Reducing postoperative venous thromboembolism complications with a standardized risk-stratified prophylaxis protocol and mobilization program.

Abstract

Data revealed that our urban, academic, safety net medical center was a high outlier for postoperative venous thromboembolism (VTE). Our goal was to implement and determine the efficacy of a standardized intervention for reducing postoperative VTE complications. We developed a strategy to decrease VTE complications, based on standardized electronic physician orders that specify early postoperative mobilization and mandatory VTE risk stratification for every patient, using the "Caprini" grading system. The derived scores dictate the nature and duration of VTE prophylaxis, including on an outpatient basis. Electronic reminders about appropriate VTE prophylaxis are automatically generated before and after operations, and on discharge. Both mechanical (pneumatic compression boots) and pharmacologic prophylaxis (unfractionated or low molecular weight heparin) are used, as indicated by risk level. We conducted a before-and-after trial, comparing National Surgical Quality Improvement Program (NSQIP) VTE outcomes (deep vein thromboses and pulmonary emboli) before and after implementing the standardized risk-stratified protocol combined with a postoperative mobilization program. Measured outcomes included NSQIP-reported raw and risk-adjusted VTE outcomes during 2 years before and after implementing the VTE prevention program. The incidence of deep venous thromboses decreased by 84%, from 1.9% to 0.3% (p < 0.01), with implementation of VTE prevention efforts; the pulmonary emboli incidence fell by 55%, from 1.1% to 0.5% (p < 0.01). Risk-adjusted VTE outcomes steadily declined from an odds ratio of 3.41 to 0.94 (p < 0.05). A patient care program, emphasizing early postoperative mobilization along with mandatory VTE risk stratification and commensurate electronic prophylaxis recommendations, significantly reduced the likelihood of VTE complications among our patients.