DVT in precipitous decline
NSQIP data leads to prevention program
Surgical patients have one less thing to worry about when they go into the hospital now: There is a much lower likelihood of deep vein thrombosis (DVT) in either legs or lungs for those who get preventive treatment based on appropriate risk assessment prior to surgery, and a quick return to walking after.
A study in the June issue of the Journal of the American College of Surgeons1 indicates that the odds of a deadly clot steadily declined after the implementation of a multicomponent prevention program in a hospital’s department of surgery.
Researchers at Boston Medical Center reported that they lowered the frequency of DVT by 84% two years after the prevention efforts began, compared with the results two years before the program. Pulmonary emboli declined by 55% in the same period, according to study authors.
"We are encouraged by the success in reducing the frequency of these devastating events among our patients by implementing this prevention program," says co-investigator David McAneny, MD, FACS, vice chair of surgery at Boston Medical Center.
Prior to the study, Boston Medical Center had higher-than-expected rates of postoperative VTE compared with other hospitals when adjusted for severities of illness. Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, the surgeons were able to identify risk factors for DVT, including older age, obesity, smoking, confinement to bed, a personal or family history of DVT or pulmonary emboli, and a long surgical procedure.
Based on scientific evidence and national practice guidelines, the researchers developed a VTE prevention program that scored and totaled patients’ individual risk factors. They then tested the program in all patients undergoing general surgery and vascular surgery procedures at their hospital.
Initially, there was an emphasis on early postoperative mobilization—getting patients up and walking three times a day, starting on the day of the operation when possible. The program later included these additional components, according to McAneny:
• Standardized risk assessment using five categories of VTE risk based on scores of 0 (lowest risk) to more than 8 (highest risk) (based on the Caprini grading system — Caprini JA, Arcelus JI, Hasty JH, et al. Semin Thromb Hemost. 1991: 17:304-312).
• Individualized, risk-based prophylaxis involving inflatable pressure boots and/or low doses of anticoagulation medications, commonly called blood thinners.
• Electronic physician orders that specified early mobilization, the requirement to score the patient’s VTE risk, and the score-based appropriate preventive treatment along with the suggested duration of prophylaxis in the hospital and, for high-risk patients, continuing at home.
• Patient education to explain the importance of preventing blood clots.
Surgeons and their teams received mandatory electronic reminders regarding VTE prophylaxis before and after the operation and when the patient was discharged from the hospital. They could choose to opt out of the recommendation for preventive medication but needed to specify why. The researchers monitored the level of adherence to the automated recommendations.
Using the NSQIP database, the investigators tracked the occurrences of VTE in patients who underwent general surgery or vascular surgery procedures during the two calendar years before and then after implementing the electronic prevention program in February 2011.
Before the program was in place, the odds of a patient having a VTE after a general or vascular surgery procedure was 3.4 times greater than expected, when adjusted for patient risk, the authors reported. Two years after the program began, the risk of developing a VTE was less than one would expect, says McAneny. In that four-year period, the reported frequency of lung clots dropped from 1.1% of 1,569 patients to 0.5% of 1,323 patients. Meanwhile, the frequency of DVT declined from 1.9% of 1,569 patients to 0.3% of 1,323 patients.
In addition, he says surgeons’ adherence to ordering the recommended prophylaxis was high. Compliance rates ranged from 100% for patients at low or moderate risk for a VTE to 77% for patients in the highest risk category. Even when patients at highest risk did not receive prevention in accordance with the recommended measures, the electronic records contained an explanation for not using blood thinners (drug allergy, active bleeding, risk of hemorrhage outweighing risk of VTE, etc.).
McAneny attributed the success of their prevention efforts to the combination of early ambulation and individualized risk assessment and prophylaxis.
He said their VTE prevention program may serve as a model for other medical centers.
- Cassidy MR, Rosenkranz P, McAneny D. Reducing postoperative venous thromboembolism complications with a standardized risk-stratified prophylaxis protocol and mobilization program. J Am Coll Surg. 2014 Jun;218(6):1095-104.
