BACKGROUND:Trauma is a major risk factor for the development of a venous thromboembolism (VTE). After observing higher than expected VTE rates within our center's Trauma Quality Improvement Program data, we instituted a change in our VTE prophylaxis protocol, moving to enoxaparin dosing titrated by anti-Xa levels. We hypothesized that this intervention would lower our symptomatic VTE rates. METHODS:Adult trauma patients at a single institution meeting National Trauma Data Standard criteria from April 2015 to September 2019 were examined with regards to VTE chemoprophylaxis regimen and VTE incidence. Two groups of patients were identified based on VTE protocol-those who received enoxaparin 30 mg twice daily without routine anti-Xa levels ("pre") versus those who received enoxaparin 40 mg twice daily with dose titrated by serial anti-Xa levels ("post"). Univariate and multivariate analyses were performed to define statistically significant differences in VTE incidence between the two cohorts. RESULTS:There were 1698 patients within the "pre" group and 1406 patients within the "post" group. The two groups were essentially the same in terms of demographics and risk factors for bleeding or thrombosis. There was a statistically significant reduction in VTE rate ( p = 0.01) and deep vein thrombosis rate ( p = 0.01) but no significant reduction in pulmonary embolism rate ( p = 0.21) after implementation of the anti-Xa titration protocol. Risk-adjusted Trauma Quality Improvement Program data showed an improvement in rate of symptomatic pulmonary embolism from fifth decile to first decile. CONCLUSION:A protocol titrating prophylactic enoxaparin dose based on anti-Xa levels reduced VTE rates. Implementation of this type of protocol requires diligence from the physician and pharmacist team. Further research will investigate the impact of protocol compliance and time to appropriate anti-Xa level on incidence of VTE.

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Purpose: Trauma patients are at high risk of venous thromboembolism (VTE). We summarize the comparative efficacy and safety of anti-Xa-guided versus fixed dosing for low molecular weight heparin (LMWH) for the prevention of VTE in adult trauma patients. Methods: We searched Medline and Embase from inception through June 1, 2022. We included randomized controlled trials or observational studies comparing anti-Xa-guided versus fixed dosing of LMWH for thromboprophylaxis in adult trauma patients. We incorporated primary data from 2 large observational cohorts. We pooled effect estimates using a random-effects model. We assessed risk of bias using the ROBINS-I tool for observational studies and assessed certainty of findings using GRADE methodology. Results: We included 15 observational studies involving 10,348 patients. No randomized controlled trials were identified. determined that, compared to fixed LMWH dosing, anti-Xa-guided dosing may reduce deep vein thrombosis [adjusted odds ratio (aOR); 0.52, 95% CI: 0.40–0.69], pulmonary embolism (aOR: 0.48, 95% CI: 0.30–0.78) or any VTE (aOR: 0.54, 95% CI: 0.42–0.69), though all estimates are based on low certainty evidence. There was an uncertain effect on mortality (aOR: 1.06, 95% CI: 0.85–1.32) and bleeding events (aOR: 0.84, 95% CI: 0.50–1.39), limited by serious imprecision. We used several sensitivity and subgroup analyses to confirm the validity of our assumptions. Conclusion: Anti-Xa-guided dosing may be more effective than fixed dosing for prevention of deep vein thrombosis, pulmonary embolism, and VTE for adult trauma patients. These promising findings justify the need for a high-quality randomized study with the potential to deliver practice changing results.

Objective: Job satisfaction and work stress are associated with provider health and patient outcomes. This study aimed to evaluate job satisfaction and workplace stressors in surgical providers (surgeons, physician assistants [PAs], and NPs). Methods: A survey was distributed to providers within a single surgical department. Job satisfaction and workplace stressors were evaluated by sex, age, profession, career length, and work hours. Results: Providers practicing for 11 to 15 years had greater job satisfaction than those practicing for more than 20 years, with no other differences by demographic group. Females cited supervisory support as a top workplace stressor more than did males (P = .01) and PAs and NPs cited supervisory support (P < .01) and compensation/finances more than surgeons (P = .05). Workplace stressors varied by practice years and work hours. Conclusions: Healthcare organizations should be aware of diversity in perceived workplace stressors. A “one size fits all” approach to provider well-being is likely to be ineffective.

Linked ContentThis article is linked to Lin et al papers. To view these articles, visit https://doi.org/10.1111/apt.15184 and https://doi.org/10.1111/apt.15398.