EHR Tools May Help Limit Postoperative VTE

Mary Beth Nierengarten

June 09, 2014

A patient care program that included early postoperative mobilization, mandatory risk stratification of venous thromboembolism (VTE), and commensurate electronic prophylaxis recommendations significantly reduced the likelihood of VTE complications among patients undergoing surgical procedures at an academic, urban hospital.

The new results were published in the June issue of the Journal of the American College of Surgeons.

Postoperative VTE remains a leading cause of morbidity and mortality in the United States, despite the availability of a well-established system to predict the chance of VTE in surgical patients, as well as guidelines for VTE prophylaxis.

In the current study, Michael R. Cassidy, MD, from the Department of Surgery, Boston University School of Medicine and Boston Medical Center, Massachusetts, and colleagues developed and implemented a standardized VTE prevention protocol at Boston Medical Center after data from the National Surgical Quality Improvement Program (NSQIP) showed that Boston Medical Center was a high outlier for VTE.

The researchers based the protocol on the use of standardized electronic physician orders that specified early postoperative mobilization and mandatory VTE risk stratification for every surgical patient at the time of operation and/or admission.

The Caprini risk stratification method was used to calculate the risk for VTE in surgical patients, based on its demonstrated ability to guide prophylaxis decisions by accurately predicting the chances of VTE in surgical patients. The investigators developed a scoring system to calculate the risk for VTE that was based on the Caprini system, and the derived score for each patient directed the nature and duration of VTE prophylaxis, including after discharge. Pharmaceutical prophylaxis with unfractured or low-molecular-weight heparin or mechanical prophylaxis with pneumatic compression boots were used on the basis of the calculated risk level.

Along with calculating a risk for VTE in each patient that guided the use of appropriate prophylaxis, the protocol also consisted of a standardized postoperative mobilization program in which each patient was required to be out of bed at least 3 times daily, beginning on the day of the operation.

To assess the efficacy of this program, the investigators used NSQIP-reported raw and risk-adjusted VTE outcomes (deep vein thromboses and pulmonary emboli) during 2 years before and after implementation of the VTE prevention program. Risk-adjusted VTE outcomes were based on the observed/expected ratios for periods before program implementation and were presented as odds ratios for the years after program implementation.

The study showed that the incidence of venous thrombosis decreased by 84% after implementation of the VTE prevention program, going from 1.9% before to 0.3% after program implementation (P < .01). The incidence of pulmonary emboli decreased by 55%, going from 1.1% before to 0.5% after program implementation (P < .01).

The study also found a steady decline in risk-adjusted VTE outcomes, going from an observed/expected ratio of 3.41 (95% confidence interval, 2.40 - 4.70) before program implementation to one of 0.94 (95% confidence interval, 0.56 - 1.58) after program implementation (P < .05).

On the basis of these results, the investigators are "optimistic that postoperative [VTE] complications may be diminished by adherence to risk-stratified and standardized patient care standards."

In an accompanying editorial, Christian A. Dankers, MD, MBA, and Stanley W. Ashley, MD, both from Boston, lauded the investigators for their efforts in developing and implementing the VTE prevention program, but they emphasized the need for further study to clarify which components of the program were most effective.

"Fully implementing the VTE reduction program proposed by Cassidy and associates would require a fair institutional commitment, both in information technology and process improvement resources. It would be helpful to know which particular aspects of the program were most impactful," they write.

"We should applaud their success as we continue the work to refine our understanding of the impact of VTE reduction strategies."

The authors and editorialists have disclosed no relevant financial relationships.

J Am Coll Surg. 2014;218:1096-1104. Article abstract, Editorial extract

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