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BACKGROUNDAlthough effective methods for venous thromboembolism prophylaxis (VTE‐P) have been known for decades, reliable implementation has been challenging.OBJECTIVEDevelop reliable VTE‐P systems for adult and for pediatric patients to reduce preventable venous thromboembolism (VTE).DESIGNWe used a discovery and diffusion system to first develop an effective system in 1 hospital location, and then spread the principle best practices across the entire 22‐hospital system.SETTINGTwenty‐two Mayo Clinic hospitals (adults and children).PATIENTSAdult and pediatric patients.INTERVENTION(1) Ensure that a VTE‐P is declared at admission by providing a mandatory VTE‐P “tollgate” that requires the provider to assess the risk for VTE and provide an appropriate order for VTE‐P. (2) Use clinical decision support to provide ongoing surveillance and alerts to providers when there is a lapse in the VTE‐P plan.MEASUREMENTSIn adults, VTE compliance as measured by the Centers for Medicare and Medicaid Services Core Measures VTE‐1 and VTE‐2, preventable VTE as measured by VTE‐6, and in pediatric patients, appropriate VTE measures as determined by chart audit.RESULTSVTE‐1 and VTE‐2 have approached 97% to 100% and preventable VTE has declined to 0% for the last 3 quarters. Similarly, the pediatric VTE‐P screening tool was evaluated and piloted with >92% compliance in risk documentation, appropriate VTE‐P >64%, and 0 VTE events during the study period.CONCLUSIONAn integrated system‐wide approach can lead to measurable improvements in VTE‐P process and outcome measures. Journal of Hospital Medicine 2016;11:S15–S21. © 2016 Society of Hospital Medicine

Objective Microscopic colitis (MC) is a common cause of chronic diarrhoea, often with additional symptoms. No validated instruments exist to assess disease activity in MC, making it difficult to compare efficacy of treatments between clinical trials. We aimed to identify clinical features that independently predicted disease severity and create a Microscopic Colitis Disease Activity Index (MCDAI). Design Patients with MC were prospectively administered a survey assessing their GI symptoms and the IBD Questionnaire (IBDQ). A single investigator also scored a physician global assessment (PGA) of disease severity on a 10-point scale. Multiple linear regression identified which symptoms best predicted the PGA. These symptoms were then combined in a weighted formula to create the MCDAI. The relationship between MCDAI and the IBDQ was investigated. Results Of the 175 patients enrolled, 13 (7.4%) did not complete the survey. The remaining 162 had a median age of 66 years (range, 57–73) and 74% were female. Several clinical features were independently associated with PGA (number of unformed stools daily, presence of nocturnal stools, abdominal pain, weight loss, faecal urgency and faecal incontinence). These parameters were combined to create the MCDAI, which strongly predicted the PGA (R 2 =0.80). A 1-unit decrease in disease activity (ΔMCDAI) was associated with a 9-unit increase in quality of life (ΔIBDQ). Conclusions The MCDAI strongly predicted the PGA and correlated with a validated measure of quality of life. Several symptoms in addition to diarrhoea are associated with disease severity in MC.

Background Many CT angiography (CTA) collateral scoring systems are either subjective or complex and time consuming. Objective To evaluate the correlation between a CTA collateral scoring system—the Opercular Index Score (OIS)—with neurological outcomes at 90 days following endovascular treatment for acute ischemic stroke (AIS) secondary to large vessel occlusion. Methods Fifty-five patients with AIS due to distal internal carotid artery, M1, or proximal M2 occlusions who underwent endovascular treatment were included. OIS was retrospectively calculated from CTA images, reconstructed from CT perfusion imaging, as the ratio of opacified M3 opercular branches in the Sylvian fissure on the unaffected side to those on the stroke side and dichotomized into favorable (OIS≤2) and poor (OIS>2). The ability of OIS to predict good neurological outcomes (modified Rankin Scale score ≤2 at 90 days) was assessed using sensitivity, specificity, and area under the curve (AUC) with receiver operating characteristic analysis. Results Thirty-five patients had a favorable OIS and 20 patients had a poor OIS. Patients with favorable OIS had an 80.0% (n=28) rate of good neurological outcomes compared with 15.0% (n=3) of patients with a poor OIS (p<0.0001). On multivariate logistic regression analysis adjusting for baseline National Institutes of Health Stroke Scale score, OIS, and device used, favorable OIS was the only variable independently associated with good neurological outcome (OR=17.2, 95% CI 3.8 to 104.3) and demonstrated a sensitivity of 90.3% and specificity of 70.8% with an AUC of 0.822. Conclusions OIS is a simple and practical non-invasive scoring system that can be used to predict collateral robustness and good neurological outcome among patients with AIS undergoing endovascular treatment.

Objective: We evaluated whether single-layer renorrhaphy (SLR) without collecting system (CS) closure is sufficient following robot-assisted partial nephrectomy (RAPN). Patients and Methods: One hundred fifty consecutive patients underwent RAPN by a single surgeon and were prospectively labeled with regard to CS entry during surgery. Patients with CS entry were subdivided into two groups: those with classical renorrhaphy (CR) (i.e., two-layer repair) and those with SLR (i.e., without CS repair). Perioperative variables and outcomes were compared between CR and SLR groups. Results: Ninety patients had CS entry during RAPN. Of these 90 patients, 64 had CR, and 26 had SLR, with mean ages of 62 and 59 years ( p = 0.22), tumor sizes of 3.4 and 3.3 cm ( p = 0.61), Mayo Adhesive Probability scores of 1.8 and 1.8 ( p = 0.95), and radius, exophytic/endophytic, nearness to CS, and laterality scores of 8.5 and 8.0 ( p = 0.16), respectively. Mean warm ischemia times (WITs) were 19.6 and 17.3 minutes ( p = 0.04), hospital stays of 3.0 and 2.8 days ( p = 0.62), and drain times of 2.9 and 2.7 days ( p = 0.65), for the CR and SLR groups, respectively. Using the Clavien-Dindo classification, there were a total of six grade III or higher complications, with no difference between the CR and SLR subgroups ( p = 1.0). Renal function using creatinine or glomerular filtration rate as surrogates showed no difference between groups preoperatively or up until 2 years postoperatively. Conclusions: Omitting CS repair during RAPN with SLR decreases WIT without altering complications, hospital stay, or drain time. Long-term renal function was not associated with CS repair.