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A multicentre controlled pre–post trial of an implementation science intervention to improve venous thromboembolism prophylaxis in critically ill patients

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Abstract

Purpose

To test whether a multicomponent intervention would increase the use of low molecular weight heparin (LMWH) over unfractionated heparin (UFH) for venous thromboembolism (VTE) prophylaxis in critically ill patients and change patient outcomes and healthcare utilization.

Methods

Controlled pre–post trial of 12,342 adults admitted to 11 ICUs (five intervention, six control) May 1, 2015 to April 30, 2017 with no contraindication to pharmacological prophylaxis and an ICU stay longer than 24 h. Models were developed to examine temporal changes in ICU VTE prophylaxis (primary outcome), VTE, major bleeding, heparin-induced thrombocytopenia (HIT), death and hospital costs.

Results

The use of LMWH increased from 45.9% to 78.3% of patient days in the intervention group and from 37.9% to 53.3% in the control group, an absolute increase difference of 17.0% (32.4% vs. 15.4%, p = 0.001). Changes in the administration of UFH were inversely related to those of LMWH. There were no significant differences in the adjusted odds of VTE (ratio of odds ratios [rOR] 1.13, 95% CI 0.51–2.46) or major bleeding (rOR 1.22, 95% CI 0.97–1.54) post-implementation of the intervention (compared to pre-implementation) between the intervention group and the control group. HIT was uncommon in both groups (n = 20 patients). There were no significant changes for ICU and hospital mortality, length of stay and costs. Results were similar when stratified according to reason for ICU admission, patient weight and kidney function.

Conclusions

A multicomponent intervention changed practice, but not clinical and economic outcomes. The benefit of implementing LMWH for VTE prophylaxis under real-world conditions is uncertain.

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Acknowledgements

The study was funded by a PRIHS Alberta Innovates—Health Solutions (20100368). HTS was supported by a Population Health Investigator Award from Alberta Innovates—Health Solutions and an Embedded Clinician Researcher Award from the Canadian Institutes of Health Research. SMB was supported by a Canada Research Chair in Critical Care Nephrology and Clinical Investigator Award from Alberta Innovates—Health Solutions. Funding sources had no role in the design, conduct, or reporting of this study and we are unaware of any conflicts of interest. Drs Stelfox and Soo had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

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Authors and Affiliations

  1. Department of Critical Care Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, T2N 4Z6, Canada

    Henry T. Stelfox, Andrea Soo, Jeanna Parsons Leigh, Daniel J. Niven, Kirsten M. Fiest, Christopher James Doig, Danny J. Zuege, Barry Kushner & Khara M. Sauro

  2. Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada

    Henry T. Stelfox, Jeanna Parsons Leigh, Daniel J. Niven, Kirsten M. Fiest, Christopher James Doig, Fiona Clement & Khara M. Sauro

  3. Alberta Health Services, Calgary, Canada

    Henry T. Stelfox, Andrea Soo, Christopher James Doig, Danny J. Zuege & Barry Kushner

  4. W21C Research and Innovation Centre, University of Calgary, Calgary, AB, Canada

    Rebecca Brundin-Mather

  5. Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada

    Sharon E. Straus

  6. Deparment of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada

    Deborah J. Cook

  7. Department of Critical Care Medicine, Faculty of Medicine and Dentistry, and the School of Public Health, University of Alberta, Edmonton, AB, Canada

    Sean M. Bagshaw

Authors
  1. Henry T. Stelfox
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  2. Rebecca Brundin-Mather
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  3. Andrea Soo
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  4. Jeanna Parsons Leigh
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  6. Kirsten M. Fiest
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  7. Christopher James Doig
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  8. Danny J. Zuege
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  9. Barry Kushner
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  10. Fiona Clement
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  11. Sharon E. Straus
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  12. Deborah J. Cook
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  13. Sean M. Bagshaw
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  14. Khara M. Sauro
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Corresponding author

Correspondence to Henry T. Stelfox.

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Funding sources had no role in the design, conduct, or reporting of this study and we are unaware of any conflicts of interest.

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The health research ethics boards at the University of Calgary (16-0541) and University of Alberta (Pro000065343) approved this study.

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Stelfox, H.T., Brundin-Mather, R., Soo, A. et al. A multicentre controlled pre–post trial of an implementation science intervention to improve venous thromboembolism prophylaxis in critically ill patients. Intensive Care Med 45, 211–222 (2019). https://doi.org/10.1007/s00134-019-05532-1

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