PMID- 30503515 OWN - NLM STAT- MEDLINE DCOM- 20200113 LR - 20200113 IS - 1879-1883 (Electronic) IS - 0002-9610 (Linking) VI - 217 IP - 6 DP - 2019 Jun TI - Determining the impact of culture on venous thromboembolism prevention in trauma patients: A Southwestern Surgical Congress Multicenter trial. PG - 1030-1036 LID - S0002-9610(18)30396-9 [pii] LID - 10.1016/j.amjsurg.2018.11.005 [doi] AB - INTRODUCTION: Venous thromboembolism (VTE) remains one of the principal causes of morbidity and death in trauma patients that survive the first 24 h. Recent literature on VTE prevention focuses on choice of chemoprophylaxis, specifically unfractionated heparin (UFH) versus low molecular weight heparin (LMWH). This singular focus on a multifactorial process may be inadequate to fully understand the optimal approach to VTE prevention. We hypothesized that variations in care between trauma centers could be used to identify key components of VTE prevention associated with better outcomes. METHODS: A 50 question survey of VTE management for years 2014-2016 was sent to 15 trauma centers. The survey included: demographics of the trauma centers, type and timing of chemoprophylaxis, ambulation expectations, and complementary services (geriatric trauma service (GTS), mobility teams, physical and occupational therapy (PT/OT)). Each center submitted their American College of Surgeons Trauma Quality Improvement Program (TQIP) Benchmark Report for Spring 2017. TQIP data included: mortality, observed rates of deep vein thrombosis (DVT) and pulmonary embolus (PE), and time to VTE prophylaxis. The survey and TQIP reports were blinded for analysis; descriptive statistics were utilized. The top DVT & PE TQIP performers were used to identify potential aspects of better care on the survey responses. The institutions' DVT and PE rates were then compared for these responses using Wilcoxon-Rank-Sum test. RESULTS: Fifteen trauma centers (13 Level-1, 2 Level-2) completed the survey; the centers admitted 1050-7200 trauma patients per year (median 3000). The majority of centers were University-affiliated (11 of 15) with general surgery residencies (14 of 15), Acute Care Surgery or Surgical Critical Care Fellowships, (9 of 15) and critical care boarded-surgeons only on-call (9 of 15). Few have geriatric trauma services (3 of 15) or mobility teams (1 of 15). Half the trauma centers have dedicated PT/OT teams for trauma or weekend coverage. With a total of 20,878 TQIP patients analyzed, the average observed DVT and PE rates were 1.27% (range 0.1-5.2%) and 0.68% (range 0-1.6%), respectively. Weekly lower extremity surveillance duplex (2 of 15) increased DVT detection (4.15% vs 0.80%, p = 0.034) but did not decrease PE rates (1.05% vs 0.62%, p = 0.229). Great variance was seen in choice, dosing and timing of chemoprophylaxis: UFH,(4) LMWH daily,(1) LMWH twice-daily,(5) LMWH weight-based dosing,(4) and LMWH anti-Xa dosing.(1) The top 3 performers for DVT and PE all used different types of chemoprophylaxis. These top performers had a prominent culture of mobility: dedicated PT/OT teams for trauma or weekends and an expectation to ambulate 3-times per day. Weekend PT/OT teams were associated with lower DVT rates (median 0.40%, range 0.10-1.10% vs 1.30%, 0.60-5.20%, p = 0.018), and ambulation 3-times per day was associated with lower PE rates (median 0.20%, range 0.00-0.20% vs 0.80%, 0.40-1.60%, p < 0.005). CONCLUSIONS: Considerable variation in VTE chemoprophylaxis exists among trauma centers. "Best practices" in this area requires further investigation. An expectation of mobility and investment in mobility resources may serve to decrease VTE rates in trauma patients compared to a singular focus on type of chemoprophylaxis administered. CI - Published by Elsevier Inc. FAU - Regner, Justin L AU - Regner JL AD - Scott & White Medical Center - Temple, TX, USA. Electronic address: justin.regner@bswhealth.org. FAU - Shaver, Courtney N AU - Shaver CN AD - Scott & White Medical Center - Temple, TX, USA. CN - SWSC Multicenter Trials Group LA - eng PT - Journal Article PT - Multicenter Study DEP - 20181120 PL - United States TA - Am J Surg JT - American journal of surgery JID - 0370473 RN - 0 (Anticoagulants) RN - 0 (Heparin, Low-Molecular-Weight) RN - 9005-49-6 (Heparin) SB - IM MH - Anticoagulants/*therapeutic use MH - Benchmarking MH - Drug Administration Schedule MH - Healthcare Disparities/*statistics & numerical data MH - Heparin/therapeutic use MH - Heparin, Low-Molecular-Weight/therapeutic use MH - Humans MH - *Organizational Culture MH - Practice Patterns, Physicians'/*statistics & numerical data MH - Quality Improvement MH - Southwestern United States MH - *Trauma Centers/organization & administration/statistics & numerical data MH - Treatment Outcome MH - Venous Thromboembolism/epidemiology/etiology/*prevention & control MH - Wounds and Injuries/*complications FIR - Frazee, Richard IR - Frazee R IRAD- Scott & White Medical Center - Temple, TX, USA. FIR - Brooks, Steven E IR - Brooks SE IRAD- Texas Tech University Health Sciences Center - Lubbock, TX, USA. FIR - Dissanaike, Sharmila IR - Dissanaike S IRAD- Texas Tech University Health Sciences Center - Lubbock, TX, USA. FIR - Brown, Carlos V IR - Brown CV IRAD- Dell Medical School, University of Texas at Austin, TX, USA. FIR - Pieracci, Fredric M IR - Pieracci FM IRAD- Denver Health Medical Center - Denver, CO, USA. FIR - Burlew, Clay Cothren IR - Burlew CC IRAD- Denver Health Medical Center - Denver, CO, USA. FIR - Davis, James W IR - Davis JW IRAD- Community Regional Medical Center, UCSF School of Medicine - Fresno, CA, USA. FIR - Dirks, Rachel IR - Dirks R IRAD- Community Regional Medical Center, UCSF School of Medicine - Fresno, CA, USA. FIR - Dunn, Julie IR - Dunn J IRAD- UCHealth North, Medical Center of the Rockies - Loveland, CO, USA. FIR - Dorlac, Warren IR - Dorlac W IRAD- UCHealth North, Medical Center of the Rockies - Loveland, CO, USA. FIR - Foreman, Michael L IR - Foreman ML IRAD- Baylor University Medical Center - Dallas, TX, USA. FIR - Rapier, Nakia R IR - Rapier NR IRAD- Baylor University Medical Center - Dallas, TX, USA. FIR - Jawa, Randeep IR - Jawa R IRAD- Stony Brook University School of Medicine - Stony Brook, NY, USA. FIR - Vosswinkel, James A IR - Vosswinkel JA IRAD- Stony Brook University School of Medicine - Stony Brook, NY, USA. FIR - Kobayashi, Leslie IR - Kobayashi L IRAD- UC San Diego Medical Center - San Diego, CA, USA. FIR - Coimbra, Raul IR - Coimbra R IRAD- UC San Diego Medical Center - San Diego, CA, USA. FIR - McNutt, Michelle K IR - McNutt MK IRAD- Memorial Hermann Red Duke Trauma Institute- Houston, TX, USA. FIR - Kao, Lillian IR - Kao L IRAD- Memorial Hermann Red Duke Trauma Institute- Houston, TX, USA. FIR - Morse, Bryan C IR - Morse BC IRAD- Grady Memorial Hospital - Atlanta, GA, USA. FIR - Scherer, Elizabeth P IR - Scherer EP IRAD- University of Texas Health Science Center - San Antonio, TX, USA. FIR - Jenkins, Donald H IR - Jenkins DH IRAD- University of Texas Health Science Center - San Antonio, TX, USA. FIR - Schroeppel, Thomas IR - Schroeppel T IRAD- UC Health South, Memorial Hospital - Colorado Springs, CO, USA. FIR - Cribari, Chris IR - Cribari C IRAD- UC Health South, Memorial Hospital - Colorado Springs, CO, USA. FIR - Truit, Michael IR - Truit M IRAD- Methodist Health System - Dallas, TX, USA. FIR - Agrawal, Vaidehi IR - Agrawal V IRAD- Methodist Health System - Dallas, TX, USA. FIR - Tyroch, Alan H IR - Tyroch AH IRAD- Texas Tech University Health Sciences Center - El Paso, TX, USA. EDAT- 2018/12/07 06:00 MHDA- 2020/01/14 06:00 CRDT- 2018/12/04 06:00 PHST- 2018/03/15 00:00 [received] PHST- 2018/11/08 00:00 [accepted] PHST- 2018/12/07 06:00 [pubmed] PHST- 2020/01/14 06:00 [medline] PHST- 2018/12/04 06:00 [entrez] AID - S0002-9610(18)30396-9 [pii] AID - 10.1016/j.amjsurg.2018.11.005 [doi] PST - ppublish SO - Am J Surg. 2019 Jun;217(6):1030-1036. doi: 10.1016/j.amjsurg.2018.11.005. Epub 2018 Nov 20.