ASH (American Society of Hematologists) has developed evidence-based “Clinical Practice Guidelines on Venous Thromboembolism” (ASH 2018).
Guidelines currently available include:
· Prophylaxis for Medical Patients
· Anticoagulation Therapy
· Heparin-Induced Thrombocytopenia (HIT)
But the guidelines for VTE in cancer, thrombophilia, and prophylaxis for surgical patients are not yet included but are “coming soon!”. And the guidelines for treatment are “now accepting public comments”.
The guidelines include strength of recommendations, based upon the strength of supporting evidence. The guidelines have over 200 recommendations in all. For example, there are 19 recommendations on prophylaxis for medical patients. These include recommendations for hospitalized patients, hon-hospitalized patients, nursing home patients, and patients travelling long distances. They discuss issues such as pharmacologic vs. mechanical prophylaxis and LMWH vs. DOAC’s.
The ASH site also has downloadable posters, pocket guides, teaching slide sets, and patient versions of the guidelines. The guidelines are also available on an app that you can download for iOS or Android devices.
Of course, no one is expected to be able to remember over 200 recommendations. We think you’ll find the pocket cards or the smartphone apps to be very valuable. Undoubtedly, these will also be updated as the “coming soon!” items become available.
ASH (American Society of Hematologists). ASH Clinical Practice Guidelines on Venous Thromboembolism. ASH 2018
Strategies to reduce infections (especially with drug-resistant organisms) in ICU patients have included chlorhexidine (CHX) mouthwash, selective oropharyngeal decontamination (SOD), and selective digestive tract decontamination (SDD). But there have been problems with some of the studies done (see, for example, our January 2009 What's New in the Patient Safety World column “”). These practices are quite widespread in ICU’s even though the strength of evidence has been debatable.
In our October 2017 What's New in the Patient Safety World column “Updated Guidelines for VAP and HAP” we discussed updated European guidelines for the management of hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) (Torres 2017). Those guidelines included an extensive review of the literature. The guideline panel decided not to issue a recommendation on the use of chlorhexidine to perform selective oral decontamination (SOD) in patients requiring mechanical ventilation until more safety data become available, due to the unclear balance between a potential reduction in pneumonia rate and a potential increase in mortality. (They did suggest the use of SOD, but not SDD, in settings with low rates of antibiotic-resistant bacteria and low antibiotic consumption, but this was a weak recommendation because of low quality of evidence.) There was a wide discrepancy in the panel's views regarding the benefits of chlorhexidine in reducing nosocomial pneumonia and the potential risks associated with its use.
In settings with low levels of antibiotic resistance, they noted SOD (with topical nonabsorbable antibiotics) and SDD (with oropharyngeal and digestive tube administration of topical nonabsorbable antibiotics and IV antibiotics) may be associated with reductions in nosocomial pneumonia and death. The potential effects of antibiotic use on antimicrobial resistance are uncertain. Considering the clinical benefits of these two strategies to be similar, the guideline panel advocated the use of SOD and avoiding supplementary IV antibiotics as in SDD. They noted the effectiveness of SOD or SDD in settings with high levels of antibiotic resistance has not been assessed.
Given the premise that the effects of chlorhexidine (CHX) mouthwash, selective oropharyngeal decontamination (SOD), and selective digestive tract decontamination (SDD) on patient outcomes in ICUs with moderate to high levels of antibiotic resistance are unknown, Wittekamp and colleagues performed a randomized controlled trial to address the issues (). They found that, among patients receiving mechanical ventilation in European ICUs with moderate to high antibiotic resistance prevalence, use of CHX mouthwash, SOD, or SDD was not associated with reductions in ICU-acquired bloodstream infections caused by multidrug-resistant gram-negative bacteria compared with standard care.
The accompanying editorial () notes that the study shows no benefits in situations with higher antibiotic resistance patterns that unfortunately still prevail in most ICUs around the world.
Note that the focus of the Torres article was on VAP, whereas the Wittekamp study was focused on ICU-acquired bloodstream infections, so there may still be some out there advocating for continued use. However, we suspect the Wittekamp study will likely reduce the use of these strategies.
Torres A, Niederman MS, Chastre J, et al. International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: guidelines for the management of hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP) of the European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Asociación Latinoamericana del Tórax (ALAT). European Respiratory Journal 2017 50: 1700582
Wittekamp BH, Plantinga NL, Cooper BS, et al. Decontamination Strategies and Bloodstream Infections with Antibiotic-Resistant Microorganisms in Ventilated PatientsA Randomized Clinical Trial. JAMA 2018; 320(20): 2087-2098
Vandenbroucke-Grauls CMJE, van der Meer JWM. Decontamination of Oral or Digestive Tract for Patients in the Intensive Care Unit. JAMA 2018; 320(20): 2081-2083
Our January 16, 2018 Patient Safety Tip of the Week “” discussed in detail the hazards associated with faxing and provided numerous recommendations for steps you should take if your practice, facility, hospital, or organization continues to communicate via fax.
But there is clearly a move afoot to abolish use of faxes in hospitals. The National Health Service (UK) has banned buying fax machines and expects a complete phase-out of fax machines by April 2020 (). And there are questions about Canada following suit ( ),( ).
Now the US may finally be considering action.
Recent statistics from the ONC (Office of the National Coordinator for Health Information Technology) ( ) show that about seven in 10 hospitals sent (66 percent) or received (73 percent) summary of care records using mail or fax in 2017.
Moreover, there is a gap between urban and rural hospitals, and big and small hospitals. Small, rural, and CAH’s (critical access hospitals) were three times as likely to send summary of care records using only non-electronic methods, and about twice as likely to receive summary of care records using only non-electronic methods compared to their counterparts. Small, rural, and CAHs were about half as likely to send and receive summary of care records using only electronic methods compared to their counterparts.
In a recent speech (), CMS Administrator Seema Verma said “If I could challenge the developers in this room here today to achieve one mission, it would be this: help us make every doctor’s office in America a fax free zone by 2020!”
Verma said “health care providers are in a 1990’s time warp…where doctors are faxing patient records, medical staff are manually entering results into EHRs, and hospitals are handing out data on a CD-ROM while the rest of the economy is functioning on fully digitized, integrated data that informs decision-making instantaneously”.
We hope your practice, facility, hospital, or organization is already planning for a phase-out of faxing. But, in the meantime, we hope you’ll go back to our January 16, 2018 Patient Safety Tip of the Week “” and make sure you are addressing the vulnerabilities associated with use of faxing.
gov.uk. Health and Social Care Secretary bans fax machines in NHS. Matt Hancock has banned the NHS from buying fax machines and has ordered a complete phase-out by April 2020. gov.uk 2018; Published 9 December 2018
Picard A. The British are axing the fax. Will Canada follow suit? The Globe and Mail (Toronto, Ontario) 2018; December 10, 2018
Picard A. Why are fax machines still the norm in 21st-century health care? The Globe and Mail (Toronto, Ontario) 2018; June 11, 2018
Johnson C, Pylypchuk Y, Patel V. Methods Used to Enable Interoperability among U.S. Non-Federal Acute Care Hospitals in 2017. ONC Data Brief 2018; No. 43; December 2018
Verma S. SPEECH: Remarks by Administrator Seema Verma at the ONC Interoperability Forum in Washington, DC. cms.gov 2018; Aug 06, 2018
Most of our patient safety columns are aimed at hospitals and healthcare professionals. But, particularly for children, parents play a huge role in safety. Recently, we came across an excellent resource for parents regarding pediatric safety. The Pediatric Health and Safety Guide () covers practical safety issues and has links to good resources.
· Home Safety Guides
· Neighborhood Safety Information
· School and Bus Safety
· Choking Hazards
· Travel Safety
· Water Safety
· Food Allergies
· Outdoor Safety
· Poison Prevention and Safety
Excellent resource with good, practical tips. Point your patients and your own families to this. Not a pediatrician or family medicine physician? Don’t worry. Most of your patients have children or grandchildren. This is a good read for all ages.
ACLS Training Center®. Pediatric Health and Safety Guide. ACLS Training Center®. 2018; Dec 3, 2018
Print “PDF version”