The clinical effectiveness and safety of intravenous unfractionated heparin following digital replantation and revascularization: A narrative systematic review.

BACKGROUND: Digital replants and revascularization (DRV) have been performed since the 1960s but there are no recognized standard peri-operative anticoagulation practices. A narrative systematic review of the clinical effectiveness and safety of therapeutic peri-operative unfractionated heparin following DRV was undertaken. METHODS: A review of the literature from 1985 to March 2022 was conducted using Medline, Embase, CINAHL and EBM reviews. Unfractionated heparin (UFH) use following DRV was compared to low-molecular weight heparin, other anticoagulants or no anticoagulation. Randomized trials, observational studies as well as guidelines were selected and independently screened. The Revised Cochrane risk-of-bias (RoB 2) tool and ROBINS-I were used to appraise risk of bias. RESULTS: While the search strategy identified 1490 references, only six studies met the inclusion criteria. Significant heterogeneity and the low methodological quality of the evidence precluded a meta-analysis. Among the four studies that documented the surgical success rate associated with the use of a therapeutic dose of UFH post DRV, only two reported improved clinical outcomes. Evidence of a higher complication rate related to UFH use was found in four studies. Low quality evidence suggests that a therapeutic dose of unfractionated heparin leads to a higher risk of complications when compared with heparin given as an intermittent bolus of unfractionated heparin or subcutaneous heparin, or prostaglandin E1 or no heparin. CONCLUSIONS: Current evidence suggests that IV UFH use following DRV has no significant impact on the success of the intervention. Heparin use may not be innocuous as some studies showed increased bleeding complications.

Experiences of Using Cochrane Systematic Reviews by Local HTA Units.

This study evaluated the use of Cochrane systematic reviews (CSRs) by Quebec's local health technology assessment (HTA) units to promote efficiency in hospital decision-making. An online survey was conducted to examine: Characteristics of the HTA units; Knowledge about works and services from the Cochrane Collaboration; Level of satisfaction about the use of CSRs; Facilitating factors and barriers to the implementation of CSRs evidence in a local context; Suggestions to improve the use of CSRs. Data accuracy was checked by 2 independent evaluators. Ten HTA units participated. From their implementation a total of 321 HTA reports were published (49.8% included a SR). Works and services provided by the Cochrane collaboration were very well-known and HTA units were highly satisfied with CSRs (80%-100%). As regards to applicability in HTA and use of CSRs, major strengths were as follow: Useful as resource for search terms and background material; May reduce the workload (eg, brief review instead of full SR); Use to update a current review. Major weaknesses were: Limited use since no CSRs were available for many HTA projects; Difficulty to apply findings to local context; Focused only on efficacy and innocuity; Cannot be used as a substitute to a full HTA report. This study provided a unique context of assessment with a familiar group of producers, users and disseminators of CSRs in hospital setting. Since they generally used other articles from the literature or produce an original SR in complement with CSRs, this led to suggestions to improve their use of CSRs. However, the main limit for the use of CRS in local HTA will remain its lack of contextualisation. As such, this study reinforces the need to consider the notion of complementarity of experimental data informing us about causality and contextual data, allowing decision-making adapted to local issues.

Yield of CT pulmonary angiography in the diagnosis of acute pulmonary embolism: short report.

OBJECTIVE: To assess computed tomography pulmonary angiography (CTPA) positive yield rate for pulmonary embolism (PE) in a Canadian academic tertiary center. RESULTS: This one-center retrospective cross-sectional study includes from 5565 (model 1) to 5296 (model 2) patients that were evaluated for suspected PE in 2015, among which 1331 (23.9% (model 1) to 25.1% (model 2)) underwent CTPA. Mean age of CTPA patients was 60.2 ± 16.6 years, of which 575 were males (43.2%). Two hundred eleven CTPA examinations were positive for PE, giving a CTPA positive yield rate of 15.9% (95% CI (13.93-17.87)). One hundred and thirteen (8.1%) CTPA were considered indeterminate, and eleven were considered nondiagnostic (0.8%). Among the 211 CTPA positive for PE, 67 (32%) were proximal emboli, 98 (47%) were segmental emboli and 44 (21%%) were subsegmental emboli. In conclusion, in this retrospective study done in a Canadian academic tertiary center, we report a positive rate of 15.9% for PE detection with CTPA, which is above the generally accepted lower threshold of 10% for the yield of CTPA.

Interventions to Reduce the Overuse of Imaging for Pulmonary Embolism: A Systematic Review.

BACKGROUND: Imaging use in the diagnostic workup of pulmonary embolism (PE) has increased markedly in the last 2 decades. Low PE prevalence and diagnostic yields suggest a significant problem of overuse. PURPOSE: The purpose of this systematic review is to summarize the evidence associated with the interventions aimed at reducing the overuse of imaging in the diagnostic workup of PE in the emergency department and hospital wards. DATA SOURCES: PubMed, MEDLINE, Embase, and EBM Reviews from 1998 to March 28, 2017. STUDY SELECTION: Experimental and observational studies were included. The types of interventions, their efficacy and safety, the impact on healthcare costs, the facilitators, and barriers to their implementation were assessed. DATA SYNTHESIS: Seventeen studies were included assessing clinical decision support (CDS), educational interventions, performance and feedback reports (PFRs), and institutional policy. CDS impact was most comprehensively documented. It was associated with a reduction in imaging use, ranging from 8.3% to 25.4%, and an increase in diagnostic yield, ranging from 3.4% to 4.4%. The combined implementation of a CDS and PFR resulted in a modest but significant increase in the adherence to guidelines. Few studies appraised the safety of interventions. There was a lack of evidence concerning economic aspects, facilitators, and barriers. CONCLUSIONS: A combined implementation of an electronic CDS and PFRs is more effective than purely educational or policy interventions, although evidence is limited. Future studies of high-methodological quality would strengthen the evidence concerning their efficacy, safety, facilitators, and barriers.

Lean and Six Sigma in acute care: a systematic review of reviews.

PURPOSE: The purpose of this paper is to present a systematic review of literature reviews, summarizing how Lean and Six Sigma management techniques have been implemented in acute care settings to date, and assessing their impact. To aid decision makers who wish to use these techniques by identifying the sectors of activity most often targeted, the main results of the interventions, as well as barriers and facilitators involved. To identify areas of future research. DESIGN/METHODOLOGY/APPROACH: A literature search was conducted, using eight databases. The methodological quality of the selected reviews was appraised with AMSTAR. A narrative synthesis was performed according to the guidelines proposed by Popay et al. (2006). Data were reported according to PRISMA. FINDINGS: The literature search identified 149 publications published from 1999 to January 2015. Seven literature reviews were included into the systematic review, upon appraisal. The overall quality of the evidence was poor to fair. The clinical settings most described were specialized health care services, including operating suites, intensive care units and emergency departments. The outcomes most often appraised related to processes and quality. The evidence suggests that Lean and Six Sigma are better adapted to settings where processes involve a linear sequence of events. RESEARCH LIMITATIONS/IMPLICATIONS: There is a need for more studies of high methodological quality to better understand the effects of these approaches as well as the factors of success and barriers to their implementation. Field studies comparing the effects of Lean and Six Sigma to those of other process redesign or quality improvement efforts would bring a significant contribution to the body of knowledge. PRACTICAL IMPLICATIONS: Lean and Six Sigma can be considered valuable process optimization approaches in acute health care settings. The success of their implementation requires significant participation of clinical personnel from the frontline as well as clinical leaders and managers. More research is needed to better understand the factors of success and the barriers to their implementation, as well as their long-term impact. ORIGINALITY/VALUE: This is the first broad systematic review of reviews, synthesizing data pertaining to implementation issues and results in acute care settings, to be published. It will benefit health care managers assessing the potential of these approaches and the potential drawbacks associated with their implementation. Moreover, it identifies directions for future research.