Assessing the use of Extended Venous Thromboembolism Prophylaxis on the Rates of Venous Thromboembolism and Postpancreatectomy Hemorrhage Following Pancreatectomy for Malignancy.

OBJECTIVE: To compare rates of venous thromboembolism (VTE) and postpancreatectomy hemorrhage (PPH) in patients with pancreatic or periampullary malignancy preimplementation and postimplementation of routine extended VTE prophylaxis. BACKGROUND: Guidelines recommend up to 28 days of VTE prophylaxis following major abdominal cancer operations. There is a paucity of data examining rates of VTE and PPH in patients who receive extended VTE prophylaxis following pancreatectomy. METHODS: Single-institution analysis of patients who underwent pancreatectomy for malignancy (2004-2021). VTE and PPH rates within 90 days of discharge were compared based on receipt of extended VTE prophylaxis with enoxaparin. RESULTS: A total of 478 patients were included. Twenty-two (4.6%) patients developed a postoperative VTE, 12 (2.5%) of which occurred postdischarge. Twenty-five (5.2%) patients experienced PPH, 13 (2.7%) of which occurred postdischarge. There was no associated difference in the development of postdischarge VTE between patients who received extended VTE prophylaxis and those who did not (2.3% vs 2.8%, P =0.99). There was no associated difference in the rate of postdischarge PPH between patients who received extended VTE prophylaxis and those who did not (3.4% vs 1.9%, P =0.43). In the subset of patients on antiplatelet agents, the addition of enoxaparin did not appear to be associated with higher VTE (3.9 vs. 0%, P =0.31) or PPH (3.0 vs. 4.5%, P =0.64) rates. CONCLUSIONS: Extended VTE prophylaxis following pancreatectomy for malignancy was not associated with differences in postdischarge VTE and PPH rates. These data suggest extended VTE prophylaxis is safe but may not be necessary for all patients following pancreatectomy.

A targeted initiative to discharge surgical patients earlier in the day is associated with decreased length of stay and improved hospital throughput.

BACKGROUND: The timing of inpatient discharges can impact hospital throughput with later discharges leading to decreased patient satisfaction, increased length of stay (LOS), and longer boarding times. METHODS: A 12-month targeted intervention that included both pre-operative and inpatient components was implemented across all surgical inpatient services to increase the proportion of patients discharged by noon. RESULTS: Discharge by noon rates increased from 14.3% to 21.5% during the 12-month initiative (p < 0.01). The case mix index adjusted LOS (aLOS) decreased from 2.17 to 2.02 days (p < 0.01). ED, PACU, and ICU boarding times were all significantly lower during the initiative (p < 0.01, p < 0.01, p = 0.03 respectively). CONCLUSIONS: A targeted initiative to discharge surgical patients earlier resulted in a 50% increase in the proportion of patients discharged by noon. Associated with this finding were improvements in hospital throughput as measured by aLOS and boarding times in the ED, ICUs, and PACU.

Diagnosis and treatment of lymphedema in patients with breast cancer.

Lymphedema is a distressing consequence of breast cancer treatment affecting the patient in all domains of quality of life. Early identification and diagnosis are key to preventing long-term consequences. The goal of lymphedema management is to slow the progression and provide symptomatic relief to maintain quality of life. Preoperative education, intensive postoperative follow-up, and long-term survivorship care are important to minimize risk factors for developing lymphedema and to provide a mechanism for early detection, treatment, and patient self-care. An interdisciplinary approach, including nutritionists, physical therapists, psychologists, and advanced practice registered nurses (APRNs), is essential to provide a patient-centered approach to the management of lymphedema. APRNs are critical in providing comprehensive assessments, ongoing follow-up care, and patient education in self-care strategies.