Implementation of a Prophylactic Anticoagulation Guideline for Patients with Traumatic Brain Injury

Tignanelli, Christopher J.; Gipson, Jonathan; Nguyen, Arthur; Martínez, Regina; Yang, Simon; Reicks, Patty; Sybrant, Cori; Roach, Robert Allen; Thorson, Melissa; West, Michael O.

doi:10.1016/j.jcjq.2019.11.007

Cited by 9 publications

(13 citation statements)

References 21 publications

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“…Patients with high-risk TBI without progression on repeat imaging can have VTE prophylaxis safely initiated at 72 hours 50 . Adherence with the modified Berne-Norwood criteria is associated with a significant reduction in VTE events for TBI patients without added risk of TBI progression 44,51,52 …”

Section: Protocol Rationale and Goalsmentioning

confidence: 99%

“…50 Adherence with the modified Berne-Norwood criteria is associated with a significant reduction in VTE events for TBI patients without added risk of TBI progression. 44,51,52 Many trauma centers follow the Brain Injury Guidelines (BIG) in which repeat CT head is not routinely done in BIG 1 and 2 injuries and is done at 6 hours after the initial head CT in BIG 3 patients. 53 Initiation of VTE chemical prophylaxis in the low-risk BIG 1 and 2 may be prudent 24 hours to 48 hours after injury if neurologic examination remains stable.…”

Section: Vte Pharmacologic Prophylaxis For Tbimentioning

confidence: 99%

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American Association for the Surgery of Trauma/American College of Surgeons-Committee on Trauma Clinical Protocol for inpatient venous thromboembolism prophylaxis after trauma

Yorkgitis

Berndtson

Cross

et al. 2021

J Trauma Acute Care Surg

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Trauma patients are at increased risk of venous thromboembolism (VTE), which includes both deep vein thrombosis and pulmonary embolism. Pharmacologic VTE prophylaxis is a critical component of optimal trauma care that significantly decreases VTE risk. Optimal VTE prophylaxis protocols must manage the risk of VTE with the competing risk of hemorrhage in patients following significant trauma. Currently, there is variability in VTE prophylaxis protocols across trauma centers. In an attempt to optimize VTE prophylaxis for the injured patient, stakeholders from the American Association for the Surgery of Trauma and the American College of Surgeons-Committee on Trauma collaborated to develop a group of consensus recommendations as a resource for trauma centers. The primary goal of these recommendations is to help standardize VTE prophylaxis strategies for adult trauma patients (age ≥15 years) across all trauma centers. This clinical protocol has been developed to (1) provide standardized medication dosing for VTE prophylaxis in the injured patient; and (2) promote evidence-based, prompt VTE prophylaxis in common, high-risk traumatic injuries.

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Section: Protocol Rationale and Goalsmentioning

confidence: 99%

Section: Vte Pharmacologic Prophylaxis For Tbimentioning

confidence: 99%

American Association for the Surgery of Trauma/American College of Surgeons-Committee on Trauma Clinical Protocol for inpatient venous thromboembolism prophylaxis after trauma

Yorkgitis

Berndtson

Cross

et al. 2021

J Trauma Acute Care Surg

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“…None of the studies were randomized trials. Studies by Haut et al, 15 Engels et al, 16 and Tignanelli et al 17 were retrospective, whereas the study by Burns et al 18 had both retrospective and prospective components. Burns et al studied 134 acute spinal cord injury patients in six VA hospitals in the United States.…”

Section: Resultsmentioning

confidence: 99%

Thromboprophylaxis in hospitalized trauma patients: a systematic review and meta-analysis of implementation strategies

Ratnasekera,

Seng,

Ciarmella

et al. 2024

Trauma Surg Acute Care Open

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IntroductionVenous thromboembolism (VTE) prophylaxis implementation strategies are well-studied in some hospitalized medical and surgical patients. Although VTE is associated with substantial mortality and morbidity in trauma patients, implementation strategies for the prevention of VTE in trauma appear to be based on limited evidence. Therefore, we conducted a systematic review and meta-analysis of published literature on active implementation strategies for VTE prophylaxis administration in hospitalized trauma patients and the impact on VTE events.MethodsA systematic review and meta-analysis was performed in adult hospitalized trauma patients to assess if active VTE prevention implementation strategies change the proportion of patients who received VTE prophylaxis, VTE events, and adverse effects such as bleeding or heparin-induced thrombocytopenia as well as hospital length of stay and the cost of care. An academic medical librarian searched Medline, Scopus, and Web of Science until December 2022.ResultsFour studies with a total of 1723 patients in the active implementation strategy group (strategies included education, reminders, human and computer alerts, audit and feedback, preprinted orders, and/or root cause analysis) and 1324 in the no active implementation strategy group (guideline creation and dissemination) were included in the analysis. A higher proportion of patients received VTE prophylaxis with an active implementation strategy (OR=2.94, 95% CI (1.68 to 5.15), p<0.01). No significant difference was found in VTE events. Quality was deemed to be low due to bias and inconsistency of studies.ConclusionsActive implementation strategies appeared to improve the proportion of major trauma patients who received VTE prophylaxis. Further implementation studies are needed in trauma to determine effective, sustainable strategies for VTE prevention and to assess secondary outcomes such as bleeding and costs.Level of evidenceSystematic review/meta-analysis, level III.PROSPERO registration numberCRD42023390538.

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“…Ultimately, the CPG adhered to a “middle of the road” approach by instituting universal prophylactic weight-based anticoagulation for all patients. Similar to anticoagulation CPGs for other disease processes [ 19 ], we incorporated a risk stratification model, whereby the intensity of anticoagulation was increased to moderate intensity (0.5 mg/kg BID enoxaparin or low intensity heparin infusion in case of renal failure) for patients with a history of thrombosis, cancer, admission to the intensive care unit (ICU), or D-dimer >10 times the upper limit of normal. The CPG is a “living” framework, and has since undergone several iterations of modifications (upstratification of patients with a prior history of deep venous thrombosis or cancer, and ICU patients, and exclusion of pregnant patients) based on evolution of the evidence.…”

Section: Methodsmentioning

confidence: 99%

Implementation of an Anticoagulation Practice Guideline for COVID-19 via a Clinical Decision Support System in a Large Academic Health System and Its Evaluation: Observational Study

Shah¹,

Switzer²,

Shippee³

et al. 2021

JMIR Med Inform

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Background Studies evaluating strategies for the rapid development, implementation, and evaluation of clinical decision support (CDS) systems supporting guidelines for diseases with a poor knowledge base, such as COVID-19, are limited. Objective We developed an anticoagulation clinical practice guideline (CPG) for COVID-19, which was delivered and scaled via CDS across a 12-hospital Midwest health care system. This study represents a preplanned 6-month postimplementation evaluation guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. Methods The implementation outcomes evaluated were reach, adoption, implementation, and maintenance. To evaluate effectiveness, the association of CPG adherence on hospital admission with clinical outcomes was assessed via multivariable logistic regression and nearest neighbor propensity score matching. A time-to-event analysis was conducted. Sensitivity analyses were also conducted to evaluate the competing risk of death prior to intensive care unit (ICU) admission. The models were risk adjusted to account for age, gender, race/ethnicity, non-English speaking status, area deprivation index, month of admission, remdesivir treatment, tocilizumab treatment, steroid treatment, BMI, Elixhauser comorbidity index, oxygen saturation/fraction of inspired oxygen ratio, systolic blood pressure, respiratory rate, treating hospital, and source of admission. A preplanned subgroup analysis was also conducted in patients who had laboratory values (D-dimer, C-reactive protein, creatinine, and absolute neutrophil to absolute lymphocyte ratio) present. The primary effectiveness endpoint was the need for ICU admission within 48 hours of hospital admission. Results A total of 2503 patients were included in this study. CDS reach approached 95% during implementation. Adherence achieved a peak of 72% during implementation. Variation was noted in adoption across sites and nursing units. Adoption was the highest at hospitals that were specifically transformed to only provide care to patients with COVID-19 (COVID-19 cohorted hospitals; 74%-82%) and the lowest in academic settings (47%-55%). CPG delivery via the CDS system was associated with improved adherence (odds ratio [OR] 1.43, 95% CI 1.2-1.7; P<.001). Adherence with the anticoagulation CPG was associated with a significant reduction in the need for ICU admission within 48 hours (OR 0.39, 95% CI 0.30-0.51; P<.001) on multivariable logistic regression analysis. Similar findings were noted following 1:1 propensity score matching for patients who received adherent versus nonadherent care (21.5% vs 34.3% incidence of ICU admission within 48 hours; log-rank test P<.001). Conclusions Our institutional experience demonstrated that adherence with the institutional CPG delivered via the CDS system resulted in improved clinical outcomes for patients with COVID-19. CDS systems are an effective means to rapidly scale a CPG across a heterogeneous health care system. Further research is needed to investigate factors associated with adherence at low and high adopting sites and nursing units.

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Implementation of a Prophylactic Anticoagulation Guideline for Patients with Traumatic Brain Injury

Cited by 9 publications

References 21 publications

American Association for the Surgery of Trauma/American College of Surgeons-Committee on Trauma Clinical Protocol for inpatient venous thromboembolism prophylaxis after trauma

American Association for the Surgery of Trauma/American College of Surgeons-Committee on Trauma Clinical Protocol for inpatient venous thromboembolism prophylaxis after trauma

Thromboprophylaxis in hospitalized trauma patients: a systematic review and meta-analysis of implementation strategies

Implementation of an Anticoagulation Practice Guideline for COVID-19 via a Clinical Decision Support System in a Large Academic Health System and Its Evaluation: Observational Study

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