BACKGROUND:Enhanced recovery after surgery (ERAS) has been hypothesized to improve surgical outcomes following colorectal surgery; however, the long-term sustainability of improvement remains unclear. MATERIALS AND METHODS:A comprehensive ERAS program was implemented for patients undergoing colorectal surgery at Johns Hopkins Hospital (JHH) in 2014. This study investigated inpatient elective colorectal surgery outcomes at JHH during three two-year postimplementation periods (2014-19) relative to a two-year baseline (2012-2013) via pre-post analyses and using difference-in-differences (DID) regression comparing JHH with a national sample of > 700 hospitals participating in the National Surgical Quality Improvement Program (NSQIP). Length of stay (LOS) was evaluated using multivariable zero-truncated negative binomial regression, whereas Surgical Site Infections (SSIs) and readmission rates were analyzed using multivariable logistic regression. Analyses controlled for ASA score, procedure type, age, sex, race, and surgical approach. RESULTS:The study included 1851 patients at JHH and 303,175 patients from the national sample. In pre-post analyses comparing JHH from baseline (2012-2013) to the final period (2018-2019), statistically significant improvements were seen for SSIs with a 4.4% reduction (OR 0.54 and 95% CI 0.35-0.86) and for readmissions with a 5.6% reduction (OR 0.57 and 95% CI 0.39-0.85), while LOS was statistically unchanged (0.41 days reduction; IRR 0.93 and 95% CI 0.85-1.01). DID analyses showed statistical equivalence for SSIs (OR 0.80 and 95% CI 0.51-1.26), greater improvement for readmission rates at JHH (OR 0.62 and 95% CI 0.42-0.92), and lower improvement for LOS at JHH (IRR 1.17 and 95% CI 1.07-1.27). CONCLUSIONS:ERAS implementation at JHH was associated with sustained improvement that was comparable (SSIs) or superior (readmissions) to national improvement trends over a period of 6 years (postimplementation), suggesting ERAS adoption in colorectal surgery is warranted for long-term outcomes improvement. Results were suggestive of a tradeoff between readmission rates and LOS.

Importance:Venous thromboembolism (VTE) is one of the most common causes of preventable harm in hospitals. While numerous efforts have been made to increase prescription of evidence-based VTE prophylaxis for hospitalized patients, many prescribed doses are either refused or missed for other reasons. Successful interventions to decrease these missed doses have been developed and tested in academic hospitals, but it remains unclear if these interventions can be scaled and implemented in community hospitals. Objective:To disseminate and implement an evidence-based, comprehensive strategy to reduce missed doses of VTE prophylaxis. Design, Setting, and Participants:This prospective cohort study was conducted on 7 floors across a community hospital within a large health system. Participants were all hospitalized adult patients admitted from July 1, 2018, to June 30, 2019 (preintervention), and July 1 to December 31, 2019 (postintervention), who were prescribed at least 1 dose of pharmacologic VTE prophylaxis. Data analysis was performed from January 2020 to January 2022. Interventions:Implementation of a dynamic, scenario-based nurse education module combined with a patient-centered education bundle triggered by a real-time alert sent to the charge nurse when a dose of prescribed VTE prophylaxis was not administered. Main Outcomes and Measures:Primary outcome was the proportion of any missed doses of prescribed pharmacologic prophylaxis. Secondary outcomes were proportions of doses refused and missed for reasons other than refusal. Results:A total of 15 752 patients were included, 8714 (55.3%) female and 7038 (44.7%) male. The mean (SD) age was 63.9 (18.5) years. Missed doses decreased significantly in the postimplementation period, 10 643 of 82 269 doses (12.9%) vs 2718 of 29 338 doses (9.3%) (OR, 0.60; 95% CI, 0.55-0.66). There were significant improvements in patient refusal (7280 doses [8.8%] vs 1696 doses [5.8%]; OR, 0.51; 95% CI, 0.46-0.58) and doses missed for reasons other than patient refusal (3363 [4.1%] vs 1022 [3.5%]; OR, 0.87; 95% CI, 0.77-0.99). There was no difference in the proportion of patients with VTE (9 patients [0.08%] vs 6 patients [0.1%]; P = .58). Conclusion and Relevance:This study found that providing engaging education to frontline nurses and just-in-time, patient-centered education to patients significantly improved administration and acceptance of prescribed VTE prophylaxis for hospitalized patients across an entire community hospital. These findings show that proven interventions developed at academic hospitals can be successfully implemented broadly in community hospitals.

OBJECTIVE:The aim of this study was to explore barriers and facilitators to implementing enhanced recovery pathways, with a focus on identifying factors that distinguished hospitals achieving greater levels of implementation success.BACKGROUND:Despite the clinical effectiveness of enhanced recovery pathways, the implementation of these complex interventions varies widely. While there is a growing list of contextual factors that may affect implementation, little is known about which factors distinguish between higher and lower levels of implementation success.METHODS:We conducted in-depth interviews with 168 perioperative leaders, clinicians, and staff from 8 US hospitals participating in the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery. Guided by the Consolidated Framework for Implementation Research, we coded interview transcripts and conducted a thematic analysis of implementation barriers and facilitators. We also rated the perceived effect of factors on different levels of implementation success, as measured by hospitals' adherence with 9 process measures over time.RESULTS:Across all hospitals, factors with a consistently positive effect on implementation included information-sharing practices and the implementation processes of planning and engaging. Consistently negative factors included the complexity of the pathway itself, hospitals' infrastructure, and the implementation process of "executing" (particularly in altering electronic health record systems). Hospitals with the greatest improvement in process measure adherence were distinguished by clinicians' positive knowledge and beliefs about pathways and strong leadership support from both clinicians and executives.CONCLUSION:We draw upon diverse perspectives from across the perioperative continuum of care to qualitatively describe implementation factors most strongly associated with successful implementation of enhanced recovery pathways.

OBJECTIVE To explore barriers and facilitators to implementing enhanced recovery pathways, with a focus on identifying factors that distinguished hospitals achieving greater levels of implementation success. SUMMARY BACKGROUND DATA Despite the clinical effectiveness of enhanced recovery pathways, the implementation of these complex interventions varies widely. While there is a growing list of contextual factors that may affect implementation, little is known about which factors distinguish between higher and lower levels of implementation success. METHODS We conducted in-depth interviews with 168 perioperative leaders, clinicians, and staff from eight U.S. hospitals participating in the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery. Guided by the Consolidated Framework for Implementation Research, we coded interview transcripts and conducted a thematic analysis of implementation barriers and facilitators. We also rated the perceived effect of factors on different levels of implementation success, as measured by hospitals' adherence with nine process measures over time. RESULTS Across all hospitals, factors with a consistently positive effect on implementation included information-sharing practices and the implementation processes of planning and engaging. Consistently negative factors included the complexity of the pathway itself, hospitals' infrastructure, and the implementation process of "executing" (particularly in altering electronic health record systems). Hospitals with the greatest improvement in process measure adherence were distinguished by clinicians' positive knowledge and beliefs about pathways and strong leadership support from both clinicians and executives. CONCLUSIONS We draw upon diverse perspectives from across the perioperative continuum of care to qualitatively describe implementation factors most strongly associated with successful implementation of enhanced recovery pathways.

Background Many hospitalized patients are not administered prescribed doses of pharmacologic venous thromboembolism prophylaxis. Methods and Results In this cluster‐randomized controlled trial, all adult non–intensive care units (10 medical, 6 surgical) in 1 academic hospital were randomized to either a real‐time, electronic alert–triggered, patient‐centered education bundle intervention or nurse feedback intervention to evaluate their effectiveness for reducing nonadministration of venous thromboembolism prophylaxis. Primary outcome was the proportion of nonadministered doses of prescribed pharmacologic prophylaxis. Secondary outcomes were proportions of nonadministered doses stratified by nonadministration reasons (patient refusal, other). To test our primary hypothesis that both interventions would reduce nonadministration, we compared outcomes pre‐ versus postintervention within each cohort. Secondary hypotheses were tested comparing the effectiveness between cohorts. Of 11 098 patient visits, overall dose nonadministration declined significantly after the interventions (13.4% versus 9.2%; odds ratio [OR], 0.64 [95% CI, 0.57–0.71]). Nonadministration decreased significantly ( P <0.001) in both arms: patient‐centered education bundle, 12.2% versus 7.4% (OR, 0.56 [95% CI, 0.48–0.66]), and nurse feedback, 14.7% versus 11.2% (OR, 0.72 [95% CI, 0.62–0.84]). Patient refusal decreased significantly in both arms: patient‐centered education bundle, 7.3% versus 3.7% (OR, 0.46 [95% CI, 0.37–0.58]), and nurse feedback, 9.5% versus 7.1% (OR, 0.71 [95% CI, 0.59–0.86]). No differential effect occurred on medical versus surgical units. The patient‐centered education bundle was significantly more effective in reducing all nonadministered ( P =0.03) and refused doses ( P =0.003) compared with nurse feedback (OR, 1.28 [95% CI, 1.0–1.61]; P =0.03 for interaction). Conclusions Information technology strategies like the alert‐triggered, targeted patient‐centered education bundle, and nurse‐focused audit and feedback can improve venous thromboembolism prophylaxis administration. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03367364.

Introduction: Venous thromboembolism (VTE) is a frequent cause of preventable harm among hospitalized patients. Many prescribed prophylaxis doses are not administered despite supporting evidence. We previously demonstrated a patient-centered education bundle improved VTE prophylaxis administration broadly; however, patient-specific factors driving nonadministration are unclear. We examine the effects of the education bundle on missed doses of VTE prophylaxis by sex. Methods: Weperformeda post-hocanalysis of anonrandomized controlled trial toevaluate the differences in missed doses by sex. Pre-intervention and intervention periods for patients admitted to 16 surgical andmedical floors between 10/2014-03/2015 (pre-intervention) and 04/ 2015-12/2015 (intervention) were compared. We examined the conditional odds of (1) overall missed doses, (2) missed doses due to patient refusal, and (3) missed doses for other reasons. Results: Overall, 16,865 patients were included (pre-intervention 6853, intervention 10,012), with 2350 male and 2460 female patients (intervention), and 6373 male and 5682 female patients (control). Anymissed dose significantly reduced on the intervention floors amongmale (odds ratioOR 0.55; 95% confidence interval CI, 0.44-0.70, P< 0.001) and female (OR 0.59; 95% CI, 0.47-0.73, P < 0.001) patients. Similar significant reductions ensued for missed doses due to patient refusal (P < 0.001). Overall, there were no sex-specific differences (P-interaction>0.05). Conclusions: Our intervention increased VTE prophylaxis administration for both female and male patients, driven by decreased patient refusal. Patient education should be applicable to a wide range of patient demographics representative of the target group. To improve future interventions, quality improvement efforts should be evaluated based on patient demographics and drivers of differences in care. (c) 2022 Elsevier Inc. All rights reserved.

BACKGROUND AND OBJECTIVES:Health services research often relies on readily available data, originally collected for administrative purposes and used for public reporting and pay-for-performance initiatives. We examined the prevalence of underreporting of diagnostic procedures for acute myocardial infarction (AMI), deep venous thrombosis (DVT), and pulmonary embolism (PE), used for public reporting and pay-for-performance initiatives.METHOD:We retrospectively identified procedures for AMI, DVT, and PE in the National Inpatient Sample (NIS) database between 2012 and 2016. From January 1, 2012, through September 30, 2015, the NIS used the International Classification of Diseases, Ninth Revision (ICD-9) coding scheme. From October 1, 2015, through December 31, 2016, the NIS used the International Classification of Diseases, Tenth Revision (ICD-10) coding scheme. We grouped the data by ICD code definitions (ICD-9 or ICD-10) to reflect these code changes and to prevent any confounding or misclassification. In addition, we used survey weighting to examine the utilization of venous duplex ultrasound scan for DVT, electrocardiogram (ECG) for AMI, and chest computed tomography (CT) scan, pulmonary angiography, echocardiography, and nuclear medicine ventilation/perfusion () scan for PE.RESULTS:In the ICD-9 period, by primary diagnosis, only 0.26% (n = 5930) of patients with reported AMI had an ECG. Just 2.13% (n = 7455) of patients with reported DVT had a peripheral vascular ultrasound scan. For patients with PE diagnosis, 1.92% (n = 12 885) had pulmonary angiography, 3.92% (n = 26 325) had CT scan, 5.31% (n = 35 645) had cardiac ultrasound scan, and 0.45% (n = 3025) had scan. In the ICD-10 period, by primary diagnosis, 0.04% (n = 345) of reported AMI events had an ECG and 0.91% (n = 920) of DVT events had a peripheral vascular ultrasound scan. For patients with PE diagnosis, 2.08% (n = 4805) had pulmonary angiography, 0.63% (n = 1460) had CT scan, 1.68% (n = 3890) had cardiac ultrasound scan, and 0.06% (n = 140) had scan. Small proportions of diagnostic procedures were observed for any diagnoses of AMI, DVT, or PE.CONCLUSIONS:Our findings question the validity of using NIS and other administrative databases for health services and outcomes research that rely on certain diagnostic procedures. Unfortunately, the NIS does not provide granular data that can control for differences in diagnostic procedure use, which can lead to surveillance bias. Researchers and policy makers must understand and acknowledge the limitations inherent in these databases, when used for pay-for-performance initiatives and hospital benchmarking.

Background Venous thromboembolism (VTE) is a leading cause of preventable harm in hospitalized patients. However, many doses of prescribed pharmacologic VTE prophylaxis are frequently missed. We investigated the effect of a patient-centered education bundle on missed doses of VTE prophylaxis in a community hospital. Methods We performed a pre-post analysis examining missed doses of VTE prophylaxis in a community hospital. A real-time alert from the electronic health record system facilitated the delivery of a patient education bundle intervention. We included all patient visits on a single floor where at least 1 dose of VTE prophylaxis was prescribed during pre- (January 1, 2018, - November 31, 2018) and post- (January 1 - June 31, 2019) intervention periods. Outcomes included any missed dose (primary) and reasons for missed doses (refusal, other [secondary]) and were compared between both periods. Results 1,614 patient visits were included. The proportion of any missed dose significantly decreased (13.8% vs. 8.2% [OR, 0.56; 95% CI, 0.48, 0.64]) between the pre-post intervention periods. Patient refusal was the most frequent reason for missed doses. In the post-intervention period, patient refusal significantly decreased from 8.8% to 5.0% (OR, 0.54; 95% CI, 0.46, 0.64). Similarly, other reasons for missed doses significantly decreased from 5.0% to 3.2% (OR, 0.62; 95% CI, 0.51, 0.77). Conclusions A real-time alert-triggered patient-centered education bundle developed and tested in an academic hospital, significantly reduced missed doses of prescribed pharmacologic VTE prophylaxis when disseminated to a community hospital.

OBJECTIVE: To evaluate the effectiveness of feedback using an emailed scorecard and a web-based dashboard on risk-appropriate VTE prophylaxis prescribing practices among general surgery interns and residents. DESIGN: Prospective cohort study. SETTING: The Johns Hopkins Hospital, an urban academic medical center. PARTICIPANTS: All 45 trainees (19 post-graduate year [PGY] 1 interns and 26 PGY-2 to PGY-5 residents) in our general surgery program. INTERVENTION: Feedback implementation encompassed three sequential periods: (1) scorecard (July 1, 2014 through June 30, 2015); (2) no feedback/wash-in (July 1 through October 31, 2015); and (3) web-based dashboard (November 1, 2015 through June 30, 2016). No feedback served as the baseline period for the intern cohort. The scorecard was a static document showing an individual's compliance with risk-appropriate VTE prophylaxis prescription compared to compliance of their de-identified peers. The web-based dashboard included other information (e.g., patient details for suboptimal prophylaxis orders) besides individual compliance compared to their de- identified peers. Trainees could access the dashboard anytime to view current and historic performance. We sent monthly emails to all trainees for both feedback mechanisms. Main outcome was proportion of patients prescribed risk-appropriate VTE prophylaxis, and mean percentages reported. RESULTS: During this study, 4088 VTE prophylaxis orders were placed. Among residents, mean prescription of risk-appropriate prophylaxis was higher in the wash-in (98.4% vs 95.6%, p < 0.001) and dashboard (98.4 vs 95.6%, p < 0.001) periods compared to the scorecard period. There was no difference in mean compliance between the wash-in and dashboard periods (98.4% vs 98.4%, p = 0.99). Among interns, mean prescription of risk-appropriate VTE prophylaxis improved between the wash-in and dashboard periods (91.5% vs 96.4%, p < 0.001). CONCLUSIONS AND RELEVANCE: Using audit and individualized performance feedback to general surgery trainees through a web-based dashboard improved prescribing of appropriate VTE prophylaxis to a near-perfect performance. ((C) 2021 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

BackgroundRacial disparities are common in healthcare. Venous thromboembolism (VTE) is a leading cause of preventable harm, and disparities observed in prevention practices. We examined the impact of a patient-centered VTE education bundle on the non-administration of preventive prophylaxis by race.MethodsA post-hoc, subset analysis (stratified by race) of a larger nonrandomized trial. Pre-post comparisons analysis were conducted on 16 inpatient units; study periods were October 2014 through March 2015 (baseline) and April through December 2015 (post-intervention). Patients on 4 intervention units received the patient-centered, nurse educator-led intervention if the electronic health record alerted a non-administered dose of VTE prophylaxis. Patients on 12 control units received no intervention. We compared the conditional odds of non-administered doses of VTE prophylaxis when patient refusal was a reason for non-administration, stratified by race.ResultsOf 272 patient interventions, 123 (45.2%) were white, 126 (46.3%) were black, and 23 (8.5%) were other races. A significant reduction was observed in the odds of non-administration of prophylaxis on intervention units compared to control units among patients who were black (OR 0.61; 95% CI, 0.46-0.81, p<0.001), white (OR 0.57; 95% CI, 0.44-0.75, p<0.001), and other races (OR 0.50; 95% CI, 0.29-0.88, p = 0.015).ConclusionOur finding suggests that the patient education materials, developed collaboratively with a diverse group of patients, improved patient's understanding and the importance of VTE prevention through prophylaxis. Quality improvement interventions should examine any differential effects by patient characteristics to ensure disparities are addressed and all patients experience the same benefits.

BACKGROUND:Patient ambulation is frequently recommended to help prevent venous thromboembolism during hospital admission. Our objective was to synthesize the evidence for ambulation as a prophylaxis for venous thromboembolism in hospital.METHODS:We conducted a systematic review. We searched MEDLINE, Embase, Scopus, Web of Science and Cochrane Central Register of Controlled Trials indexed from their inception through April 2020 for studies of adult patients admitted to hospital, in which ambulation or mobilization alone or concomitant with prophylaxis was indicated for prevention of venous thromboembolism. We searched ClinicalTrials.gov for unpublished trials. We included randomized controlled trials (RCTs) and observational studies. Two reviewers independently screened articles and assessed risk of bias using 2 validated tools. We scored studies on quality of reporting, internal and external validity and study power; combined scores determined the overall quality.RESULTS:Eighteen articles met the inclusion criteria: 8 retrospective and 2 prospective cohorts, 7 RCTs and 1 secondary analysis of an RCT. The intervention (ambulation or mobilized) groups varied across studies. Five studies examined exercise as a therapeutic prophylaxis for thrombosis and 9 described an ambulation protocol. Five studies attempted to quantify amount and duration of patient ambulation and 3 reported ambulation distance. In the 5 studies rated as good or excellent statistical quality, findings were mixed. Incidence of venous thromboembolism was lowest when pharmacologic anticoagulants were added as part of the prescribed prophylaxis regimen.INTERPRETATION:We did not find high-quality evidence supporting ambulation alone as an effective prophylaxis for venous thromboembolism. Ambulation should not be considered an adequate prophylaxis for venous thromboembolism, nor as an adequate reason to discontinue pharmacologic prophylaxis for venous thromboembolism during a patient's hospital admission.

BACKGROUND: Although enhanced recovery pathways (ERPs) have demonstrated promising results in published literature, their effectiveness has been inconsistent. The objective of this study was to identify the most important data use practices associated with successful implementation of ERPs. STUDY DESIGN: As part of a national ERP implementation initiative, data regarding hospitals' previous ERP implementation experience were collected. Specifically, 4 data use practices (data collection, report generation, feedback to leadership, and feedback to frontline providers) and 2 data types (process measures and outcome measures) were correlated with ERP implementation outcomes (hospital-reported success and patient outcomes from the American College of Surgeons [ACS] NSQIP data). RESULTS: Of 140 hospitals evaluated, 73 (52.1%) reported previous ERP implementation, with wide variations in data use practices. Of these, 33 (45.2%) reported successful implementation. Feedback of both process and outcome measure data was performed by only 15.1% of hospitals, but was associated with significantly higher likelihood of successful implementation when compared with no feedback (relative risk [RR] 2.45, 95% CI 1.69 to 3.56; p < 0.001) and feedback of only outcome measure data (RR 2.73, 95% CI 1.06 to 7.00; p = 0.037). Using ACS NSQIP data from 6,888 colorectal surgery patients from 52 hospitals with colorectal ERPs, hospital-reported success was associated with significantly lower surgical site infection rates (6.6% vs 8.1%; p = 0.011) and shorter length of stay (6.2 vs 7.0 days; p < 0.001). CONCLUSIONS: The most important data use practice associated with successful ERP implementation was data feedback to frontline providers of both process and outcome measures. However, this was rarely performed in a national cohort of hospitals and represents a substantial but straightforward opportunity for improvement. (C) 2019 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.

TO THE EDITOR: We read with interest the new clinical practice guidelines for venous thromboembolism (VTE) made available on 27 November 2018.[1][1] The evidence-based guidelines from the American Society of Hematology (ASH) highlight the risk of VTE in a variety of settings and provide

Purpose: This study compared a nti-Xa activity in critically ill patients receiving UFH for VTE prophylaxis between two weight groups (<100 kg vs >= 100 kg). Methods: This prospective, observational study included critically ill patients on UFH 5000 or 7500 units every 8 h. A peak and trough anti-Xa activity assay was ordered for each patient at steady state. Goal peak anti-Xa activity was 0.1-0.3 units/mL. Results: From March 2017 to June 2018, 75 patients were enrolled with 44 in the <100 kg group and 31 in the >= 100 kg group. There was no significant difference in the percentage of patients with peak anti-Xa activity within goal range between patients <100 kg and >= 100 kg (55.3% vs 35.7%, p = 0.12). The odds ratio for achieving peak anti-Xa activity within goal range as weight-based dose increased was 1.03 (95% CI 0.99-1.07). No differences were found in trough anti-Xa activity, VTE, bleeding, length of stay, or death. Conclusions: Though only one-third of patients >= 100 kg had peak anti-Xa activity within goal range, no significant difference was found between the weight groups. Additional prospective studies with adequate sample sizes are warranted to further investigate appropriate weight-based dosing of UFH in critically ill patients. (C) 2019 Elsevier Inc. All tights reserved.

BACKGROUND:Process measure compliance has been associated with improved outcomes in enhanced recovery after surgery (ERAS) programs. Herein, we sought to assess the impact of compliance with measures directly influenced by anesthesiology in an ERAS for colorectal surgery cohort. METHODS:From January 2013 to April 2015, data from 1140 consecutive patients were collected for all patients before (pre-ERAS) and after (ERAS) implementation of an ERAS program. Compliance with 9 specific process measures directly influenced by the anesthesiologist or acute pain service was analyzed to determine the impact on hospital length of stay (LOS). RESULTS:Process measure compliance was associated with a stepwise reduction in LOS. Patients who received >4 process measures (high compliance) had a significantly shorter LOS (incident rate ratio [IRR], 0.77; 95% CI, 0.70-0.85); P < .001) compared to low compliance (0-2 process measures) counterparts. Multivariable regression suggests that utilization of multimodal nausea and vomiting prophylaxis (IRR, 0.78; 95% CI, 0.68-0.89; P < .001), scheduled postoperative nonsteroidal pain medication use (IRR, 0.76; 95% CI, 0.67-0.85; P < .001), and strict adherence to a postoperative opioid administration (IRR, 0.58; 95% CI, 0.51-0.67; P < .001) protocol for breakthrough pain were independently associated with reduced LOS. CONCLUSIONS:Our findings suggest that increased compliance with process measures directly influenced by the anesthesiologists and in concert with a formal anesthesia protocol is associated with reduced LOS. Engaging anesthesiology colleagues throughout the surgical encounter increases the overall value of perioperative care.

IMPORTANCE Numerous interventions have improved prescription of venous thromboembolism (VTE) prophylaxis; however, many prescribed doses are not administered to hospitalized patients, primarily owing to patient refusal. OBJECTIVE To evaluate a real-time, targeted, patient-centered education bundle intervention to reduce nonadministration of VTE prophylaxis. DESIGN, SETTING, AND PARTICIPANTS This nonrandomized controlled, preintervention-postintervention comparison trial included 19 652 patient visits on 16 units at The Johns Hopkins Hospital, Baltimore, Maryland, from April 1 through December 31, 2015. Data analysis was performed from June 1, 2016, through November 30, 2017, on an intention-to-treat basis. INTERVENTIONS Patients on 4 intervention units received a patient-centered education bundle if a dose of VTE prophylaxis medication was not administered. Patients on 12 control units received no intervention. MAIN OUTCOMES AND MEASURES Conditional odds of nonadministration of doses of VTE prophylaxis (primary outcome) before and after the intervention on control vs intervention units. Reasons for nonadministration (ie, patient refusal and other) and VTE event rates (secondary outcomes) were compared. RESULTS A total of 19 652 patient visits where at least 1 dose of VTE prophylaxis was prescribed were included (51.7% men; mean [SD] age, 55.6 [17.1] years). Preintervention and postintervention groups were relatively similar in age, sex, race, and medical or surgery unit. From the preintervention period to the postintervention period, on intervention units, the conditional odds of VTE prophylaxis nonadministration declined significantly (9.1% [95% CI, 52%-16.2%] vs 5.6% [95% CI, 3.1%-9.9%]; odds ratio [OR], 0.57; 95% CI, 0.48-0.67) compared with no change on control units (13.6% [95% CI, 9.8%-18.7%] vs 13.3% [95% CI, 9.6%-18.5%]; OR, 0.98; 95% CI, 0.91-1.07; P < .001 for interaction). The conditional odds of nonadministration owing to patient refusal decreased significantly on intervention units (5.9% [95% CI, 2.6%-13.6%] vs 3.4% [95% CI, 1.5%-7.8%]; OR, 0.53; 95% CI,0.430.65) compared with no change on control units (8.7% [95% CI, 5.4%-14.0%] vs 8.5% [95% CI, 5.3%-13.8%]; OR, 0.98; 95% CI, 0.89-1.08; P < .001 for interaction). On intervention units, the conditional odds of nonadministration owing to reasons other than patient refusal decreased (2.3% [95% CI, 1.5%-3.4%] vs 1.7% [95% CI, 1.1%-2.6%]; OR, 0.74; 95% CI, 0.58-0.94), with no change on control units (34% [95% CI, 2.7%-4.4%] vs 3.3% [95% CI, 2.6%4.2%]; OR, 0.98; 95% CI, 0.87-1.10; P = .04 for interaction). No differential effect occurred on medical vs surgical units (OR, 0.86; 95% CI, 0.60-1.23; P = .41 for interaction). There was no statistical difference in the proportion of VTE events among patients on intervention vs control units (0.30% vs 0.18%; OR, 0.60; 95% CI, 0.16-2.23). CONCLUSIONS AND RELEVANCE In this study, a targeted patient-centered education bundle significantly reduced nonadministration of pharmacologic VTE prophylaxis in hospitalized patients. This novel strategy improves health care quality by leveraging electronic data to target interventions in real time for at-risk patients.

AIM:To characterize resources to safely mobilize different types of hospitalized patients.BACKGROUND:Current approaches to determine nurse-patient ratios do not always include information regarding the specific demands of patients who require extra resources to mobilize. Workflows must be designed with knowledge of resource requirements to integrate patient mobility into the daily nursing team care plan.METHODS:Nurse-led mobility sessions were evaluated on two adult hospital units, which consisted of nurse-patient encounters focused on patient mobility only. The resources assessed for each session were time-to-mobilize patient, time-to-document, need for additional staff support, and the need for assistive devices. Mobility sessions were also categorized by patient ambulation status, level of mobility limitations (low, medium and high) and diagnosis.RESULTS:In 212 total mobility sessions, the median time-to-mobilize and time-to-document were 7.75 and 1.27 min, respectively. Additional staff support was required for 87% and 92% of patients with medium and high mobility limitations, respectively. All patients with low mobility limitations ambulated, and only 14% required additional staff. Ambulating patients with high mobility limitations was the most time-intensive (median 12.55 min). Ambulating stroke patients required one additional staff and an assistive device in 92% and 69% of the sessions, respectively.CONCLUSION:This study describes the resources associated with mobilizing inpatients with different levels of mobility impairments and diagnoses.IMPLICATIONS FOR NURSING MANAGEMENT:These results could assist nursing management with facilitating appropriate daily nurse-patient ratios and justify the need for assistive devices and staff support to safely mobilize patients.

Background. Venous thromboembolism (VTE) is an important complication after solid organ transplantation. We sought to evaluate any association between VTE and in-hospital death, length of hospitalization, and total hospital charges for patients hospitalized for lung transplantation (LT). Methods. We retrospectively reviewed the Nationwide Inpatient Sample to identify patients hospitalized for LT from 2000 to 2011. We evaluated the incidence of VTE during hospitalization for LT, risk factors for VTE, and the association between VTE and in-hospital death, length of hospitalization, and total hospital charges. Results. Of the 16,318 adults hospitalized for LT during the study period, VTE developed in 1,029 (6.3%), including 854 (5.4%) with deep vein thrombosis alone and 175 (1.1%) with pulmonary embolism. The factors associated with VTE included age older than 60 years (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.03 to 1.94), female sex (OR, 0.61; 95% CI, 0.44 to 0.86), and receiving mechanical ventilation support for 96 hours or more (OR, 3.38; 95% CI, 2.49 to 4.58). The adjusted odds of in-hospital death in patients with pulmonary embolism was thrice as high as those without any VTE (OR, 3.40; 95% CI, 1.29 to 8.99). Among LT patients with VTE, the average length of hospitalization was 38% (95% CI, 27% to 48%) longer, and the total cost of hospitalization was 23% (95% CI, 16% to 30%) higher compared with LT patients without VTE. Conclusions. VTE is a relatively frequent complication among LT recipients and is associated with increased death, total hospital length of stay, and hospital charges. These data indicate that prophylaxis practices should be reexamined to reduce this preventable complication. (c) 2018 by The Society of Thoracic Surgeons

PURPOSE:Results of a study to characterize patterns of nonadministration of medication doses for venous thromboembolism (VTE) prevention among hospitalized patients are presented.METHODS:The electronic records of all patients admitted to 4 floors of a medical center during a 1-month period were examined to identify patients whose records indicated at least 1 nonadministered dose of medication for VTE prophylaxis. Proportions of nonadministered doses by medication type, intended route of administration, and VTE risk categorization were compared; reasons for nonadministration were evaluated.RESULTS:Overall, 12.7% of all medication doses prescribed to patients in the study cohort (n = 75) during the study period (857 of 6,758 doses in total) were not administered. Nonadministration of 1 or more doses of VTE prophylaxis medication was nearly twice as likely for subcutaneous anticoagulants than for all other medication types (231 of 1,112 doses [20.8%] versus 626 of 5,646 doses [11.2%], p < 0.001). For all medications prescribed, the most common reason for nonadministration was patient refusal (559 of 857 doses [65.2%]); the refusal rate was higher for subcutaneous anticoagulants than for all other medication categories (82.7% versus 58.8%, p < 0.001). Doses of antiretrovirals, immunosuppressives, antihypertensives, psychiatric medications, analgesics, and antiepileptics were less commonly missed than doses of electrolytes, vitamins, and gastrointestinal medications.CONCLUSION:Scheduled doses of subcutaneous anticoagulants for hospitalized patients were more likely to be missed than doses of all other medication types.