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Reducing Postoperative VTE Complications with a Risk-Stratified Protocol and Mobilization Program
Michael R Cassidy, MD, Pamela Rosenkranz, RN, BSN, MEd, David McAneny, MD, FACS
Department of Surgery, Boston University School of Medicine and Boston Medical Center, Boston, MA

Background: 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 in reducing postoperative VTE complications. Methods: We developed a strategy to decrease VTE complications, based upon 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 upon discharge. Both mechanical (pneumatic compression boots) and pharmacologic prophylaxis (fractionated or low molecular weight heparin) are employed, as indicated by risk level. We conducted a before-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 two years before and after implementing the VTE prevention program.

Results: The incidence of DVTs decreased by 84%, from 1.9% to 0.3% (P<0.01), with the implementation of VTE prevention efforts, while the PE incidence fell by 55%, from 1.1% to 0.5% (P<0.01). Risk-adjusted VTE outcomes steadily declined from an odds ratio (OR) of 3.41 to 0.94. Conclusion: A patient care program, emphasizing early postoperative mobilization along with mandatory VTE risk stratification and corresponding electronic prophylaxis recommendations, significantly reduced the likelihood of VTE complications among our patients.

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