tailor messaging to frontline staff.Funding: NoneDisclosures: None

scholarly journals 421. Effect of SARs-Cov-2 mRNA Vaccination in Healthcare Workers with Household COVID Exposure

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S311-S311
Author(s):  
Laura Selby ◽  
Richard Starlin
Keyword(s):  
Healthcare Workers ◽  
Screening Program ◽  
Medical Center ◽  
Severe Disease ◽  
Academic Medical Center ◽  
Tertiary Care ◽  
Limited Data ◽  
Viral Shedding ◽  
Academic Medical ◽  
Significant Burden

Abstract Background Healthcare workers have experienced a significant burden of COVID-19 disease. COVID mRNA vaccines have shown great efficacy in prevention of severe disease and hospitalization due to COVID infection, but limited data is available about acquisition of infection and asymptomatic viral shedding. Methods Fully vaccinated healthcare workers at a tertiary-care academic medical center in Omaha Nebraska who reported a household exposure to COVID-19 infection are eligible for a screening program in which they are serially screened with PCR but allowed to work if negative on initial test and asymptomatic. Serial screening by NP swab was completed every 5-7 days, and workers became excluded from work if testing was positive or became symptomatic. Results Of the 94 employees who were fully vaccinated at the time of the household exposure to COVID-19 infection, 78 completed serial testing and were negative. Sixteen were positive on initial or subsequent screening. Vaccine failure rate of 17.0% (16/94). Healthcare workers exposed to household COVID positive contact Conclusion High risk household exposures to COVID-19 infection remains a significant potential source of infections in healthcare workers even after workers are fully vaccinated with COVID mRNA vaccines especially those with contact to positive domestic partners. Disclosures All Authors: No reported disclosures

scholarly journals An innovative resident-driven mortality case review curriculum to teach and drive system-based practice improvements in the United States

2018 ◽  
Vol 15 ◽  
pp. 31
Author(s):  
Nila S. Radhakrishnan ◽  
Margaret C. Lo ◽  
Rohit Bishnoi ◽  
Subhankar Samal ◽  
Robert Leverence ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Systems Of Care ◽  
Medical Center ◽  
Academic Medical Center ◽  
Tertiary Care ◽  
The United States ◽  
Case Review ◽  
Failure To Rescue ◽  
Internal Medicine Residents ◽  
Mortality Case

Purpose: Traditionally, the morbidity and mortality conference (M&MC) is a forum where possible medical errors are discussed. Although M&MCs can facilitate identification of opportunities for systemwide improvements, few studies have described their use for this purpose, particularly in residency training programs. This paper describes the use of M&MC case review as a quality improvement activity that teaches system-based practice and can engage residents in improving systems of care. Methods: Internal medicine residents at a tertiary care academic medical center reviewed 347 consecutive mortalities from March 2014 to September 2017. The residents used case review worksheets to categorize and track causes of mortality, and then debriefed with a faculty member. Selected cases were then presented at a larger interdepartmental meeting and action items were implemented. Descriptive statistics and thematic analysis were used to analyze the results. Results: The residents identified a possible diagnostic mismatch at some point from admission to death in 54.5% of cases (n= 189) and a possible need for improved management in 48.0% of cases. Three possible management failure themes were identified, including failure to plan, failure to communicate, and failure to rescue, which accounted for 21.9%, 10.7 %, and 10.1% of cases, respectively. Following these reviews, quality improvement initiatives proposed by residents led to system-based changes. Conclusion: A resident-driven mortality review curriculum can lead to improvements in systems of care. This novel type of curriculum can be used to teach system-based practice. The recruitment of teaching faculty with expertise in quality improvement and mortality case analyses is essential for such a project.

scholarly journals Depression Screening and Measurement-Based Care in Primary Care

2020 ◽  
Vol 11 ◽  
pp. 215013272093126
Author(s):  
Kimberly A. Siniscalchi ◽  
Marion E. Broome ◽  
Jason Fish ◽  
Joseph Ventimiglia ◽  
Julie Thompson ◽  
...  
Keyword(s):  
Primary Care ◽  
Task Force ◽  
Medical Center ◽  
Academic Medical Center ◽  
Unmet Need ◽  
The United States ◽  
Depression Screening ◽  
Improvement Project ◽  
Measurement Based Care

The health issue addressed is the unmet need to universally screen and treat depression, which is one of the most common mental health disorders among adults in the United States. The US Preventive Services Task Force recommends screening adults for depression in primary care and using evidence-based protocols. This quality improvement project implemented VitalSign6, a measurement-based care program, to improve depression screening and treatment of adults in primary care at an academic medical center. A pre-post design was used to determine effectiveness of changes in screening, outcomes, and satisfaction. Of 1200 unique adult patients, 95.4% received initial screening. Providers diagnosed and administered measurement-based care to 236 patients. After 14 weeks, 27.5% returned for at least 1 follow-up. Results showed a statistically significant decrease in self-reported depression scores from baseline to follow-up. VitalSign6 was effective in improving identification and management of depression in primary care.

scholarly journals Clinical Ordering Practices of the SARS-CoV-2 Antibody Test at a Large Academic Medical Center

2020 ◽  
Vol 7 (10) ◽  
Author(s):  
Joesph R Wiencek ◽  
Carter L Head ◽  
Costi D Sifri ◽  
Andrew S Parsons
Keyword(s):  
United States ◽  
Medical Center ◽  
Academic Medical Center ◽  
Antibody Test ◽  
The United States ◽  
Molecular Testing ◽  
Antibody Testing ◽  
Academic Medical ◽  
Public Health Epidemiology ◽  
Testing Costs

Abstract Background The novel severe acute respiratory coronavirus 2 (SARS-CoV-2) that causes coronavirus disease 2019 (COVID-19) originated in December 2019 and has now infected almost 5 million people in the United States. In the spring of 2020, private laboratories and some hospitals began antibody testing despite limited evidence-based guidance. Methods We conducted a retrospective chart review of patients who received SARS-CoV-2 antibody testing from May 14, 2020, to June 15, 2020, at a large academic medical center, 1 of the first in the United States to provide antibody testing capability to individual clinicians in order to identify clinician-described indications for antibody testing compared with current expert-based guidance from the Infectious Diseases Society of America (IDSA) and the Centers for Disease Control and Prevention (CDC). Results Of 444 individual antibody test results, the 2 most commonly described testing indications, apart from public health epidemiology studies (n = 223), were for patients with a now resolved COVID-19-compatible illness (n = 105) with no previous molecular testing and for asymptomatic patients believed to have had a past exposure to a person with COVID-19-compatible illness (n = 60). The rate of positive SARS-CoV-2 antibody testing among those indications consistent with current IDSA and CDC guidance was 17% compared with 5% (P < .0001) among those indications inconsistent with such guidance. Testing inconsistent with current expert-based guidance accounted for almost half of testing costs. Conclusions Our findings demonstrate a dissociation between clinician-described indications for testing and expert-based guidance and a significantly different rate of positive testing between these 2 groups. Clinical curiosity and patient preference appear to have played a significant role in testing decisions and substantially contributed to testing costs.

scholarly journals Healthcare personnel absenteeism, presenteeism, and staffing challenges during epidemics

2020 ◽  
pp. 1-4
Author(s):  
Douglas W. Challener ◽  
Laura E. Breeher ◽  
JoEllen Frain ◽  
Melanie D. Swift ◽  
Pritish K. Tosh ◽  
...  
Keyword(s):  
Seasonal Influenza ◽  
Medical Center ◽  
Academic Medical Center ◽  
The United States ◽  
Healthcare Personnel ◽  
Linear Regression Models ◽  
Influenza Like Illness ◽  
Healthcare Workforce ◽  
Academic Medical ◽  
Hourly Employees

Abstract: Objective: Presenteeism is an expensive and challenging problem in the healthcare industry. In anticipation of the staffing challenges expected with the COVID-19 pandemic, we examined a decade of payroll data for a healthcare workforce. We aimed to determine the effect of seasonal influenza-like illness (ILI) on absences to support COVID-19 staffing plans. Design: Retrospective cohort study. Setting: Large academic medical center in the United States. Participants: Employees of the academic medical center who were on payroll between the years of 2009 and 2019. Methods: Biweekly institutional payroll data was evaluated for unscheduled absences as a marker for acute illness-related work absences. Linear regression models, stratified by payroll status (salaried vs hourly employees) were developed for unscheduled absences as a function of local ILI. Results: Both hours worked and unscheduled absences were significantly related to the community prevalence of influenza-like illness in our cohort. These effects were stronger in hourly employees. Conclusions: Organizations should target their messaging at encouraging salaried staff to stay home when ill.

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