Sigmund Ruttimann

The indication of venous thromboembolism (VTE) prophylaxis in acutely ill patients admitted to medical departments is not well-defined. Consensus groups have published recommendations and guidelines, addressing this issue. We investigated whether a guideline (explicit risk assessment) would improve the formerly used implicit risk assessment. We compared two groups of patients consecutively admitted to our department during a 4-months period each. Group 1 was assessed prospectively and treated according to a guideline (explicit assessment). Group 2 consisted of the patients hospitalised in the four months prior to the introduction of the guideline (implicit assessment). Their data were abstracted retrospectively from the medical charts. Main outcome measures were symptomatic VTE and major bleedings, and the consumption of unfractionated (UFH) and fractionated (LMWH) heparins. Follow-up lasted until 90 days after hospital discharge. Symptomatic VTE occurred in 5/686 (0.7%) patients of group 1 vs 9/622 (1.4%) patients of group 2 during the hospital phase (p>0.05), and in 9/646 (1.4%) vs 10/572 (1.7%) during the whole study period (p>0.05). In group 1, 350 (51%) patients did not qualify for thromboprophylaxis according to the guideline, and none of them experienced any symptomatic VTE event. Three patients (0.5%) in group 1 and 4 patients (0.6%) in group 2 experienced a major bleeding event (p>0.05). Average consumption of UFH and LMWH did not differ between the groups. The introduction of a guideline for explicit assessment of thromboembolic risk was not significantly superior to the formerly used implicit assessment. However, based on the small number of events observed in this study, a minor advantage cannot be ruled out. Targeted indication for thromboprophylaxis, whether explicit or implicit, avoided application of UFH or LMWH in half of the patients in our setting.

We tested a low-cost, multifaceted intervention program comprising formulary restriction measures, continued comprehensive education, and guidelines to improve in-hospital use of antibiotics and related costs. In a short-term analysis, total antibiotic consumption per patient admitted, which was expressed as defined daily doses (DDD), decreased by 36% (P < .001), and intravenous DDDs decreased by 46% (P < .01). Overall expenditures for antibiotic treatment decreased by 53% (US$100 per patient admitted). The 2 main cost-lowering factors were a reduction in prescription of antibiotics (35% fewer treatments; P < .0001) and more diligent use of 5 broad-spectrum antibiotics (23% vs. 10% of treatments; P = .001). Quality of care was not compromised. A pharmacy-based, prospective, long-term surveillance of DDDs and costs over 4 years showed an ongoing effect. This comprehensive intervention program, which aimed to reduce antibiotic consumption and costs, was highly successful and had long-lasting effects.