Lara-Reyna Jacques, Alali Lea, Wedderburn Raymond, Margetis Konstantinos
Department of Neurological Surgery, Mount Sinai Health System, New York, NY, USA; Department of Surgery, Division of Trauma and Surgical Critical Care, Mount Sinai Morningside/ Mount Sinai West, New York, NY, USA.
Department of Neurological Surgery, Mount Sinai Health System, New York, NY, USA; Campbell University School of Osteopathic Medicine, Lillington, NC, USA.
Clin Neurol Neurosurg. 2022 Apr;215:107212. doi: 10.1016/j.clineuro.2022.107212. Epub 2022 Mar 15.
To determine the level of compliance of The American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) for initiation of venous thromboembolism (VTE) prophylaxis after non-operative traumatic brain injury (TBI) and the explanation for the deviations.
A retrospective review from May 2018 to February 2020 in a Level II trauma center for patients with TBI and length of stay of more than 24 h. We performed an analysis of overall and subgroup compliance with guidelines. The ACS TQIP criteria for low and moderate-risk for hemorrhagic progression were used for subgroup classification.
Of 393 patients, 239 (60.8%) patients received chemoprophylaxis in a mean of 64 (SD: +/-42) hours since admission. "Compliance" was achieved in 52.2% of patients. In subgroup analysis, 51.4% of patients in "low-risk" and 55.1% in "moderate-risk" were "compliant." The most common rationale for non-compliance in "low-risk" was a stay less than 48 h in 35.9% of patients. However, in "moderate-risk," the most common non-compliance was starting prophylaxis before the recommended 72 h from admission in 37% of cases.
Guidelines streamline clinical practice to optimize outcomes, but there are scenarios in which deviation of the recommendations may be indicated based on clinical judgment. We show that a stay of less than 48 h was the most common rationale for not starting prophylaxis in "low-risk" patients. However, in the "moderate-risk" subgroup, the most common reason was starting chemoprophylaxis before the recommended time frame, which we called a "paradoxical" non-compliance.
确定美国外科医师学会（ACS）创伤质量改进项目（TQIP）在非手术性创伤性脑损伤（TBI）后启动静脉血栓栓塞（VTE）预防措施的依从性水平以及偏差原因。
对2018年5月至2020年2月期间在一家二级创伤中心住院时间超过24小时的TBI患者进行回顾性研究。我们对指南的总体和亚组依从性进行了分析。ACS TQIP关于出血进展低风险和中度风险的标准用于亚组分类。
在393例患者中，239例（60.8%）患者在入院后平均64（标准差：±42）小时接受了化学预防。52.2%的患者达到了“依从性”。在亚组分析中，“低风险”患者中有51.4%、“中度风险”患者中有55.1%为“依从”。“低风险”组不依从的最常见原因是35.9%的患者住院时间少于48小时。然而，在“中度风险”组中，最常见的不依从情况是37%的病例在入院后未达到推荐的72小时就开始进行预防。
指南简化了临床实践以优化治疗效果，但在某些情况下，基于临床判断可能需要偏离推荐。我们发现住院时间少于48小时是 “低风险” 患者未开始预防的最常见原因。然而，在 “中度风险” 亚组中，最常见的原因是在推荐时间框架之前开始化学预防，我们称之为 “矛盾的” 不依从。
