Deborah Cook1, Mark Duffett2, Francois Lauzier3, Chenglin Ye4, Peter Dodek5, Bojan Paunovic6, Rob Fowler7, Michelle E Kho8, Denise Foster9, Tom Stelfox10, Taz Sinuff7, Nicole Zytaruk4, France Clarke4, Gordon Wood11, Michael Cox12, Jim Kutsiogiannis13, Michael Jacka13, Marios Roussos14, Hari Kumar15, Gordon Guyatt16. 1. Department of Medicine, McMaster University, Hamilton, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada. Electronic address: debcook@mcmaster.ca. 2. Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada; Department of Pediatrics, McMaster University, Hamilton, Canada. 3. Centre de recherche FRQS du Centre hospitalier affilié universitaire de Québec, Axe Traumatologie - urgence - soins intensifs, Division de soins intensifs adultes, départements de médecine et d'anesthésiologie, Université Laval, Quebec, Canada. 4. Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada. 5. Division of Critical Care Medicine and Center for Health Evaluation and Outcome Sciences, St Paul's Hospital and University of B.C., Vancouver, Canada. 6. Section of Critical Care Medicine, Department of Internal Medicine, University of Manitoba, Winnipeg, Canada. 7. Department of Medicine and Department of Critical Care Medicine, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada. 8. Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada; School of Rehabilitation Science, McMaster University, Hamilton, Canada. 9. Division of Critical Care Medicine, Vancouver General Hospital, Vancouver, Canada. 10. Department of Critical Care Medicine, Institute of Public Health, University of Calgary, Calgary, Canada. 11. Department of Anesthesia, Vancouver Island Health Authority, Victoria, Canada; Department of Critical Care, Vancouver Island Health Authority, Victoria, Canada. 12. Department of Pulmonary and Critical Care, St John's Mercy Hospital, St Louis, MO, USA. 13. Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada. 14. Department of Critical Care, Thunder Bay Regional Health Sciences Centre, Division of Clinical Sciences, Northern Ontario School of Medicine, Thunder Bay, Canada; Department of Internal Medicine, Thunder Bay Regional Health Sciences Centre, Division of Clinical Sciences, Northern Ontario School of Medicine, Thunder Bay, Canada. 15. Department of Surgery, Saint John Regional Hospital, St John, Canada; Department of Critical Care, Saint John Regional Hospital, St John, Canada. 16. Department of Medicine, McMaster University, Hamilton, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.
Abstract
BACKGROUND: The objective of this study was to identify the self-reported barriers to and facilitators of prescribing low-molecular-weight heparin (LMWH) thromboprophylaxis in the intensive care unit (ICU). METHODS: We conducted an interviewer-administered survey of 4 individuals per ICU (the ICU director, a bedside pharmacist, a thromboprophylaxis research coordinator, and physician site investigator) regarding LMWH thromboprophylaxis for medical-surgical patients in 27 ICUs in Canada and the United States. Items were generated by the research team and adapted from previous surveys, audits, qualitative studies, and quality improvement research. Respondents rated the barriers to LMWH use, facilitators (effectiveness, affordability, and acceptability thereof), and perceptions regarding LMWH use. RESULTS: Respondents had 14.5 (SD, 7.7) years of ICU experience (response rate, 99%). The 5 most common barriers in descending order were as follows: drug acquisition cost, fear of bleeding, lack of resident education, concern about bioaccumulation in renal failure, and habit. The top 5 rated facilitators were preprinted orders, education, daily reminders, audit and feedback, and local quality improvement committee endorsement. Centers using preprinted orders (mean difference [P<.01]) and computerized physician order entry (P<.01) compared with those centers not using those tools reported higher affordability for these 2 facilitators. Compared with physicians and pharmacists, research coordinators considered ICU-specific audit and feedback of thromboprophylaxis rates to be a more effective, acceptable, and affordable facilitator (odds ratio, 6.67; 95% confidence interval, 1.97-22.53; P<.01). Facilitator acceptability ratings were similar within centers but differed across centers (P≤.01). CONCLUSIONS: This multicenter survey found several barriers to use of LMWH including cost, concern about bleeding, and lack of resident knowledge of effectiveness. The diversity of reported facilitators suggests that large scale programs may address generic barriers but also need site-specific interprofessional knowledge translation activities.
BACKGROUND: The objective of this study was to identify the self-reported barriers to and facilitators of prescribing low-molecular-weight heparin (LMWH) thromboprophylaxis in the intensive care unit (ICU). METHODS: We conducted an interviewer-administered survey of 4 individuals per ICU (the ICU director, a bedside pharmacist, a thromboprophylaxis research coordinator, and physician site investigator) regarding LMWH thromboprophylaxis for medical-surgical patients in 27 ICUs in Canada and the United States. Items were generated by the research team and adapted from previous surveys, audits, qualitative studies, and quality improvement research. Respondents rated the barriers to LMWH use, facilitators (effectiveness, affordability, and acceptability thereof), and perceptions regarding LMWH use. RESULTS: Respondents had 14.5 (SD, 7.7) years of ICU experience (response rate, 99%). The 5 most common barriers in descending order were as follows: drug acquisition cost, fear of bleeding, lack of resident education, concern about bioaccumulation in renal failure, and habit. The top 5 rated facilitators were preprinted orders, education, daily reminders, audit and feedback, and local quality improvement committee endorsement. Centers using preprinted orders (mean difference [P<.01]) and computerized physician order entry (P<.01) compared with those centers not using those tools reported higher affordability for these 2 facilitators. Compared with physicians and pharmacists, research coordinators considered ICU-specific audit and feedback of thromboprophylaxis rates to be a more effective, acceptable, and affordable facilitator (odds ratio, 6.67; 95% confidence interval, 1.97-22.53; P<.01). Facilitator acceptability ratings were similar within centers but differed across centers (P≤.01). CONCLUSIONS: This multicenter survey found several barriers to use of LMWH including cost, concern about bleeding, and lack of resident knowledge of effectiveness. The diversity of reported facilitators suggests that large scale programs may address generic barriers but also need site-specific interprofessional knowledge translation activities.
Authors: Henry T Stelfox; Rebecca Brundin-Mather; Andrea Soo; Jeanna Parsons Leigh; Daniel J Niven; Kirsten M Fiest; Christopher James Doig; Danny J Zuege; Barry Kushner; Fiona Clement; Sharon E Straus; Deborah J Cook; Sean M Bagshaw; Khara M Sauro Journal: Intensive Care Med Date: 2019-02-01 Impact factor: 17.440
Authors: Khara Sauro; Sean M Bagshaw; Daniel Niven; Andrea Soo; Rebecca Brundin-Mather; Jeanna Parsons Leigh; Deborah J Cook; Henry Thomas Stelfox Journal: BMJ Open Date: 2019-03-15 Impact factor: 2.692
Authors: Emily McKenzie; Melissa L Potestio; Jamie M Boyd; Daniel J Niven; Rebecca Brundin-Mather; Sean M Bagshaw; Henry T Stelfox Journal: Health Expect Date: 2017-05-31 Impact factor: 3.377