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Article
Publication date: 11 April 2023

Hesham Metwalli Mousli, Iman El Sayed, Adel Zaki and Sherif Abdelmonem

This study intends to improve the quality of venous thromboembolism (VTE) prophylaxis practices including proper VTE risk assessment and the appropriate prophylaxis measures for…

Abstract

Purpose

This study intends to improve the quality of venous thromboembolism (VTE) prophylaxis practices including proper VTE risk assessment and the appropriate prophylaxis measures for surgical urology patients.

Design/methodology/approach

The authors applied the Six-Sigma define, measure, analyze, improve and control (DMAIC) improvement methodology in a pre–post interventional study that involved all adult patients above 18 years old indicated and scheduled for urology surgical interventions including endoscopic urological surgeries in a urology specialized 60-bed hospital. The pre-intervention sample included all patients meeting the inclusion criteria over a period of six months. Post-intervention sample included all patients meeting the inclusion criteria over a period of six months. The improvement areas included both the VTE risk assessment as well as the VTE prophylaxis prescription.

Findings

DMAIC methodology has achieved a substantial sustained improvement in surgical urology VTE prophylaxis practices with an average of 70% on both levels; VTE risk assessment practices and VTE prophylaxis prescribing practices were statistically significant. The post-intervention results also showed a statistically controlled process with no special cause variations. Based on the study results, the Six-Sigma DMAIC methodology can be considered of high value when applied in healthcare clinical practice improvement projects.

Research limitations/implications

The project study includes some pitfalls that can be addressed as follows: 1. The lack of VTE rate incidence tracking. This limitation can be partly refuted when the authors conduct a literature review and explore that the VTE prophylaxis effectiveness had been proven with sufficient evidence to an extent that pushed several scientific societies to develop their own guidelines to support VTE prophylaxis. (Algattas et al., 2018). 2. Another limitation of this study can be that it handled only surgical patients and more specifically surgical urology patients. Of course, VTE prophylaxis is a crucial life-threatening problem not only for the surgical admitted patients but also for all the medical admitted patients either in hospital wards or ICUs. However, the prediction that surgical patients especially surgical urology patients are more prone to VTE development risk as they have -in several cases-two or three main additive risk factors which are age, procedure duration and malignancy in elderly men. (Tikkinen et al., 2014). So, the authors consider the study project to be a prototype that hopefully can be utilized for future study projects that will manage both other surgical specialty patients and medical patients on the national level and can track accurately and effectively report the VTE incidence rates.

Practical implications

Several recommendations can be extracted from the research project that is summarized in the following points: Paying focused attention to continuous healthcare quality improvement initiatives and projects as a main approach for healthcare improvement especially for the public health-related problems. This might be achieved through periodic region-specific or specialty-specific focus groups from which public health problems could be addressed and prioritized to be considered as a part of country healthcare campaigns regarding cost-utility and feasibility studies. The adoption of a system thinking approach in dealing with the improvement strategies; all efforts and resources are to be employed to achieve a common objective. This includes the generation of a national-wide electronic health information system that can aid in healthcare resource allocation and direct the healthcare efforts towards the most important, high-priority public health problems. Electronic national-wide health record is really an effort, and resources consuming activity, but actually, it's worth exerting efforts, and its valuable outcomes may be seen several years later. 3. Development of unified national specialized VTE prophylaxis pathways to standardize the patient-specific VTE prophylaxis plans. Standardization of healthcare pathways enables healthcare professionals to follow an evidence-based practice which will be reflected on the improvement of healthcare quality level, cost-effectiveness enhancement, and timely patient care on all levels especially in high critical areas like ER and ICU. 4. Incorporation of VTE prophylaxis costs in the universal health insurance diagnosis-related group (DRG) insurance packages and service pricing. Universal health insurance is a nationwide strategy that is aiming to cover all Egypt residents by the year 2030. Universal health insurance is being following the DRG reimbursement policy that is thought to control all the healthcare-associated costs so, the VTE prophylaxis costs shall be added as the main cost item to encourage all healthcare facilities to follow an evidence-based VTE prophylaxis pathway taking into consideration the high-risk patient categories who will definitely represent a high-cost burden on the long run if they suffer a VTE event.

Originality/value

DMAIC improvement methodology applications in healthcare are still relatively limited, especially on the clinical level. The study can be considered one of a kind in Egypt dealing with a comprehensive DMAIC methodology application on the clinical level.

Details

The TQM Journal, vol. 36 no. 2
Type: Research Article
ISSN: 1754-2731

Keywords

Article
Publication date: 9 October 2007

J. Labarere and J‐L. Bosson

It is unknown whether data from observational studies can assist guideline developers in areas where scientific evidence is lacking. The purpose of this study is to develop a…

Abstract

Purpose

It is unknown whether data from observational studies can assist guideline developers in areas where scientific evidence is lacking. The purpose of this study is to develop a local clinical guideline for prophylaxis against venous thromboembolism based on observational study results.

Design/methodology/approach

The authors performed a classification tree analysis on original data from a cross‐sectional study of risk factors, prophylaxis, and prevalence of deep vein thrombosis in 818 medical in‐patients hospitalised in French teaching and community hospitals. The dependent variable was the use of pharmacological prophylaxis. The rate of any deep vein thrombosis detected by routine compression ultrasonography was used as an illustrative variable. Using group consensus of expert panelists, a practice guideline was developed based on the results of this study and a systematic review of the literature.

Findings

The resulting classification tree involved eight terminal subsets. The mean misclassification rate was 31 per cent in tenfold cross‐validation and the area under the ROC curve was 0.75. The classification tree was converted into graded recommendations. According to these recommendations, 455 patients (56 per cent) required prophylaxis. The corresponding rate of deep vein thrombosis was 11 per cent (28/245, [CI = 8‐16]) in 245 prophylaxis users and 11 per cent (23/210, [7‐16]) in 210 prophylaxis non‐users. Conversely, 363 patients (44 per cent) did not require prophylaxis: 63 actually received prophylaxis and six had deep vein thrombosis (2 per cent, [0.6‐4]).

Research limitations/implications

Further prospective validation of the guideline is important prior to its implementation.

Originality/value

Integrating data from observational studies may be an effective way to develop guidelines when robust scientific evidence is lacking.

Details

International Journal of Health Care Quality Assurance, vol. 20 no. 7
Type: Research Article
ISSN: 0952-6862

Keywords

Article
Publication date: 1 June 2002

S. Clark and M. Greenwood

Describes how the implementation of thromboembolic prophylaxis in patients undergoing oral and maxillofacial surgical procedures was audited. In 1997, four oral and maxillofacial…

499

Abstract

Describes how the implementation of thromboembolic prophylaxis in patients undergoing oral and maxillofacial surgical procedures was audited. In 1997, four oral and maxillofacial units were asked about their practice of prophylaxis for thromboembolic disease (TED). Proformas were sent to each unit to assess 45 patients retrospectively. These patients were chosen at random from within defined groups of surgery. The audit was repeated in 1998, after presentation and discussion of initial findings. Of 117 patients at low risk of TED, 72 (62 per cent) and 50 (81 per cent) of 62 patients at moderate risk received prophylaxis. In the second run of the audit, there was a 7 per cent increase in the number of patients at moderate risk receiving prophylaxis. Patients admitted for trauma surgery were the most likely to have TED prophylaxis omitted. Concludes that there was an improvement between the first and second run of the audit, but some patients were still not being treated appropriately.

Details

British Journal of Clinical Governance, vol. 7 no. 2
Type: Research Article
ISSN: 1466-4100

Keywords

Abstract

Details

Clinical Governance: An International Journal, vol. 13 no. 4
Type: Research Article
ISSN: 1477-7274

Article
Publication date: 31 August 2012

Dushan Thavarajah and Martin Wetherill

Venous thromboembolism (VTE) prophylaxis guidelines were originally published by the National Institute of Clinical Excellence (NICE) in April 2007. Controversy eclipsed their…

Abstract

Purpose

Venous thromboembolism (VTE) prophylaxis guidelines were originally published by the National Institute of Clinical Excellence (NICE) in April 2007. Controversy eclipsed their release. Consequently, the VTE prophylaxis publication was reviewed and republished in January 2010. The NICE guidelines recommend that all patients are assessed for risk before pharmacological prophylaxis is offered and reassessed at 24 hours to check adverse reactions; and that prophylaxis is appropriate. This paper aims to look at their implementation.

Design/methodology/approach

A prospective audit and re‐audit in one orthopaedic department was completed to see how well the new guidelines were adhered to, find out first‐hand what problems there were, and how they might be remedied.

Findings

Audit and re‐audit highlighted that attaching an assessment tool to drug charts is plausible.

Research limitations/implications

The study was limited to one centre and used a relatively weak research design.

Practical implications

As a process, the clinical impact of risk assessment for VTE is questionable as many patients will be high risk. Removing reassessment at 24 hours from the NICE guidance is recommended.

Originality/value

The authors put the NICE guideline into clinical practice, demonstrating how effectively it can work with their method, but also highlighting its flaws.

Details

International Journal of Health Care Quality Assurance, vol. 25 no. 7
Type: Research Article
ISSN: 0952-6862

Keywords

Article
Publication date: 11 June 2018

Robert Shapiro, Rose Laignel, Caitlin Kowcheck, Valerie White and Mahreen Hashmi

Previous studies indicate adherence to pre-operative antibiotic prophylaxis guidelines has been inadequate. The purpose of this paper is to determine adherence rates to current…

Abstract

Purpose

Previous studies indicate adherence to pre-operative antibiotic prophylaxis guidelines has been inadequate. The purpose of this paper is to determine adherence rates to current perioperative antibiotic prophylaxis guidelines in gynecologic surgery at a tertiary care, academic institution. As a secondary outcome, improving guidelines after physician re-education were analyzed.

Design/methodology/approach

A retrospective chart review (2,463 patients) was completed. The authors determined if patients received perioperative antibiotic prophylaxis in accordance with current guidelines from the America College of Obstetricians and Gynecologists. Data were obtained before and after physician tutorials. Quality control was implemented by making guideline failures transparent. Statistical analysis used Fisher’s exact and agreement tests.

Findings

In total, 23 percent of patients received antibiotics not indicated across all procedures. This decreased to 9 percent after physician re-education and outcome transparency (p<0.0001). Laparoscopy was the procedure with the lowest guideline compliance prior to education. The compliance improved from 52 to 92 percent (p<0.0001) after re-education.

Practical implications

Gynecologic surgeons overuse antibiotics for surgical prophylaxis. Physician re-education and transparency were shown to enhance compliance.

Originality/value

Educational tutorials are an effective strategy for encouraging physicians to improve outcomes, which, in turn, allows the healthcare system a non-punitive way to monitor quality and mitigate cost.

Details

International Journal of Health Care Quality Assurance, vol. 31 no. 5
Type: Research Article
ISSN: 0952-6862

Keywords

Article
Publication date: 11 March 2019

Kunal Karamchandani, Kyle Barden and Jansie Prozesky

The purpose of this paper is to review surgical antimicrobial prophylaxis administration practices in a small cohort and assess compliance with national guidelines.

Abstract

Purpose

The purpose of this paper is to review surgical antimicrobial prophylaxis administration practices in a small cohort and assess compliance with national guidelines.

Design/methodology/approach

Patients that developed surgical site infections (SSI) in a tertiary care academic medical center over a two-year period were identified. Their electronic medical records were reviewed for compliance with national guidelines with respect to surgical antibiotic prophylaxis.

Findings

Over a two-year period, 283 SSI patients were identified. An appropriate antibiotic was chosen in 80 percent, an appropriate dose was administered in 45 percent and timing complied in 89 percent. The antibiotics were appropriately re-dosed in only 9.2 percent in whom the requirement was met. The prescribing guidelines were adhered to in entirety in only 54 patients (23.8 percent).

Practical implications

Timely and appropriate antibiotic administration prior to surgery is essential to prevent SSI. Proper diligence is required to accomplish this task effectively.

Originality/value

Based on the findings, it appears that merely, “checking a box” for antibiotic administration during surgery is not enough, and a multidisciplinary approach should be followed to ensure “appropriate” antibiotic administration.

Details

International Journal of Health Care Quality Assurance, vol. 32 no. 2
Type: Research Article
ISSN: 0952-6862

Keywords

Content available

Abstract

Details

Clinical Governance: An International Journal, vol. 13 no. 3
Type: Research Article
ISSN: 1477-7274

Article
Publication date: 1 June 2000

Lesley Hall and Martin Eccles

This paper describes the implementation of a clinical guideline across three acute Trusts. A Clinical Effectiveness Steering Group identified prevention of venous thromboembolism…

Abstract

This paper describes the implementation of a clinical guideline across three acute Trusts. A Clinical Effectiveness Steering Group identified prevention of venous thromboembolism as a health priority. A local guideline development group adapted the recommendations of an existing review and produced a local guideline. Then, a multidisciplinary implementation group developed the practical aspects of implementing guidelines into routine daily practice. They identified appropriate staff to carry out risk assessment and to administer appropriate prophylaxis, as necessary. They also produced a “guideline pack” containing a training resource manual and implementation aids. Following this a multiple strategy implementation programme was used to introduce the guidelines, and an evaluation was carried out eight to ten months after the introduction of the guidelines. The evaluation identified a number of areas for improving current practice. Guideline implementation is a complex, time‐consuming process.

Details

Clinical Performance and Quality Healthcare, vol. 8 no. 2
Type: Research Article
ISSN: 1063-0279

Keywords

Article
Publication date: 12 March 2018

Oisín Conaty, Leah Gaughan, Colum Downey, Noreen Carolan, Megan Joanne Brophy, Ruth Kavanagh, Deborah A.A. McNamara, Edmond Smyth, Karen Burns and Fidelma Fitzpatrick

The purpose of this paper is to improve surgical antimicrobial prophylaxis (SAP) prescribing in orthopaedic surgery using the model for improvement framework.

Abstract

Purpose

The purpose of this paper is to improve surgical antimicrobial prophylaxis (SAP) prescribing in orthopaedic surgery using the model for improvement framework.

Design/methodology/approach

Orthopaedic patients receiving joint replacements, hip fracture repairs or open-reduction internal-fixation procedures were included. Antimicrobial(s); dose, time of administration and duration of SAP were evaluated for appropriateness based on the local SAP guidelines. After baseline data collection, a driver diagram was constructed with interventions devised for plan-do-study-act cycles. Data were fed back weekly using a point prevalence design (PPD). Interventions included SAP guideline changes, reminders and tools to support key messages.

Findings

SAP in 168 orthopaedic surgeries from 15 June 2016 to 31 January 2017 was studied. Prescribing appropriateness improved from 20 to 78 per cent. Junior doctor changeover necessitated additional education and reminders.

Practical implications

Due to constant staff changeover; continuous data collection, communication, education and reminders are essential to ensure continuous compliance with clinical guidance. Patients with hip fractures are difficult to weigh, requiring weight estimation for weight-based antimicrobial dosing. Unintended consequences of interventions included the necessity to change pre-operative workflow to accommodate reconstitution time of additional antimicrobials and inadvertent continuation of new antimicrobials post-operatively.

Originality/value

Rather than perform the traditional retrospective focused audit, we established a prospective, continuous, interventional quality improvement (QI) project focusing on internal processes within the control of the project team with rapid cyclical changes and interventions. The weekly PPD was pragmatic and enabled the QI project to be sustained with no additional resources.

Details

International Journal of Health Care Quality Assurance, vol. 31 no. 2
Type: Research Article
ISSN: 0952-6862

Keywords

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