Reliability of a point‐based VTE risk assessment tool in the hands of medical residents

Beck, Michael; Haidet, Paul; Todoric, Krista; Lehman, Erik; Sciamanna, Chris

doi:10.1002/jhm.860

Cited by 17 publications

(12 citation statements)

References 37 publications

(37 reference statements)

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“…There are several caveats to those considering the use of these more complex point‐based models. Complex point‐based RAM suffer from poor interobserver agreement . They have also had limited ability to exclude low‐risk patients from prophylaxis in validation studies, and have not been tested extensively in medical populations.…”

Section: Choosing a Vte Rammentioning

confidence: 99%

“…Complex point-based RAM suffer from poor interobserver agreement. 32 They have also had limited ability to exclude low-risk patients from prophylaxis in validation studies, 33 and have not been tested extensively in medical populations. Although AT9 considers the Caprini RAM relatively easy to use, 9 our experience in collaboratives suggests that for many hospitals, the model is too complex to be used reliably.…”

Section: Approach 3: Buckets Of Riskmentioning

confidence: 99%

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Venous thromboembolism prevention guidelines for medical inpatients: Mind the (implementation) Gap

Maynard

Jenkins

Merli

2013

Journal of Hospital Medicine

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BACKGROUND Hospital‐associated nonsurgical venous thromboembolism (VTE) is an important problem addressed by new guidelines from the American College of Physicians (ACP) and American College of Chest Physicians (AT9). METHODS Narrative review and critique. RESULTS Both guidelines discount asymptomatic VTE outcomes and caution against overprophylaxis, but have different methodologies and estimates of risk/benefit. Guideline complexity and lack of consensus on VTE risk assessment contribute to an implementation gap. Methods to estimate prophylaxis benefit have significant limitations because major trials included mostly screening‐detected events. AT9 relies on a single Italian cohort study to conclude that those with a Padua score ≥4 have a very high VTE risk, whereas patients with a score <4 (60% of patients) have a very small risk. However, the cohort population has less comorbidity than US inpatients, and over 1% of patients with a score of 3 suffered pulmonary emboli. The ACP guideline does not endorse any risk‐assessment model. AT9 includes the Padua model and Caprini point‐based system for nonsurgical inpatients and surgical inpatients, respectively, but there is no evidence they are more effective than simpler risk‐assessment models. CONCLUSIONS New VTE prevention guidelines provide varied guidance on important issues including risk assessment. If Padua is used, a threshold of 3, as well as 4, should be considered. Simpler VTE risk‐assessment models may be superior to complicated point‐based models in environments without sophisticated clinical decision support. Journal of Hospital Medicine 2013;8:582–588. © 2013 Society of Hospital Medicine

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Section: Choosing a Vte Rammentioning

confidence: 99%

Section: Approach 3: Buckets Of Riskmentioning

confidence: 99%

Venous thromboembolism prevention guidelines for medical inpatients: Mind the (implementation) Gap

Maynard

Jenkins

Merli

2013

Journal of Hospital Medicine

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“…4,5 At many medical institutions, residents perform the majority of admission risk assessments and order VTE prophylaxis; despite few studies showing if residents can reliably apply a VTE risk assessment tool. 15,16 In the present study, appropriate VTE prophylaxis was given in only 18.75% of low risk, 29.17% of moderate risk and 65.51% of high risk patients. These data suggest that those patients with high risk were easily picked up and given appropriate VTE prophylaxis whereas there is a tendency of under prophylaxis in medium and low risk individuals.…”

Section: A Each Risk Factor Carries 1 Pointmentioning

confidence: 75%

Evaluation of Practice Pattern of Vte Prophylaxis in Postoperative Patients

Belgod¹,

Pandyan²,

Thinagaran³

2015

jemds

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Venous thromboembolism (VTE) is one of the common complications in surgical patients. Venous thromboembolism (VTE), which is manifested as deep vein thrombosis (DVT) and pulmonary embolism (PE), represents a significant cause of death, disability, and discomfort. With the various evidence based studies now we have a better understanding of the VTE/PE risk factors and preventive measures. However most of the hospitals and doctors fall short in implementing the knowledge while treating their patients. Hence the need for the present study to assess the practice pattern of VTE prophylaxis in surgical patients. MATERIALS AND METHODS: It's a retrospective study in which 100 patients were randomly selected from the operation theatre registry. Individual risk assessment was done and VTE prophylaxis given was recorded and then compared with the Caprini's VTE risk assessment model and suggested prophylaxis. RESULTS AND CONCLUSION: Appropriate VTE prophylaxis was given only in 42.03% of the postoperative patients (18.75% of low risk, 29.17% of moderate risk and 65.51% of high risk patients). The remaining 57.97% of patients were at increased risk of developing DVT and pulmonary embolism thus increasing the chances of morbidity and mortality. The prophylaxis was inadequate mainly in the moderate and low risk individuals. Hence there is a strong need for a standard hospital policy for VTE risk assessment and prophylaxis in surgical patients. KEYWORDS: Evaluation of practice pattern of VTE prophylaxis in postoperative patients. INTRODUCTION:Venous thromboembolism (VTE) is one of the common complications in surgical patients. 1 Venous thromboembolism (VTE), which is manifested as deep vein thrombosis (DVT) and pulmonary embolism (PE), represents a significant cause of death, disability, and discomfort. The risk for VTE in surgical patients depends both on patient related factors and the type of surgery. 1,2 The commonly used guidelines for VTE risk assessment and prophylaxis are Caprini's VTE risk assessment model and American College of Chest Physicians (ACCP) consensus guidelines for VTE prophylaxis. Use of LMWH, pneumatic compression stockings or graded compression stockings have greatly reduced the incidence of VTE and thereby reducing the morbidity and mortality. 2 Pulmonary embolism (PE) is now the most common cause of preventable death in surgical patients.With the various evidence based studies now, we have a better understanding of the VTE risk factors and preventive measures. The high incidence of postoperative VTE and the availability of effective methods of prevention mandate that thromboprophylaxis should be considered in every surgical patient. However most of the hospitals and doctors fall short in implementing the knowledge while treating their patients. 3,4,5 Hence the need for the present study to assess the practice pattern of VTE prophylaxis in surgical patients.

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“…We compared previously published inter-rater reliability and adherence data to new inter-rater reliability and adherence data within the same residency program. We found that early in the academic year, and without any exposure to the risk assessment tool, our residents showed variation in risk assessment, VTE plan, and protocol adherence [9]. One year after integrating a point-based prophylaxis tool, the inter-rater reliability remained largely unchanged, but that overall adherence improved.…”

Section: Discussionmentioning

confidence: 99%

“…However, residents perform the majority of admission risk assessments and order VTE prophylaxis; despite few studies showing if residents can reliably apply a VTE risk assessment tool [9, 10]. Reliable application of risk assessment tools can reduce practice variation [11].…”

Section: Introductionmentioning

confidence: 99%

Using Clinical Vignettes to Evaluate VTE Protocol Adherence

2012

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BackgroundVenous thromboembolism (VTE) prophylaxis is underutilized in hospitalized medical patients. Underutilization might occur as a result of resident practice variation incurred by using a complex risk assessment tool.ObjectiveTo examine what impact repetitive exposure to an electronic point-based VTE risk assessment tool has on resident inter-rater reliability and protocol adherence.DesignPre and post intervention cross-sectional cohort study.SettingSingle academic center.PatientsConvenience samples of Internal Medicine residents.InterventionsResidents completed clinical vignettes before and after any exposure to an electronic risk assessment tool and reminder alert. They were asked to make three determinations using a point-based VTE risk assessment tool: risk stratification, identify contraindications, and VTE prevention strategy.MeasurementsInter-rater reliability for risk assessment, contraindications, and VTE prophylaxis strategy and protocol adherence.ResultsKappa scores for VTE risk assessment did not change, but improved for VTE plan increasing from 0.28 to 0.37. Protocol adherence improved from 71% in 2008 to 79% (P = 0.06). There was a significant decrease in under-prophylaxis (22% to 6%, P < 0.0001) but a significant increase in over-prophylaxis (7% to 16%, P = 0.001).ConclusionsUsing clinical vignettes, we determined that daily exposure to an electronic risk assessment tool did not improve the inter-rater reliability of a point-based risk assessment tool when used by medical residents. This might be due to inexperienced providers using a complex point-based tool. Overall, adherence improved, and under-prophylaxis decreased, but over-prophylaxis increased. Clinical vignettes are a generalizable method to monitor resident prophylaxis practices and way to identify educational and process improvement opportunities.KeywordsResident; Inter-rater reliability; Venous thromboembolism; Agreement; Risk assessment score

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Reliability of a point‐based VTE risk assessment tool in the hands of medical residents

Cited by 17 publications

References 37 publications

Venous thromboembolism prevention guidelines for medical inpatients: Mind the (implementation) Gap

Venous thromboembolism prevention guidelines for medical inpatients: Mind the (implementation) Gap

Evaluation of Practice Pattern of Vte Prophylaxis in Postoperative Patients

Using Clinical Vignettes to Evaluate VTE Protocol Adherence

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