An 84-year-old woman with a past medical history of significant hyperlipidemia, hypertension, impaired glucose tolerance, and asthma along with progressive shortness of breath for 2 weeks and exacerbating swelling of lower extremity was presented to the hospital. She had visited her primary care physician for the same symptoms and was administered with furosemide before the hospital presentation. Her lower extremity swelling and other symptoms did not show any improvement with furosemide administration, which prompted her visit to the emergency room. Upon presentation, new-onset atrial fibrillation showing a heart rate of 170 beats per min was observed. Further physical examination revealed irregular heart rhythms with bibasilar crackles on auscultation. Initial lab results were normal except for the following values: hemoglobin of 11.3, pro B-type Natriuretic Peptide (pro-BNP) of 5197, and INR of 1.1. She was administered with oral diltiazem, which failed to improve her heart rate. Eventually, intravenous administration of diltiazem was started. She was also administered with IV digoxin and was further initiated on anticoagulation with enoxaparin. As part of the cardiology workup, she underwent a transthoracic echocardiogram showing left ventricular ejection fraction of 40%-45% and mild-to-moderate global hypokinesis. The right ventricle was dilated with mildly reduced systolic function, biatrial enlargement with severe tricuspid regurgitation, and pulmonary artery systolic pressure of 45 mmHg. A hypermobile mass, which measured 2.39 cm×1.1 cm, was also observed in the left atrium. This mass was attached to the interatrial septum. The initial differential diagnosis included myxoma, thrombus, or other tumors. Intravenous administration of heparin was started preemptively, whereas transesophageal echocardiogram (TEE) was being planned to rule out the large thrombus. TEE confirmed a large mass in the left atrium attached to the septum by a thin stalk measuring up to 4.3 cm in length [Supplementary Figure 1, Supplementary Video 1(2D), Supplementary Video 2 (3D)]. Spontaneous contrast was observed in the L atrial appendix and no thrombus was detected. The patient underwent subsequent surgical excision of the mass and ligation of the left atrial appendage using an atrial clip device. Pathological examination confirmed the findings of left atrial myxoma. Verbal consent was obtained from the patient.
PURPOSE: Currently venous thromboembolism (VTE) is still considered a common preventable condition in hospitalized patients. However a significant proportion of VTE cases occur in patients who have received appropriate prophylactic measures according to the current guidelines. Financial implications for healthcare institutions for quality performance and costs incurred from the event can be substantial. We propose a classification system for preventable VTE versus non-preventable VTE cases based on compliance with appropriate prophylaxis based on current evidenced based guidelines. METHODS: Patients with hospital acquired VTE were identified in an academic tertiary care center. 120 cases during January 2015 to February 2016 were randomly selected for analysis for adherence to VTE prophylaxis guidelines. VTE prophylaxis compliance was based on American College of Chest Physicians 9th edition (ACCP) guidelines. Prescription order compliance was defined by appropriate pharmacological and/or mechanical prophylaxis being prescribed for the patient if indicated. Mechanical prophylaxis compliance was defined as appropriate adherence to mechanical prophylaxis during the indicated period. Pharmacological prophylaxis compliance was defined as appropriate dosing being administered during the indicated period. If there was full compliance with the measures, then health care delivery was termed as 'optimal' or defect-free. If any hospitalized patients develop VTE despite optimal care, it was classified as potentially non-preventable VTE. If any lapse in adherence to the guidelines was identified, it was termed as 'sub-optimal' care. The VTE cases resulting from sub-optimal care were classified as potentially preventable. An algorithm for classification of Hospital Acquired VTEs was developed using the above defined compliance measures. RESULTS: One hundred and twenty hospital acquired venous thromboembolism events were analyzed. 42 of 120 (35%) VTE cases are potentially preventable and 78 of 120 (65%) are potentially non-preventable. Pharmacological prophylaxis was ordered in 97.5% and mechanical prophylaxis was ordered in 89.16% prior to the development of VTE. Gap in pharmacological prophylaxis was found in 16 cases (13.33%), 15 cases (12.5%) had gap in mechanical prophylaxis and gaps in pharmacological and mechanical prophylaxis was found in 11 cases (9.12%). CONCLUSIONS: Majority (65%) of hospital acquired VTEs are Non-Preventable based on compliance with the 9th edition ACCP Guidelines for VTE prevention. CLINICAL IMPLICATIONS: Quality performance measures should target preventable VTE events rather than all hospital acquired VTE episodes.
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