Quality Initiative to Improve Compliance With Perioperative Anticoagulation.

PURPOSE: Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in gynecologic oncology surgical patients. Many centers use neuraxial analgesia (NA), which affects the timing of prophylactic anticoagulation. In 2012, we determined that the rate of VTE in patients undergoing laparotomy with NA was higher than in those who received alternative pain control. In addition, compliance with preoperative anticoagulation guidelines was only 40%. We undertook a quality initiative (QI) project to increase compliance to 80% in NA cases and maintain 90% in non-NA cases. METHODS: A multidisciplinary working group designed and deployed a QI intervention bundle. Compliance was defined as the receipt of a prophylactic dose of anticoagulant within 1 hour after NA or before skin incision regardless of anesthesia type. Data were abstracted from the medical record after the study period. Cases from the year before QI were used for comparison. Primary outcome was compliance and secondary outcome was the rate of VTE. RESULTS: One hundred women were treated under the QI project and 182 historical cases (HCs) were used for comparison. Overall compliance improved (96% QI v 73% HC; P < .001). This difference was marked in cases with NA (95% QI v 40% HC; P < .001) and remained stable in non-NA cases (97% QI v 91% HC; P = .29). The overall rate of VTE, independent of anesthesia type, remained unchanged (2.1% HC v 0% QI; P = .3). CONCLUSION: Relatively simple and inexpensive initiatives to improve routine processes within the surgical pathway are feasible and attract staff participation. Such efforts are likely to translate into greater levels of patient safety.

Lean methodology improves efficiency in outpatient academic Gynecologic Oncology clinics.

OBJECTIVES: Patient satisfaction scores may be used as a measure of quality of care, but outpatient scores are significantly and negatively affected by long clinic wait times. Patients in academic Gynecologic Oncology clinic at UVA for chemotherapy visits experience multiple wait times during a complex multipurpose visit. The purpose of this study was to utilize Lean methodology to identify variability in patient flow in order to guide solutions for improvement. METHODS: A value stream map of our clinic process was created. Patient surveys and clinical timestamps were used to identify which visit components were contributing to delays and to identify process variability. After results were analyzed, a process change was instituted, with the patient surveys then repeated. RESULTS: In the first phase, women experienced short wait times for the first appointment, but the average wait time between appointments gradually increased, with a peak mean wait time of 65 min (range 38-108) just prior to drug infusion. The total mean wait time (including all visits) was 119 min (range 81-154). After instituting process intervention, the overall wait time decreased significantly (82 vs 119 min, p=0.001), but was still affected by aspects of the process that were outside of the investigators' control. CONCLUSIONS: Analyzing patient flow through an academic Gynecologic Oncology clinic can elucidate inefficiencies and guide improvements. Change in process can meaningfully affect overall waiting time. Next steps include instituting a more global change in process, as well as linking results to patient satisfaction scores.

Continuous epidural infusion anesthesia and analgesia in gynecologic oncology patients: less pain, more gain?

OBJECTIVE: There is a lack of consistent data regarding gynecologic oncology (GO) patients and the use of neuraxial anesthesia for post-operative pain management. Our objective was to compare the use of continuous epidural infusion (CEI) as part of post-operative pain management to more traditional management schemes. METHODS: GO patients undergoing laparotomy from July 1st, 2011 through July 31st, 2012 were identified. Patient demographic data and peri-operative details were abstracted from the medical record. The primary outcome was a mean patient visual analog pain score. Secondary outcomes included length of stay, post-operative urinary tract infection (UTI) and venous thromboembolic (VTE) events. RESULTS: There were 237 laparotomies during the study time period. Fifty-six women had CEI for post-operative pain management and 181 did not. Patients with CEI had lower pain scores on POD #0 (3.8 vs 5.3, p < 0.01), #1 (2.6 vs 4.0, p < 0.01) and #2 (2.5 vs 3.5, p < 0.01) compared to women without CEI. There was no difference in the length of stay between those with and without CEI (103 vs 94 h, p = 0.32). Women with CEI did have a longer length of urinary catheterization (56 vs 26 h, p = 0.01) but not an increased rate of UTI (5.5% vs 1.8%, p = 0.24). There was a higher rate of post-operative VTE events among women with CEI (8.9% vs 1.7%, p = 0.02). CONCLUSIONS: In this small series, GO patients undergoing laparotomy had improved post-operative pain control when their analgesia regimen included CEI. However, the higher rate of VTE events among CEI users is concerning and merits further investigation.

The Patient Protection and Affordable Care Act: impact on the care of gynecologic oncology patients in the absence of Medicaid expansion in central Virginia.

OBJECTIVE: Many gynecologic oncology (GO) patients in Virginia are low income and their care is supplemented by Disproportionate Share Hospital (DSH) funds. Our objective is to estimate how many new GO patients may lose access to care if the state forgoes Medicaid expansion. METHODS: New patients referred to the GO service between July 1, 2010 and July 1, 2012 were identified. Data were collected regarding age, race, referral diagnosis, payor, and state pay scale. Pay scale 1 (PS1) is equal to the federal poverty level (FPL). Assumptions included the following: (1) pay scale is a surrogate for income, (2) PS1 patients will be ineligible for discounted insurance through the exchanges, and (3) decreasing DSH funds will result in a reduction of the free-care pool. RESULTS: There were 1623 referrals to the GO service and the majority (83%) was Caucasian. The payor distribution was 44% commercial insurance, 5.6% Medicaid, 31% Medicare, and 10.4% uninsured. Among the 361 women who were PS1, 32% were uninsured. Thirty percent of PS1 patients were minorities and 47.4% had a malignancy. Of note, 52% of new patients with cervical cancer were PS1. CONCLUSION: Seven percent of new GO patients are PS1 and uninsured. This population contains a disproportionate number of minorities and women with cancer. These women will have difficulty affording care as DSH funding decreases, particularly in states with lean Medicaid that opt out of Medicaid expansion. The burden of lack of access to care will be shouldered by an unfortunate few.