Overview

This program at an academic medical center utilized a systemic post-discharge venous thromboembolism prophylaxis protocol to improve post-surgical patient outcomes. 

Department

Department of Medicine

Collaborators

Peter A Najjar MD MBA
Arin L Madenci, MD, MPH
Cheryl K Zogg MSPH MHS
Eric B Schneider PhD
Christian A Dankers MD MBA
Marc T Pimentel MD MPH
Amrita S Chabria PharmD MS
Joel E Goldberg MD MPH FACS
Gaurav Sharma MD
Gregory Piazza MD MS
Ronald Bleday MD FACS
Dennis P Orgill MD PhD FACS
Allen Kachalia MD JD

Status/Stage of Development

Completed

Practice Setting

Academic Medical Center

National/Policy Context

  • Venous thromboembolism (VTE) is a frequently preventable complication of major abdominal and pelvic surgery. It is the most common preventable cause of death within 30 days of operation for intra-abdominal malignancy. 
    • Furthermore, there are even higher rates of postoperative VTE in patients with inflammatory bowel disease (IBD). Thus, pharmacologic prophylaxis against VTE has been widely adopted in the inpatient setting, which has been shown to be safe and effective. 
    • However, at least 30-50% of VTEs occur after discharge for patients undergoing abdominal surgery for malignancy or IBD.
  • The American College of Chest Physicians, the National Cancer Care Network, and the American Society of Clinical Oncology have recommended routine post-discharge prophylaxis after major abdominopelvic cancer surgery for the past decade. 
  • Nevertheless, post-discharge prophylaxis remains underused due to barriers including lack of awareness, lack of local adaptation of national guidelines, and logistical challenges to ensure patient compliance.

Local/Organizational Context

  • An institution-wide quality improvement initiative was undertaken to reduce post-discharge VTE (see Research and Planning).

Patient Population Served and Payor Information

  • Brigham and Women’s Hospital is the largest hospital of the Longwood Medical and Academic Area in Boston, Massachusetts, which serves a diverse cultural and socioeconomic patient population. 

Leadership

  • A hospital-wide multidisciplinary VTE prevention task force was created to ensure adherence to evidence-based best practices in VTE prophylaxis. This task force was led collaboratively by the Department of Surgery and the Department of Quality and Safety.
    • It included representation from surgery, hematology, vascular medicine, internal medicine, anesthesia, clinical pharmacy services, and nursing.
  • The study was conceived and designed by Dr.’s Peter Najjar, Arin Madenci, Christian Dankers, Marc Pimentel, Ronald Bleday, Dennis Orgill, and Allen Kachalia.

Project Research + Planning

  • A post-discharge VTE event analysis at Brigham and Women’s Hospital showed high rates of VTE, warranting systemic intervention (Figure 1).
  • The VTE task force developed a hospital-specific, post-discharge prophylaxis algorithm for at-risk surgical patients. The algorithm utilized inclusion and exclusion criteria, as well as a detailed risk-assessment tool based on a well-validated instrument — the Caprini score. Local post-discharge prophylaxis guidelines were adapted for surgical patients (Figure 1). Specific guidance on LMWH selection and dosing was also provided for clinicians (enoxaparin 40 mg subcutaneously daily for 28 days postoperatively). 
  • The leadership disseminated the algorithms and prescribing guidelines through the Department of Surgery clinical and quality committees and at morbidity and mortality conferences. 
  • A clinical champion in surgery carried out local protocol implementation in the Department of Surgery (Figure 1). 

Tools or Products Developed

  • Post-discharge VTE prophylaxis program for surgical patients: Post-discharge prophylaxis guidelines were adapted specifically for patients undergoing major abdominal surgery for cancer or IBD. This comprehensive program included provider education, local guideline adaptation, bedside medication delivery, and education for at-risk patients. (See “Workflow” for program details.)

Training

  • Research nurses were trained to collect preoperative risk factors, intraoperative factors, and postoperative outcomes.
  • Clinicians were given post-discharge prophylaxis guidelines adapted for surgical patients. They were also given specific guidance on LMWH selection and dosing.

Team Members Involved
  • Physicians
  • RNs
Workflow Steps

  • Patients were included if they underwent a major abdominal or pelvic surgical procedure for cancer or IBD, and had a Caprini score ≥ 5 on discharge.
  • Physicians prescribed eligible patients a 4-week outpatient supply of low molecular weight heparin (LMWH), including syringes, that was delivered to the patient’s bedside before discharge. 
  • Trained nursing staff then provided patients with pre-discharge instruction on how to self-administer the LMWH. 
  • To monitor adherence to the newly implemented algorithm, American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) nurse reviewers collected real-time data on procedure, discharge risk score, and discharge medications in a separately maintained electronic database. 
  • The rate of post-discharge prophylaxis prescription in eligible patients was recorded in this database and regularly communicated to surgical teams during follow-up morbidity and mortality conferences.

Outcomes

  • Rates of inpatient VTE did not significantly differ between cohorts (0.7%, n = 6 pre-intervention vs 1.7%, n = 4 post-intervention, p = 0.25). 
    • However, compared to the pre-intervention cohort, patients in the post-intervention cohort showed a significantly lower post-discharge VTE rate (2.5%, n = 20 pre-intervention vs 0.0%, n = 0 post-intervention; p < 0.01).
  • Over 90% compliance was achieved by September 1, 2014. LMWH prescription rates remained >70% during the post-intervention period. 

Benefits

  • Implementation of this post-discharge VTE prophylaxis program — which included provider education, local guideline adaptation, bedside medication delivery, and education for at-risk patients — was associated with a dramatic reduction in post-discharge VTE events among eligible patients.
  • This implementation addressed many obstacles that had been identified as barriers to national implementation of evidence-based best practices for VTE prophylaxis, including lack of awareness, familiarity, agreement, self-efficacy, outcomes expectancy, and inertia of previous practice and external barriers.

Intervention-Specific Challenges

  • During implementation of the new protocol, the high volume of LMWH prescriptions upon discharge revealed challenges due to highly variable insurance coverage and frequent unavailability of LMWH in commercial outpatient pharmacies. 
    • Thus, the Departments of Surgery and Quality and Safety, in collaboration with the hospital’s outpatient pharmacy, developed a bedside medication delivery program for post-discharge enoxaparin during the wash-in phase. 
    • This allowed surgical teams to ensure that patients had the medication in hand at the time of discharge and that patients were well trained on prophylaxis self-administration. 
    • In addition, the outpatient pharmacy was usually able to bill patients’ prescription benefit plans for the retail cost of the enoxaparin. 
      • This revenue stream, although variable depending on insurance coverage, resulted in substantial additional margin enabling both additional pharmacy staffing to cope with higher prescription volume, as well as financial assistance to patients with no insurance or high copays.

Glossary

  • Caprini score: A risk assessment model that stratifies the risk of VTE in surgical patients. It takes into account multiple risk factors and produces a score from 0-5+.

Sources

  • Najjar PA, Madenci AL, Zogg CK, Schneider EB, Dankers CA, Pimentel MT, Chabria AS, Goldberg JE, Sharma G, Piazza G, Bleday R, Orgill DP, Kachalia A. Implementation of a Comprehensive Post-Discharge Venous Thromboembolism Prophylaxis Program for Abdominal and Pelvic Surgery Patients. J Am Coll Surg. 2016 Dec;223(6):804-813. doi: 10.1016/j.jamcollsurg.2016.09.010. Epub 2016 Sep 28. PubMed PMID: 27693288; PubMed Central PMCID: PMC6309555.
  • Mukherjee D, Lidor AO, Chu KM, Gearhart SL, Haut ER, Chang DC. Postoperative venous thromboembolism rates vary significantly after different types of major abdominal operations. J Gastrointest Surg. 2008 Nov;12(11):2015-22. doi: 10.1007/s11605-008-0600-1. Epub 2008 Jul 31. PubMed PMID: 18668299.
  • Agnelli G, Bolis G, Capussotti L, Scarpa RM, Tonelli F, Bonizzoni E, Moia M, Parazzini F, Rossi R, Sonaglia F, Valarani B, Bianchini C, Gussoni G. A clinical outcome-based prospective study on venous thromboembolism after cancer surgery: the @RISTOS project. Ann Surg. 2006 Jan;243(1):89-95. PubMed PMID: 16371741; PubMed Central PMCID: PMC1449979.
  • Cockbain AJ, Singh-Sekhon N, Ilsley DW. Extended Venous Thromboembolism Prophylaxis After Colorectal Cancer Resection: A UK Perspective. Ann Surg. 2016 Feb;263(2):e26. doi: 10.1097/SLA.0000000000001006. PubMed PMID: 25371122.

Innovators
  • Christian Dankers, MD
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