The duration of LMWH bridging therapy in practice may be significantly greater than previously reported in clinical trials, and the incidence of patients requiring prolonged (>14 days) LMWH therapy is relatively high. Outpatient LMWH as employed in clinical practice safely bridges patients to oral anticoagulation. Strategies to shorten the duration of LMWH therapy are needed and are likely to improve clinical outcomes and reduce health care expenses. In prospective clinical trials low-molecular-weight-heparin (LMWH) has proven effective in transitioning patients with venous thromboembolic disease to therapeutic warfarin anticoagulation. However, it is unknown if the anticoagulation results obtained in these trials, which involved rigidly performed anticoagulation monitoring, are achieved in standard clinical practice involving patients with a variety of indications for anticoagulation. We conducted a retrospective analysis of 100 patients initiating warfarin while receiving LMWH under the management of a university-based anticoagulation management service. The mean total duration of LMWH therapy was 12.0 +/- 8.2 days, of which 9.8 +/- 8.0 days (median 7.5 days; interquartile range 4.3-13.0 days) occurred in the outpatient setting. Forty-one percent of patients received outpatient LMWH for <7 days, 40% for 7-14 days, and 19% for >14 days. We conclude that the duration of LMWH bridging therapy in practice may be significantly greater than previously reported in clinical trials, and the incidence of patients requiring prolonged (>14 days) LMWH therapy is relatively high.
Purpose: At one tertiary, academic medical center, two general medicine units averaged 94% and 97% occupancy causing strain on patient throughput. This project was implemented at these two comparable general medicine units, totaling 64 beds. On each of these units, Pareto analyses on causal factors related to discharge order to exit time (DOTE) were performed. DOTE was defined as the period in minutes from when a provider orders a discharge to when the patient actually exits a room. Prime DOTE reduction opportunities were elicited that highlighted the need to address coordination of hospital discharge transportation; that is, arriving family members averaged 120 and 129 min for the two units, and medicars and ambulances averaged 122 and 156 min, which fell above the established 90-min overall strategic DOTE goal. Coordinating efficient discharges decreases the likelihood of hospital bottlenecking and improves patient satisfaction. Case Management Setting: The health care team is composed of physician and provider services, nursing, and case management, as well as the patient and family. Team-focused interventions aimed at reducing DOTE included leveraging interdisciplinary communication technology and messaging for efficiency and accuracy within the health care team and proactive scheduling of hospital discharge transportation arrival. Process objectives measured included percentage of the health care team educated and utilization of the discharge suite. Outcome objectives measured included median DOTE times, patient satisfaction, and emergency department boarding volume and times. Significantly, admissions for coronavirus disease-2019 (COVID-19) cases were also rapidly increasing early on during program implementation resulting in one of the two general medicine units to be designated for COVID-19 overflow. Research Methodology: Using Lean methodology, the project design was formed based on the Institute for Healthcare Improvement's work on improving hospital-wide patient flow and the Agency for Healthcare Research and Quality's (AHRQ) IDEAL patient discharge framework to better achieve the well-known, triple aim. In response to COVID-19 demands, the Plan–Do–Study–Act process was warranted to be able to manage acute changes, using iterative processing. Results and Implications: This program evaluation study assessed whether a communication training program that taught an interdisciplinary team of case managers, nurses, physicians, and related staff how to reduce DOTE was useful. The program had a material impact on the DOTE metric knowing that the hospital's ultimate strategic goal is to reduce DOTE to 90 min or less. A reduction in discharge time was documented when using weekly data from the hospital's discharge dashboard powered by the Maestro database. More specifically, nurses fully trained in the interdisciplinary communications program aimed to reduce DOTE had significantly lower DOTE outcomes on their discharges compared with untrained staff (i.e., average untrained = 127 min, average trained = 93...
Background: Unplanned 30-day rehospitalization rates for AMI (19.9%) and CHF (24.4%) represent a huge health care burden for patients and providers. Delays in follow-up and lack of adherence to standardized guidelines, by providers and patients, contribute to these findings. The hospital-to-home transition is one area with the potential to effect changes in this complex problem. Specially trained outpatient cardiovascular nurse practitioners (NP) aim to “bridge” the transitional care gap in the Cardiovascular Medicine Bridge Program (BRIDGE). NPs, acting as an extension of the inpatient team, adjust treatments depending on patient status, educate patients, and ensure adherence to lifestyle and therapeutic guidelines. Purpose: To assess differences between patients who attended the BRIDGE clinic and those who did not. Methods: This was a retrospective study of all patients referred to BRIDGE, from June 2008 to February 2009. Univariate techniques were used to compare those who attended BRIDGE and those who did not, in terms of age, diagnoses, comorbidities, time to follow-up visit with a cardiologist, and unplanned readmission. Results: Of 359 patients, 239 (67%) attended BRIDGE, mean time from discharge to BRIDGE follow-up was 19.8 days. Mean age of attendees was 63.9, non-attendees M = 61.2, P = .110; 66.6% were male. Patients were more likely to attend BRIDGE if they had greater than two comorbidities (≤ 2 comorbidities 10.5% vs. > 2 comorbidities 18.3%, P = .046). Primary cardiac diagnoses accounted for 217 (60.6%) BRIDGE referrals (ACS 21.2%, CAD 13.7%, CHF 13.4%, other cardiac 12.3%); cardiac was a secondary diagnosis or complication for the remaining 39.4%. Mean days from discharge to first cardiology appointment was 73.0 for attendees and 53.6 for non-attendees, P = .018. BRIDGE attendees had significantly lower 30-day readmission and ED rates than those who did not attend (readmit: attend 8.7 % vs. not attend 21.7%, P = .001, ED visits: attend 13.5% vs. not attend 28.2%, P = .005). Conclusion: Individuals who attended the BRIDGE clinic had fewer unplanned readmissions, when compared to patients who did not take advantage of this opportunity. These preliminary findings suggest that this strategy can improve efficiency of acute cardiac care in the US.
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