Sustained success of a Caprini postoperative venous thromboembolism prevention protocol over one decade.

BACKGROUND: The objective of this study was to review the long-term efficacy of a post-operative venous thromboembolism (VTE) prevention program at our institution. METHODS: We performed a review of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data at our hospital from January 2008-December 2022. The primary outcome was risk-adjusted VTE events. RESULTS: In 2009, a postoperative general surgery patient was three times more likely to have a postoperative VTE event than predicted (O/E ratio 3.02, 95% CI 1.99-4.40). After implementing a mandatory VTE risk assessment model and a risk-commensurate prophylaxis protocol in the electronic medical record in 2011, the odds ratio of a patient developing a postoperative VTE declined to 0.70 by 2014 (95% CI 0.40-1.23). This success persisted through 2022. CONCLUSIONS: Since the implementation of a standardized postoperative VTE prevention program in 2011, our institution has sustained a desirably low likelihood of VTE events in general surgery patients.

I text for I COUGH: A clinical pilot study to evaluate the impact of text messaging upon postoperative ambulation in the hospital.

BACKGROUND: The "I COUGH" protocol is associated with improved postoperative pulmonary outcomes, and ambulation is an essential component. I COUGH is an acronym for Incentive spirometry, Coughing, Oral care, Understanding (patient and staff education), Getting-out-of-bed, and Head-of-bed elevation. This trial sought to enhance one component, specifically ambulation after operations. METHODS: Randomized trial of inpatients in a safety-net, academic medical center. The intervention group received standard I COUGH education along with text message reminders to ambulate postoperatively, whereas the control group received standard education alone. Postoperative walking frequency was compared to each participant's ambulation on the day prior to enrollment. RESULTS: The intervention group had an average improvement of 1.8 ± 1.8 walks per day per patient, while the average change for the control group was 0.2 ± 1.0 walks per day per patient. This represents a 9-fold increase in ambulation for the intervention group (p = 0.03). CONCLUSIONS: Implementation of text message reminders increased ambulation and improved adherence to the I COUGH protocol following operations. This system should be further investigated as an adjunct to postoperative care.

Two novel risk factors for postoperative venous thromboembolism: A reconsideration of standard risk assessment and prophylaxis.

BACKGROUND: Postoperative venous thromboembolism (VTE) is usually preventable with adequate prophylaxis. In an institutional study, patients with emergency operations (EO), multiple operations (MO), and perioperative sepsis (PS) were more likely to develop VTE despite standard prophylaxis. METHODS: General surgery patients in the NSQIP database from 2011 to 2014 were stratified into VTE and non-VTE groups, and statistical analyses were performed. RESULTS: Among 1,610,086 patients, 13,673 (0.8%) were diagnosed with VTE. The VTE odds ratios for patients with EO, MO and PS were 1.4 (95%CI:1.3-1.5), 1.9 (95%CI:1.7-2.0), and 2.4 (95%CI:2.2-2.5), respectively. VTE odds ratios increased with concurrence of two factors (EO+PS: 2.0 (95%CI:1.9-2.2)) (EO+MO: 2.3 (95%CI:1.9-2.7)) (MO+PS: 2.5 (95%CI:2.2-2.7)) and further still for patients with all three factors (2.7, 95%CI:2.4-3.0). CONCLUSION: General surgery patients with EO, MO, or PS have a greater likelihood of developing postoperative VTE. These factors are not necessarily captured in contemporary risk assessment models that guide chemoprophylaxis, and so these high-risk patients may receive insufficient prophylaxis.

The impact of preoperative carbohydrate loading on patients with type II diabetes in an enhanced recovery after surgery protocol.

BACKGROUND: We aimed to determine the effects of preoperative carbohydrate-loading (CHO) as part of an enhanced recovery after surgery (ERAS) pathway on patients with/without type II diabetes (DMII). METHODS: Retrospective review of ERAS patients with CHO, including 80 with DMII, 275 without DMII in addition to 89 patients with DMII from the previous (non-ERAS) year. Outcomes included glucose-levels, insulin requirements, and complications. Logistic regression was used to determine the association of any complication with perioperative glucose control variables. RESULTS: Among ERAS versus non-ERAS patients with DMII, there were significant differences in median preoperative (142 mg/dL versus 129.5 mg/dL, p = 0.017) and postoperative day-1 glucose levels (152 mg/dL, versus 137.5 mg/dL, p = 0.004). There were no differences in insulin requirements, hypoglycemic episodes, or complications. Complications were not associated with Hgb-A1C%, home DMII-medications, or preoperative glucose measurement on logistic regression. CONCLUSIONS: Patients with DMII tolerated CHO without increasing insulin requirements or substantially affecting glucose levels or complications.

The I COUGH Multidisciplinary Perioperative Pulmonary Care Program: One Decade of Experience.

BACKGROUND: Surgical quality improvement programs can provide meaningful benefits for patient outcomes, but sustainability of initial success is rarely described. In response to data that revealed a greater than predicted likelihood of postoperative pulmonary complications in one hospital, the study team designed a standardized program to improve care. This study offers a long-term perspective of the effort, including special challenges and lessons learned about sustaining success. METHODS: A before-after study was conducted at an academic safety-net hospital. A multidisciplinary team developed tactics to reduce pulmonary complications, designated by the acronym I COUGH: Incentive spirometry, Coughing/deep breathing, Oral care, Understanding (education), Getting out of bed, and Head of bed elevation. Clinical practices were audited and compared to actual and risk-adjusted pulmonary outcomes. RESULTS: Improvements in compliance with the I COUGH elements were initially promising, but baseline behaviors eventually returned. Adverse outcomes have inversely correlated with process adherence in "sawtooth" patterns. Rejuvenation efforts have successively extended beyond the literal principles of the acronym to foster broader institutional commitment to perioperative pulmonary care, restoring favorable trends in both process and outcomes. A more comprehensive I COUGH program now extends beyond the acronym, applying numerous concepts to support the original program. CONCLUSION: I COUGH, a standardized perioperative pulmonary care program, initially improved performance and reduced pulmonary complications. However, loss of early program momentum corresponded with a return to baseline outcomes. Fortunately, an overall favorable trend has resulted from a coordinated rededication to I COUGH that requires steadfast commitment and creative responses to numerous cultural barriers.

Evaluation of a Standardized Risk-Based Venous Thromboembolism Prophylaxis Protocol in the Setting of Thyroid and Parathyroid Surgery.

BACKGROUND: An elevated odds ratio for venous thromboembolism (VTE) prompted development of a Caprini risk assessment and risk-based prophylaxis protocol for all general surgery patients. This system includes pre- and postoperative prophylactic heparin as well as extended courses of low molecular weight heparin for high-risk patients. This study evaluated the safety of this chemoprophylaxis program in thyroid and parathyroid surgery. STUDY DESIGN: A retrospective review was conducted of all general surgery patients undergoing thyroid or parathyroid operations after implementation of the Caprini prophylaxis protocol. Descriptive statistics were performed to evaluate bleeding complications, risk score categories, and chemoprophylaxis. RESULTS: Of 1,012 consecutive patients, 72% were determined to be at low/moderate risk for VTE, 26% were high risk, and 2% were highest risk. Only 29% of eligible high/highest-risk patients actually received extended prophylaxis after discharge. Fifteen patients (1.5%) developed wound hematomas that required evacuations, 12 of them within 24 hours of the index operation. Among patients who developed bleeding complications, 5 (33%) had Caprini scores indicating low/moderate-risk for VTE, and 10 (67%) were in the high/highest-risk categories. Only 1 patient developed a delayed hematoma that required a return to the hospital for evacuation. One patient developed a VTE complication. CONCLUSIONS: Although the incidence of VTE is quite low for patients undergoing thyroid and parathyroid operations, the Caprini prophylaxis protocol identifies a subset of high-risk patients who may benefit from extended VTE prophylaxis without the likelihood of added harm. Conversely, Caprini scores might also select low-risk patients who require no chemoprophylaxis, possibly reducing risks of hemorrhage.

Patterns of Failure of a Standardized Perioperative Venous Thromboembolism Prophylaxis Protocol.

BACKGROUND: Venous thromboembolism (VTE) is a leading contributor to morbidity after operations. We previously implemented a standardized VTE risk assessment, based on the Caprini score, along with risk-stratified prophylaxis. This system reduced the odds ratio of a VTE event from 3.02 to 0.75. We investigated patterns of failure to determine characteristics of patients in whom VTE develops despite the protocol. METHODS: We reviewed all nontrauma general surgery patients with evidence of VTE after the inception of a VTE risk assessment and prophylaxis program. Characteristics were recorded, including demographics, diagnoses, operations, risk profile, prophylaxis prescribed, and regimen compliance. RESULTS: Twenty-seven patients failed the protocol and manifested VTE, representing an overall VTE rate of 0.3%. Of these patients, 63% had emergency operations and 52% underwent multiple operations, compared with 13% and 2.0% of the nontrauma general surgery population in whom VTE did not develop, respectively (p < 0.001). Of patients with VTE, 52% had pre-existing or postoperative infections, 22% had malignancies, but only 15% had missed 1 or more doses of pharmacologic prophylaxis during hospitalization. Five VTEs manifested after discharge; one of those patients was prescribed extended prophylaxis beyond hospitalization, and an extended course was not provided to 3 who were eligible. One patient had underestimation of the Caprini score due to lack of awareness of a family history of VTE. CONCLUSIONS: Emergency and multiple operations seem to confer dramatic hazards for VTE, despite standard prophylaxis. These factors are not currently captured in the Caprini model, but might be significant modifiers of risk that should prompt reassessment, perhaps with a weighted numeric value along with enhanced prophylaxis. It is encouraging that most patients received appropriate prophylaxis in compliance with the protocol.

Caprini venous thromboembolism risk assessment permits selection for postdischarge prophylactic anticoagulation in patients with resectable lung cancer.

OBJECTIVE: Postoperative venous thromboembolism (VTE) creates an 8-fold increase in mortality after lung resection. About one third of postoperative VTEs occur after discharge. The Caprini risk assessment model has been used by other specialties to calculate the risk of a VTE. Patients deemed high risk by the model are candidates for prophylactic anticoagulation after discharge, reducing the VTE risk by 60%. Our primary aims were to determine the frequency of VTE events and evaluate whether the Caprini model could risk-stratify patients. METHODS: Patients undergoing lung cancer resections during 2005 to 2013 were evaluated. Exclusion criteria were preoperative filter and therapeutic anticoagulation. A total of 232 patients were reviewed and Caprini scores calculated. Subjects were risk stratified into groups of low risk (0-4), moderate risk (5-8), and high risk (≥ 9). Occurrence of VTE events (deep vein thrombosis; pulmonary embolism) were identified by imaging. RESULTS: The 60-day VTE incidence was 5.2% (12 of 232); 33.3% occurred postdischarge (n = 4). Half (6 of 12) were pulmonary emboli, 1 of which caused a death, in an inpatient with a score of 16. The VTE incidence increased with Caprini score. Scores in the low, moderate, and high risk groups were associated with a VTE incidence of 0%, 1.7%, and 10.3%, respectively. With a high risk score cutoff of 9, the sensitivity, specificity, and accuracy are 83.3%, 60.5%, and 61.6%, respectively. CONCLUSIONS: One third of VTE events occurred after discharge. Postoperative VTE incidence was correlated with increasing Caprini scores. Patients in the high risk group had an incidence of 10.3%. Elevated scores may warrant extended chemoprophylaxis for patients after discharge.

Evaluation of the Caprini Model for Venothromboembolism in Esophagectomy Patients.

BACKGROUND: Patients undergoing esophagectomy for cancer are in the highest-risk group for venous thromboembolism, with a 7.3% incidence reported by the National Surgical Quality Improvement Program. Venothromboembolism (VTE) doubles esophagectomy mortality. The Caprini risk assessment model (RAM) is a method to stratify postoperative thromboembolism risk for consideration of prolonged preventive anticoagulation in higher-risk patients. Our aim was to examine the potential use of this model for reducing the VTE incidence in esophagectomy patients. METHODS: The records of patients who underwent an esophagectomy by the thoracic surgery service at our institution between June 2005 and June 2013 were reviewed. The inclusion criteria were a diagnosis of esophageal cancer treated with esophagectomy (any approach) and with available 60-day postoperative follow-up. Exclusion criteria were the presence of an inferior vena cava filter or chronic anticoagulation therapy. The Caprini risk score and the number of VTE events were recorded retrospectively for each patient. RESULTS: Seventy patients satisfied eligibility criteria. The VTE incidence was 14.3%. Patients with esophageal thromboembolism had a higher Caprini score distribution than patients without thromboembolism (p < 0.001). Adjusted logistic regression analysis demonstrated increased odds of VTE with increasing score (p < 0.05), with good discrimination. CONCLUSIONS: In this first report examining the Caprini model categories in an esophagectomy population, the VTE incidence in true high-risk patients was high. From this retrospective calculation of risk and events, patients in the highest-risk Caprini group may benefit from an enhanced course of postoperative anticoagulation.

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

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 for reducing postoperative VTE complications. STUDY DESIGN: 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. RESULTS: 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). CONCLUSIONS: 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.

I COUGH: reducing postoperative pulmonary complications with a multidisciplinary patient care program.

IMPORTANCE: Postoperative pulmonary complications can be a devastating consequence of surgery. Validated strategies to reduce these adverse outcomes are needed. OBJECTIVES: To design, implement, and determine the efficacy of a suite of interventions for reducing postoperative pulmonary complications. DESIGN: A before-after trial comparing our National Surgical Quality Improvement Program (NSQIP) pulmonary outcomes before and after implementing I COUGH, a multidisciplinary pulmonary care program. SETTING: An urban, academic, safety-net hospital. PARTICIPANTS: All patients who underwent general or vascular surgery at our institution during a 1-year period before and after implementation of I COUGH. INTERVENTIONS: A multidisciplinary team developed a strategy to reduce pulmonary complications based on comprehensive patient and family education and a set of standardized electronic physician orders to specify early postoperative mobilization and pulmonary care. Designated by the acronym I COUGH, the program emphasizes incentive spirometry, coughing and deep breathing, oral care (brushing teeth and using mouthwash twice daily), understanding (patient and family education), getting out of bed at least 3 times daily, and head-of-bed elevation. Nursing and physician education promoted a culture of mobilization and I COUGH interventions. I COUGH was implemented for all general surgery and vascular surgery patients at our institution in August 2010. MAIN OUTCOMES AND MEASURES: The NSQIP-reported incidence and risk-adjusted ratios of postoperative pneumonia and unplanned intubation, which NSQIP reports as observed-expected (OE) ratios for the 1-year period before implementing I COUGH and as odds ratios (ORs, statistically comparable to OE ratios) for the period after its implementation. RESULTS: Before implementation of I COUGH, our incidence of postoperative pneumonia was 2.6%, falling to 1.6% after its implementation, and risk-adjusted outcomes fell from an OE ratio of 2.13 to an OR of 1.58. The incidence of unplanned intubations was 2.0% before I COUGH and 1.2% after I COUGH, with risk-adjusted outcomes decreasing from an OE ratio of 2.10 to an OR of 1.31. CONCLUSIONS AND RELEVANCE: I COUGH, a standardized postoperative care program emphasizing patient education, early mobilization, and pulmonary interventions, reduced the incidence of postoperative pneumonia and unplanned intubation among our patients.