Discussant
Dr. Michael S. Nussbaum (Jacksonville, FL): Emily, that was an excellent presentation. This paper addresses a very important and timely issue related to VTE prophylaxis in surgical patients, and you have demonstrated that the approach to prophylaxis is quite variable, even when you looked at multiple hospitals in a single system.
As everyone knows, VTE prophylaxis is a Surgical Care Improvement Project (SCIP) measure, and it specifically measures our compliance with the application of VTE measures. The specific requirements are VTE prophylaxis within 24 h preoperatively and up to 24 h postoperatively. You used much stricter criteria for your definition of appropriate VTE prophylaxis in this study, requiring measures on admission and until discharge.
Why did you choose to use the stricter approach? Would the patients that you deemed as not meeting your criteria have met the more lax SCIP criteria?
As you pointed out, 12 patients had VTE complications, and these were in a higher risk category. Eleven of the 12 who suffered VTE received some form of prophylaxis but four of these patients did not receive appropriate prophylaxis by your criteria but would they have met the SCIP measures?
Why didn’t you use sequential compression devices (SCDs)at any of your hospitals? Was that a financial issue? I was surprised that SCDs were not an option for VTE prophylaxis.
What is your rationale for continuing VTE prophylaxis once a postoperative patient is ambulatory? You required that they remain on prophylaxis until they were discharged from the hospital. What justification do you have for this approach in ambulatory patients?
As a final comment, I agree with you that not having BMI information on these patients is a weak point of the paper, because morbidly obese patients are going to be at higher risk for developing VTE, and also you were not able to determine if appropriate dosing was used in such patients.
Closing Discussant
Dr. Robin S. McLeod: To answer your first question about adequate prophylaxis, I think the SCIP measures criteria are used as really for quality indicators for pay for to assess hospital performance. But if you look at what you need for the evidence for optimal patient care, that’s when the evidence is clear that patients require prophylaxis for the entire duration of their hospital stay, and no one refutes it that patients should have prophylaxis until discharge.
And, in fact, in some situations, in some particular cancer operations, that there is some evidence that perhaps it should be continued after surgery discharge. So this is really looking at a quality improvement initiative for patients, not looking at it as an indicator for paid-for assessing hospital performance. So that would be the big difference.
I think just to go on to maybe with regards to your third question, in our study, there were 11 of 12 patients who developed a VTE, patients that got/received some type of prophylaxis. Four of them got what we called inappropriate prophylaxis. However, all of these patients were high risk patients and had multiple risk factors, and they got a DVT. So it’s what is appropriate.
I guess the last thing I could say about that is that if you look at the Chest guidelines, the Chest guidelines’ recommendations are that prophylaxis should be given until discharge.
With respect to the use of the sequential compression devices, I think that is a difference, sort of a cultural difference between Canada and the United States. I suspect that the reason the cultural difference is there is because in Canada at McMaster University, they were probably doing some of the early pharmacological trials in DVT prophylaxis. We have a real history of that. And I think there was a big influence there.
Sequential compression devices are not used at any hospitals in Toronto even though they are an accepted method of prophylaxis. But if you look at it, I think that the evidence in support of pharmacological prophylaxis is much stronger, stronger for pharmacological prophylaxis. And the other point is that compression devices, the compliance with compression devices is overall low. So I think that people are moving probably towards pharmacological rather than away from it.
And the BMI, I think it would just make our point even stronger that you need to give it prophylaxis in this group of patients. We realize that it is a limitation of this study in terms of looking at risk factors.
Discussant
Dr. Kimberly Brown (Kansas City, KS): Did you notice any system differences that may explain some of the variations in compliance, such as whether any of your hospitals have computerized physician order entry, where you’re prompted to enter medication orders for VTE prophylaxis?
The other question I had was, did any of these patients undergo laparoscopic procedures? Because the application of the Chest guidelines to laparoscopic procedures allows some room for interpretation among our different surgeons, and we are not required to monitor and report VTE prophylaxis measures for laparoscopic procedures for our SCIP.
Closing Discussant
Dr. Robin S. McLeod: I think that’s a really interesting question; it is really interesting, your first one, and that is the variation in the seven hospitals.
Just to back up, our Best Practice in General Surgery initiatives is one of the reasons why we have was undertaken it, to minimize variation amongst the because there is a differences amongst the seven hospitals, and it really has sort of gained momentum and there is support to try to standardize things.
None of the seven hospitals have pre-printed orders forms for patients admitted through the ER—these are all patients who were admitted through the emergency room. We do have pre-printed orders for elective patients but not through the emergency room. And the variation in use of VTE prophylaxis is it’s very surprising, actually, because I would suspect that probably 99.9% of orders that are written in emergency patients are written by residents, and our residents rotate around the seven hospitals. So even with probably the same people, or same group of people ordering them, that there is there was quite a big difference, a lot of variation. Other than that, we can’t say why.
Again, I have to emphasize, this is a group of emergency patients that were admitted through the emergency department, only 140 out of the 350 actually went to surgery. So some of them were treated non-operatively. So I think the some of the patients had laparoscopic issue, procedures but we did not look at its effect. We did collect that data. But I have to say we haven’t analyzed it.
But I think that however, this group of patients have so many risk factors, in addition to just the surgical procedure, that they probably all should have prophylaxis. In fact, sort of one of the things in this area in terms of improving one of the main trends in order to increase compliance with VTE prophylaxis is to make it simple. And our recommendations are all patients now who come to a general surgery ward, with a couple of exceptions, that is, outpatient surgery, anorectal procedures, that they should get receive prophylaxis. And we may over treat a few, but if people get it in their mind if it becomes a habit, then those that would benefit prophylaxis won’t be forgotten.
Robin S. McLeod holds the Angelo and Alfredo De Gasperis Families Chair in Colorectal and IBD Research.