Educational interventions were conducted in November 2001 in conjunction with 2 physicians (R.M., a respirologist, and M.B., an internal medicine specialist) and consisted of written memos sent to all physicians, nurse clinicians, and pharmacists and presentations at departmental and committee meetings (e.g., meetings of hospital department heads, family practice and internal medicine departments, the Pharmacy and Therapeutics Committee, joint pharmacy and nursing committees, and pharmacy staff). Both the memos and the presentations reported on use of VTE prophylaxis for patients with COPD and CHF admitted to the institution and described current practice guidelines for VTE prophylaxis in medical patients. Following the educational intervention, a chart review was conducted of consecutive patients with exacerbation of CHF or COPD (or both) who were admitted over the 5-month period between December 1, 2001, and April 30, 2002.
Several exclusion criteria were applied. Pregnant and breast-feeding women, patients with hypercoagulability disorders, those who had received anticoagulant therapy within the 48 hours before admission, and those who had experienced VTE within the year before admission were excluded. Because there is little evidence in the literature to support the first-line use of mechanical methods to prevent VTE (intermittent pneumatic compression or the wearing of graded compression elastic stockings), patients who had received this type of therapy were excluded. Patients with other well-defined indications for VTE prophylaxis or anticoagulation were excluded (i.e., acute myocardial infarction; ischemic stroke; general, gynecologic, or urologic surgery; major orthopedic surgery [elective hip or knee replacement, surgery for hip fracture]; neurosurgery; trauma; spinal cord injury). Patients admitted to the intensive care unit, patients with sepsis (including hospital- and community-acquired pneumonia), and patients with active cancer or a history of cancer were excluded because they have many confounding risk factors for VTE, which would have made the study population exceptionally heterogeneous. Patients with contraindications to LDUH or LMWH therapy were excluded (i.e., hypersensitivity to heparin, heparin- induced thrombocytopenia, active bleeding [hemophilia, intracranial hemorrhage], conditions that could increase the risk of hemorrhage [bacterial endocarditis, active tuberculosis, or uncontrolled severe hypertension, defined as systolic pressure above 180 mm Hg and diastolic pressure above 120 mm Hg], or ulcerative lesions of the gastrointestinal tract]). erectalis 20 mg
The following data, collected by one investigator (R.P.), were recorded in a standardized Microsoft Access database: patient demographic characteristics, risk factors for VTE, length of hospital stay, and pharmacologic VTE prophylaxis (drug, dose, and frequency). VTE prophylaxis was defined as one of the following regimens, as outlined in the ACCP guidelines1 and depending on the agents available on formulary at the authors’ institution: LDUH 5000 units subcutaneously every 8 to 12 h or enoxaparin 40 mg subcutaneously once daily for 7 to 10 days or until discharged from hospital.A survey about perceived barriers to VTE prophylaxis for patients with CHF or COPD was sent to the hospital mailboxes of all physicians at the beginning of April 2002, following preliminary analysis of the chart review. The survey was formatted to allow physicians to select 1 or more of 4 perceived barriers: oversight, belief that risks of prophylaxis exceed benefits, lack of awareness of indications, and cost. Space was also allowed for comments. The survey form included a reminder of the current guidelines and the results of the interim analysis of the chart review.