Hospital-Acquired Venous Thromboembolism (VTE): A Retrospective Consecutive Case Series

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 4280-4280 ◽  
Author(s):  
Brandyn Daniel Lau ◽  
Elliott R Haut ◽  
Bhunesh Maheshwari ◽  
Peggy S Kraus ◽  
Deborah Hobson ◽  
...  
Keyword(s):  
Best Practice ◽  
Medical Service ◽  
Case Series ◽  
Common Complication ◽  
Surgical Service ◽  
Order Entry ◽  
Vte Prophylaxis ◽  
Pharmacologic Prophylaxis ◽  
The Mean ◽  
Hospital Acquired

Abstract Abstract 4280 Introduction: Venous thromboembolism (VTE) is a common complication in hospitalized patients. To reduce the incidence of this potentially preventable adverse event, we incorporated computerized clinical decision support-enabled “smart order sets” in our electronic order entry system which have significantly increased the prescription of risk-appropriate VTE prophylaxis. Despite our performance improvement, hospital-acquired VTE remains a common complication at our institution. The purpose of the current study was to examine the clinical characteristics of patients developing VTE during their hospital stay and identify potentially modifiable causes for these events. Methods: We conducted a retrospective review of an administrative database of objectively-confirmed VTE among patients hospitalized at the Johns Hopkins Hospital during fiscal year 2011. Demographic and clinical data including VTE risk category, ordered VTE prophylaxis and the number of missed doses of VTE prophylaxis were retrieved from our computerized provider order entry system. VTE were attributed to central venous catheter (CVC) if they occurred in the same vascular distribution. VTE were deemed preventable if risk-appropriate prophylaxis was not ordered or if any doses of pharmacologic prophylaxis were missed. CVC-VTE were not classified as preventable. Results: Between July 1, 2010 and June 30, 2011, 139 hospitalized adult patients were classified as developing potentially preventable VTE. The mean age is 61.3 (SD: 17.7) years, 54.0% were male, the mean BMI was 28.2 (SD: 7.6) kg/m2 and 70.5% had a surgical procedure during hospitalization. Median length of hospitalization was 15 days and median time to VTE was 6 days. Eighty nine patients (64.0%) were classified as being at high or very high risk for VTE; 52 patients admitted to a surgical service and 37 admitted to the medical service. Fifty patients (36.0%) were judged to be at moderate risk, 23 patients admitted to a surgical service and 27 admitted to the medical service. Eighty five patients (61.2%) developed DVT, 45 patients (32.4%) developed PE, and 9 patients (6.5%) had superficial thrombophlebitis (ST). Forty nine events were CVC-VTE; 38 CVC- DVT, 3 CVC- PE and 7 CVC-ST. Among 139 patients who developed in-hospital VTE, 117 patients (84.2%) experienced events that were not preventable by best practice prophylaxis (49 CVC-VTE, 2 ST, 58 received all doses of risk-appropriate prophylaxis). Among 88 patients with potentially preventable VTE events, best-practice prophylaxis was prescribed for 76 (86.5%). The most common reason for potential preventable VTE was missed doses of VTE prophylaxis. For those ordered best-practice prophylaxis, 18 patients (23.7%) missed one or more doses of pharmacologic prophylaxis, 12 patients on the medical and 6 patients on a surgical service. For 7 patients (38.9%), the provider determined that their clinical condition was inappropriate for one or more doses of prophylaxis administration; 4 patients on the medical service and 3 patients on a surgical service. Eight patients (25%) refused one or more doses of prophylaxis; 7 patients on the medical service and 1 patient on a surgical service. Conclusions: This retrospective consecutive case series of hospital-acquired VTE reveals that a substantial percentage of VTE among hospitalized patients are not preventable even with best practice prophylaxis. Therefore, process measures (prescription of risk-appropriate VTE prophylaxis) rather than outcomes (VTE) is the appropriate quality improvement metric for assessing provider and institutional performance. In addition, we noted that missed doses of VTE prophylaxis were the most common finding among patients suffering potentially preventable hospital-acquired VTE. Patient refusal and provider omission were the two leading reasons for missed doses of VTE prophylaxis. These findings underscore the need to track rates of ordered and administered doses of best-practice VTE prophylaxis and identify reasons and solutions for these quality deficits. Disclosures: Streiff: sanofi-aventis: Consultancy, Honoraria; BristolMyersSquibb: Research Funding; Eisai: Consultancy; Janssen Healthcare: Consultancy; Daiichi-Sankyo: Consultancy.

scholarly journals Improved Compliance With Venous Thromboembolism Pharmacologic Prophylaxis for Patients With Gynecologic Malignancies Hospitalized for Nonsurgical Indications Did Not Reduce Venous Thromboembolism Incidence

2015 ◽  
Vol 25 (1) ◽  
pp. 152-159 ◽  
Author(s):  
Lauren S. Prescott ◽  
Lisa M. Kidin ◽  
Rebecca L. Downs ◽  
David J. Cleveland ◽  
Ginger L. Wilson ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
High Risk Population ◽  
Gynecologic Malignancies ◽  
National Guidelines ◽  
Vte Prophylaxis ◽  
Patients With Cancer ◽  
Discharge Outcomes ◽  
Pharmacologic Prophylaxis ◽  
Prophylactic Anticoagulation ◽  
Hospital Acquired

ObjectiveNational guidelines recommend prophylactic anticoagulation for all hospitalized patients with cancer to prevent hospital-acquired venous thromboembolism (VTE). However, adherence to these evidence-based recommended practice patterns remains low. We performed a quality improvement (QI) project to increase VTE pharmacologic prophylaxis rates among patients with gynecologic malignancies hospitalized for nonsurgical indications and evaluated the resulting effect on rates of development of VTE.Materials and MethodsIn June 2011, departmental VTE practice guidelines were implemented for patients with gynecologic malignancies who were hospitalized for nonsurgical indications. A standardized VTE prophylaxis module was added to the admission electronic order sets. Outcome measures included number of admissions receiving VTE pharmacologic prophylaxis within 24 hours of admission; and number of potentially preventable hospital-acquired VTEs diagnosed within 30 and 90 days of discharge. Outcomes were compared between a preguideline implementation cohort (n = 99), a postguideline implementation cohort (n = 127), and a sustainability cohort assessed 2 years after implementation (n = 109). Patients were excluded if upon admission they had a VTE, were considered low risk for VTE, or had a documented contraindication to pharmacologic prophylaxis.ResultsAdministration of pharmacologic prophylaxis within 24 hours of admission increased from 20.8% to 88.2% immediately following the implementation of guidelines, but declined to 71.8% in our sustainability cohort (P < 0.001). There was no difference in VTE incidence among the 3 cohorts [n = 2 (4.2%) vs n = 3 (3.9%) vs n = 3 (4.2%), respectively; P = 1.00].ConclusionsOur QI project improved pharmacologic VTE prophylaxis rates. A small decrease in prophylaxis during the subsequent 2 years suggests a need for continued surveillance to optimize QI initiatives. Despite increased adherence to guidelines, VTE rates did not decline in this high-risk population.

Effectiveness of Standardized Venous Thromboembolism Prophylaxis Order Sets in Patients Undergoing Abdominal or Pelvic Surgery for Cancer

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 4248-4248
Author(s):  
Molly Weidner Mandernach ◽  
Richard Lottenberg ◽  
Thomas Johns ◽  
Elaine Speed ◽  
Russell L Findlay ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
High Risk ◽  
Risk Stratification ◽  
Pelvic Surgery ◽  
Vte Prophylaxis ◽  
Order Sets ◽  
Pharmacologic Prophylaxis ◽  
The Mean ◽  
Length Of Hospitalization ◽  
Order Set

Abstract Abstract 4248 Background: In our tertiary academic medical center, standardized pre-printed physician order sets were implemented in 2008 for inpatient venous thromboembolism (VTE) risk stratification and prophylaxis on the day of admission. Electronic medical records were not utilized during the study period. Recommendations for pharmacologic prophylaxis were derived from the 2008 American College of Chest Physicians (ACCP) guidelines. Patients undergoing abdominal or pelvic surgery for cancer were specifically identified in the highest risk category with enoxaparin, fondaparinux, or warfarin (goal INR 2–3) provided as options for pharmacologic VTE prophylaxis. Sequential compression devices (SCDs) were also recommended. This retrospective analysis evaluates adherence to risk stratification and recommendations for pharmacologic VTE prophylaxis in patients undergoing abdominal or pelvic surgery for cancer. Methods: Using the hospital administrative database, all patients ≥ 18 years hospitalized between January 1, 2009 and December 31, 2010 were identified by ICD-9 codes for cancer and surgery performed. Patients undergoing an abdominal or pelvic surgery for cancer lasting >45 minutes were included. Exclusion criteria were age >90 years, patients requiring therapeutic anticoagulation, length of hospitalization <24 hours or >30 days, transplant recipients, patients requiring multiple visits to the operating room during hospitalization, laparoscopic or transurethral procedures, and esophagectomy. Primary outcomes included adherence to order set risk stratification and pharmacologic VTE prophylaxis recommendations, and timing, type, and dose of pharmacologic VTE prophylaxis prescribed. Chart review of physician orders for mechanical and pharmacologic prophylaxis for each day of hospitalization was completed on all patients. Operative reports, medication administration records, and progress notes were reviewed if clarification of physician orders was required. Administration of the prescribed medication during hospitalization was not verified. Results: A total of 773 hospital admissions representing 767 patients met inclusion criteria. The mean length of hospitalization was 7 +/− 5 days during the study period. The mean age was 62 +/− 12 years and 51% were female. Pharmacologic prophylaxis was prescribed 5645 of 6147 patient days (91.8%). Enoxaparin was prescribed 630 (9.8%) patient days, and fondaparinux in 15 patient days (0.002%). Although not indicated as an option for this patient population in our order set, low dose unfractionated heparin (LDUH) was prescribed 4991 (81.2%) of the patient days and was to be dosed every 8 hours (80%) or every 12 hours (19.8%). Warfarin was not prescribed. Mechanical thromboprophylaxis with SCDs was ordered 93.7% of the patient encounters on the day of surgery. The standardized pre-printed physician order set was utilized for prescribing prophylaxis at the time of admission for 630 (82.1%) patient encounters. Clinicians risk stratified only 350 (45.3%) of these patient encounters per the order set guidelines. Of those, 131 (37.4%) were appropriately deemed high risk based upon “abdominal/pelvic cancer undergoing operative procedure”. In the high risk group, LDUH was prescribed in 90 (68.7%) patient encounters, and enoxaparin as recommended in 30 (22.9%). Eleven (8.4%) were not prescribed pharmacologic prophylaxis on the day of admission. Conclusion: Completion of standardized pre-printed physician order sets with appropriate risk stratification in patients undergoing major, open abdominal or pelvic surgery for cancer is underutilized in our institution. Although pharmacologic prophylaxis is prescribed for the majority of inpatient days, LDUH is primarily ordered despite preferred recommendations in favor of enoxaparin or fondaparinux. Thus, an opportunity exists to implement an educational intervention to improve adherence to evidence based order set risk stratification and pharmacologic VTE prophylaxis recommendations. Disclosures: No relevant conflicts of interest to declare.

Long-term outcomes of lumbar microdiscectomy in the pediatric population: a large single-institution case series

2019 ◽  
Vol 24 (5) ◽  
pp. 549-557
Author(s):  
Malia McAvoy ◽  
Heather J. McCrea ◽  
Vamsidhar Chavakula ◽  
Hoon Choi ◽  
Wenya Linda Bi ◽  
...  
Keyword(s):  
Conservative Management ◽  
Functional Outcomes ◽  
Pediatric Patients ◽  
Clinical Presentation ◽  
Case Series ◽  
Csf Leak ◽  
Single Institution ◽  
The Mean

OBJECTIVEFew studies describe long-term functional outcomes of pediatric patients who have undergone lumbar microdiscectomy (LMD) because of the rarity of pediatric disc herniation and the short follow-up periods. The authors analyzed risk factors, clinical presentation, complications, and functional outcomes of a single-institution series of LMD patients over a 19-year period.METHODSA retrospective case series was conducted of pediatric LMD patients at a large pediatric academic hospital from 1998 to 2017. The authors examined premorbid risk factors, clinical presentation, physical examination findings, type and duration of conservative management, indications for surgical intervention, complications, and postoperative outcomes.RESULTSOver the 19-year study period, 199 patients underwent LMD at the authors’ institution. The mean age at presentation was 16.0 years (range 12–18 years), and 55.8% were female. Of these patients, 70.9% participated in competitive sports, and among those who did not play sports, 65.0% had a body mass index greater than 25 kg/m2. Prior to surgery, conservative management had failed in 98.0% of the patients. Only 3 patients (1.5%) presented with cauda equina syndrome requiring emergent microdiscectomy. Complications included 4 cases of postoperative CSF leak (2.0%), 1 case of a noted intraoperative CSF leak, and 3 cases of wound infection (1.5%). At the first postoperative follow-up appointment, minimal or no pain was reported by 93.3% of patients. The mean time to return to sports was 9.8 weeks. During a mean follow-up duration of 8.2 years, 72.9% of patients did not present again after routine postoperative appointments. The total risk of reoperation was a rate of 7.5% (3.5% of patients underwent reoperation for the same level; 4.5% underwent adjacent-level decompression, and one patient [0.5%] ultimately underwent a fusion).CONCLUSIONSMicrodiscectomy is a safe and effective treatment for long-term relief of pain and return to daily activities among pediatric patients with symptomatic lumbar disc disease in whom conservative management has failed.

scholarly journals 63 Chronic Femoral Osteomyelitis Case Series: Outcomes and Economic Impact at A United Kingdom Based Tertiary Centre

2021 ◽  
Vol 108 (Supplement_2) ◽  
Author(s):  
E Lau ◽  
Z Arshad ◽  
A Aslam ◽  
A Thahir ◽  
M Krkovic
Keyword(s):  
Economic Impact ◽  
Treatment Protocol ◽  
Case Series ◽  
Consecutive Series ◽  
Financial Loss ◽  
Patient Demographics ◽  
Tertiary Centre ◽  
The Mean ◽  
Eq Vas

Abstract Introduction Osteomyelitis refers to an inflammatory process affecting bone and bone marrow. This study reviews chronic femoral osteomyelitis treatment and outcomes, including economic impact. Method We retrospectively collected data from a consecutive series of 14 chronic femoral osteomyelitis patients treated between January 2013 and January 2020. Data collected include patient demographics, comorbidities, pathogens, complications, treatment protocol and costs. Functional outcome was assessed using EuroQOL five-dimensional interview administration questionnaire (EQ-5D-5L™) and EuroQOL Visual Analogue Scale (EQ-VAS™). Results Of these, 92.9% had one or more osteomyelitis risk factor, including smoking and diabetes. Samples from 78.6% grew at least one pathogen. Only 42.9% achieved remission after initial treatment, but 85.7% were in remission at final follow-up, with no signs of recurrence throughout the follow-up period (mean: 21.4 months). The average treatment cost was £39,249.50 with a net mean loss of £19,080.10 when funding was considered. The mean-derived EQ-5D score was 0.360 and the mean EQ-VAS score was 61.7, lower than their values for United Kingdom’s general population, p = 0.0018 and p = 0.013 respectively. Conclusions Chronic femoral osteomyelitis treatment is difficult, resulting in significant economic burden. With previous studies showing cheaper osteomyelitis treatment at specialist centres, our net financial loss incurred suggests the need for management at specialised centres.

scholarly journals Failed Surgery for Patellar Tendinopathy in Athletes: Midterm Results of Further Surgical Management

2021 ◽  
Vol 9 (3) ◽  
pp. 232596712199455
Author(s):  
Nicola Maffulli ◽  
Francesco Oliva ◽  
Gayle D. Maffulli ◽  
Filippo Migliorini
Keyword(s):  
Surgical Management ◽  
Revision Surgery ◽  
Case Series ◽  
Sports Participation ◽  
Patellar Tendinopathy ◽  
Symptom Duration ◽  
Level Of Evidence ◽  
Training Time ◽  
The Mean

Background: Tendon injuries are commonly seen in sports medicine practice. Many elite players involved in high-impact activities develop patellar tendinopathy (PT) symptoms. Of them, a small percentage will develop refractory PT and need to undergo surgery. In some of these patients, surgery does not resolve these symptoms. Purpose: To report the clinical results in a cohort of athletes who underwent further surgery after failure of primary surgery for PT. Study Design: Case series; Level of evidence, 4. Methods: A total of 22 athletes who had undergone revision surgery for failed surgical management of PT were enrolled in the present study. Symptom severity was assessed through the Victorian Institute of Sport Assessment Scale for Patellar Tendinopathy (VISA-P) upon admission and at the final follow-up. Time to return to training, time to return to competition, and complications were also recorded. Results: The mean age of the athletes was 25.4 years, and the mean symptom duration from the index intervention was 15.3 months. At a mean follow-up of 30.0 ± 4.9 months, the VISA-P score improved 27.8 points ( P < .0001). The patients returned to training within a mean of 9.2 months. Fifteen patients (68.2%) returned to competition within a mean of 11.6 months. Of these 15 patients, a further 2 had decreased their performance, and 2 more had abandoned sports participation by the final follow-up. The overall rate of complications was 18.2%. One patient (4.5%) had a further revision procedure. Conclusion: Revision surgery was feasible and effective in patients in whom PT symptoms persisted after previous surgery for PT, achieving a statistically significant and clinically relevant improvement of the VISA-P score as well as an acceptable rate of return to sport at a follow-up of 30 months.

scholarly journals First experience with augmented reality neuronavigation in endoscopic assisted midline skull base pathologies in children

2021 ◽  
Author(s):  
Valentina Pennacchietti ◽  
Katharina Stoelzel ◽  
Anna Tietze ◽  
Erwin Lankes ◽  
Andreas Schaumann ◽  
...  
Keyword(s):  
Augmented Reality ◽  
Skull Base ◽  
Skull Base Surgery ◽  
Morphological Variability ◽  
Case Series ◽  
Relevant Information ◽  
Navigation Systems ◽  
Postoperative Mri ◽  
The Mean ◽  
Clinical Conditions

Abstract Introduction Endoscopic skull base approaches are broadly used in modern neurosurgery. The support of neuronavigation can help to effectively target the lesion avoiding complications. In children, endoscopic-assisted skull base surgery in combination with navigation systems becomes even more important because of the morphological variability and rare diseases affecting the sellar and parasellar regions. This paper aims to analyze our first experience on augmented reality navigation in endoscopic skull base surgery in a pediatric case series. Patients and methods A retrospective review identified seventeen endoscopic-assisted endonasal or transoral procedures performed in an interdisciplinary setting in a period between October 2011 and May 2020. In all the cases, the surgical target was a lesion in the sellar or parasellar region. Clinical conditions, MRI appearance, intraoperative conditions, postoperative MRI, possible complications, and outcomes were analyzed. Results The mean age of our patients was 14.5 ± 2.4 years. The diagnosis varied, but craniopharyngiomas (31.2%) were mostly represented. AR navigation was experienced to be very helpful for effectively targeting the lesion and defining the intraoperative extension of the pathology. In 65% of the oncologic cases, a radical removal was proven in postoperative MRI. The mean follow-up was 89 ± 79 months. There were no deaths in our series. No long-term complications were registered; two cerebrospinal fluid (CSF) fistulas and a secondary abscess required further surgery. Conclusion The implementation of augmented reality to endoscopic-assisted neuronavigated procedures within the skull base was feasible and did provide relevant information directly in the endoscopic field of view and was experienced to be useful in the pediatric cases, where anatomical variability and rarity of the pathologies make surgery more challenging.

Management of optic disc pit-associated maculopathy: A case series from a tertiary referral center

2021 ◽  
pp. 112067212110237
Author(s):  
Ilkay Kilic Muftuoglu ◽  
Ecem Onder Tokuc ◽  
V Levent Karabas
Keyword(s):  
Optic Disc ◽  
Case Series ◽  
Internal Limiting Membrane ◽  
Maximum Height ◽  
Optic Disc Pit ◽  
Tertiary Referral Center ◽  
Number Of Patients ◽  
The Mean ◽  
Foveal Center

Purpose: To report outcomes of pars plana vitrectomy (PPV) combined with internal limiting membrane (ILM) stuffing technique in patients with optic disc pit associated maculopathy (ODP-M). Methods: Data including best-corrected visual acuity (BCVA), central macular thickness (CMT), foveal center point thickness (FCP), and maximum height of fluid (max_fluid) (intraretinal or subretinal) were collected from the medical records of the patients. Results: Six eyes of six patients with a mean age of 28.0 ± 17.68 years (range: 9–53 year) underwent PPV + ILM plug surgery. The mean follow-up duration was 25.62 ± 26.11 months (range: 11.80–78.00 month) duration. The mean BCVA increased from 1.25 ± 1.04 logMAR (20/355, Snellen equivalent) to 0.86 ± 1.09 logMAR (20/144, Snellen equivalent) at last follow-up ( p = 0.043). Compared to baseline, CMT, FCP, and max_fluid significantly decreased at all visits after the surgery ( p < 0.05 for all visits). At last follow-up, 66.6% of the eyes (four eyes) showed complete resolution of fluid at a mean of 5.25 ± 4.99 months (range: 1–12 months) after the surgery. Conclusion: PPV with ILM plug seemed to be an effective surgical technique in ODP-M. Studies with longer follow-up and higher number of patients are needed to confirm our results.

Analysis of Clinical, Imaging, and Pathologic Features of 36 Patients with Primary Intraspinal Primitive Neuroectodermal Tumors: A Case Series and Literature Review

2021 ◽  
Author(s):  
Xuefeng Wei ◽  
Xu Zhang ◽  
Zimu Song ◽  
Feng Wang
Keyword(s):  
Literature Review ◽  
Single Case ◽  
Case Reports ◽  
Case Series ◽  
Subtotal Resection ◽  
Study Cohort ◽  
Primitive Neuroectodermal Tumors ◽  
Pathologic Features ◽  
Neuroectodermal Tumors ◽  
The Mean

Abstract Background and Study Aims Primary intraspinal primitive neuroectodermal tumors (PNETs) account for ∼0.4% of all intraspinal tumors, but information about these tumors in the medical literature is limited to single case reports. We report four cases of primary intraspinal PNETs and present a systematic literature review of the reported cases. Materials and Methods We retrospectively reviewed and analyzed the clinical data of 4 patients with primary intraspinal PNETs who underwent neurosurgical treatment at our clinic between January 2013 and January 2020, and of 32 cases reported in the literature. Results The female-to-male ratio was 2.6:1. The mean patient age was 21.42 ± 15.76 years (range: 1–60 years), and patients <36 years of age accounted for 83.30% of the study cohort. Progressive limb weakness and numbness were the chief symptoms (accounting for ∼55.6%). The mean complaint duration was 0.89 ± 0.66 months for males and 2.72 ± 3.82 months for females (p = 0.028). Epidural (41.7%) was the most common site, and thoracic (47.3%) was the most frequent location. Most PNETs were peripheral, and magnetic resonance imaging (MRI) appearance was isointense or mildly hypointense on T1-weighted images and hyperintense on T2-weighted images. Homogeneous contrast enhancement was observed. The 1-year survival rate of patients who underwent chemoradiation after total or subtotal lesion resection was better compared with patients who did not undergo chemotherapy, radiotherapy, or total or subtotal resection. The modality of treatment was associated with survival time (p = 0.007). Conclusion Primary intraspinal PNETs mainly occur in young people with a female preponderance. In patients with a rapid loss of lower limb muscle strength and large intraspinal lesions on MRI, PNETs should be considered. Surgical resection and adjuvant radio chemotherapy are key prognostic factors.

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