Mandatory risk assessment reduces Venous Thromboembolism in Bariatric Surgery

Transcription

1 Mandatory risk assessment reduces Venous Thromboembolism in Bariatric Surgery Abdelrahman Nimeri, MBBCh, FACS, FASMBS President, Pan Arab Society for Metabolic & Bariatric Surgery Surgeon Champion, ACS NSQIP & MBSAQIP. Chief of General, Thoracic & Vascular Surgery. Director, Bariatric & Metabolic Institute Abu Dhabi Adjunct Associate Professor of Surgery, UAE University

2 LAGB 2% Case Mix Disclosure No disclosures OAGB MGB 2% Revision 17% RYGB 46% LoopDS 0% LSG LSG 33% RYGB LAGB Revision OAGB MGB LoopDS Communications Committee

3 Take Home Message Morbidly obese patients area at a high risk of VTE and 80% of VTE happened after discharge. Switching from SQ heparin to LMWH, mandatory risk assessment of patients and sending high risk patients on LMWH for 2 weeks led to lower rates of VTE in LSG and RYGB. The highest risk patients need higher doses of LMWH and their anti factor Xa measured for a goal of IU.

4 VTE in Bariatric Surgery Patients undergoing bariatric surgery are considered high risk for (VTE), & the use of chemoprophylaxis is recommended in the perioperative period. Some bariatric surgery patients are considered higher risk for VTE than others. 80% of bariatric surgery patients develop VTE after discharge from the hospital.

5 VTE in Bariatric Surgery Using a fixed dose of VTE chemoprophylaxis for all bariatric surgery patients is not the best strategy. There is a need to identify bariatric surgery patients who need extended prophylaxis after discharge.

6 Journal of the American College of Surgeons 2013 Jun;216(6):1082-8

7 Are results of bariatric surgery different in the Middle East?: Early experience of an International bariatric surgery program & an ACS NSQIP outcome comparison Our patients were statistically significantly different in: BMI Abu Dhabi Age BMI DM II HTN Journal of the American College of Surgeons 2013 Jun;216(6):1082-8

8 BMI Abu Dhabi Other ACS NSQIP Hospitals Journal of the American College of Surgeons 2013 Jun;216(6): Our patients were statistically significantly different in: No risk factors Resectional Outpatient ASA 1-2

9 BMI Abu Dhabi had statistically significant lower sepsis, Mortality & LOS BMI Abu Dhabi Other ACS NSQIP Hospitals Mortality Sepsis/leak LOS Journal of the American College of Surgeons 2013 Jun;216(6):1082-8

10 Outcomes were similar regarding and were not statistically significant: 2.3 BMI Abu Dhabi Other ACS NSQIP Hospitals Reoperation DVT UTI Bleeding Postop events Journal of the American College of Surgeons 2013 Jun;216(6):1082-8

11 Participating Hospitals 680

12 History of the ACS NSQIP Originated in the Veterans Health Administration and has been operational since 1991 In 2001, ACS received funding to implement NSQIP pilot program in private sector hospitals. In 2004, ACS expanded the program to additional private sector hospitals (SKMC joined in 2009). In 2011, the ACS launched different NSQIP participation options tailored to hospital needs.

13 Quality Improvement Process Ruby & Jejomar abstract data Data are analyze by ACS - NSQIP Risk Adjusted Data is reported back to SKMC SKMC Monitor Interventions with the Data SKMC act on the Data

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21 Methods We aim to compare the rates of VTE in our bariatric surgery patients at the Bariatric & Metabolic Institute (BMI) Abu Dhabi compared to those of the (ACS NSQIP) before and after we implemented mandatory risk assessment for VTE for patients undergoing bariatric surgery, and we changed our chemoprophylaxis in the hospital and after discharge.

22 Changes to chemoprophylaxis for VTE In 2012, we changed our management of VTE prophylaxis as follows: first, we started mandatory risk assessment of all bariatric surgery patients on admission (LSG) and (LRYGB). In addition, we switched from unfractionated heparin (UFH) three times a day to low molecular weight Heparin 40 mg BID in all patients.

23 Changes to cemoprophylaxis for VTE Furthermore, we initiated an aggressive strategy to identify high-risk patients, started them on a higher rate of LMWH, and sent them on LMWH for 2 weeks after discharge from the hospital. We used the Caprini risk scoring system for VTE risk assessment on admission as part of the electronic medical record (EMR). No IVC filters for any patients.

24 Risk stratification for patients Patients are stratified as mild risk (Caprini score of 3 or less), moderate risk (Caprini score of 4), high risk (Caprini score of 5 6), and highest risk (Caprini score of more than 6) for VTE. All patients undergoing bariatric surgery receive sequential compression devices knee length and 5000 IU of UFH subcutaneously at the time of induction of anesthesia.

25 Risk stratification for patients The all receive 40 mg of LMWH twice a day starting 8 h after the dose of UFH. For all patients with a Caprini score of 5 or more receive the same dose of LMWH for 2 weeks after discharge. For patients with a Caprini score of more than 6, we place them on LMWH 60 twice a day and we measure their antifactor Xa 4 h after the third dose of LMWH (goal IU).

26 Our very first SAR

27 Process of QI at SKMC Denial phase; more than one SAR showing the same results before we decide to act. Putting together a multidisciplinary task force. Looking at our own occurrences. Our own reasons for having the problem. Tackle the lowest hanging fruits. Follow our results based on the SARs.

28 Assembled a hospital wide MDT task force: Chairman David Spence MD Abdelrahman Nimeri Nicolas Turrin Louya Al Jabban Fadi Zalloum Christelle Du Plessis Leonila Sumpreque Michel Bussieres Tristan Mananghaya Bisher Mustafa Karen Mc Kenna

29 Chart review of DVT/PE cases We compared all our cases against the best practice guidelines. We identified that VTE prophylaxis is a major concern in our cases. An audit confirmed our findings that VTE prophylaxis poor compliance.

30 S.No KM Admn Date Age Sex Ward Surgical Speciality Surgery date Microbiology date Organism Post op Symptamatic UTI CAUTI Foley Insertion Foley Removal Treatment Conclusion /03/11 73 F B2 Neuro 01/04/10 07/04/10 E COLI ESBL YES YES 02/04/10 04/12/2010 PIPTAZ CAUTI /05/10 87 F D0 General 19/5/10 30/05/11 pseudomonas YES YES 19/05/11 NOT DOCU YES CAUTI.No documentation on cath removal.but the specimen took from a urine cath /06/10 19 M D0, B6, B4 Neuro 11/06/10 08/07/10 Pseudomonas Aeruginosa YES NO 11/06/10 27/06/10 NO 27/06/10 - condom catheter /04/10 38 M B4 Ortho 22/04/10 06/05/10 Morgenella morgani YES NO 22,26/4/10 26/4,3/5/10 cipro Symptmatic post op UTI c/s done after 3 days of cath removal /06/10 66 F B2 Ortho 10/06/10 29/06/10 Proteus mirabilis yes NO N/A N/A NO Not CRBSI,no foley cath at the time of culture,no treatment done /01/10 71 M B3 Ortho 07/01/10 13/01/10 E COLI ESBL YES NO NOT DOCU 10/01/10 MERO/PIPTA Z Not CAUTI,Sample done after 3 daya of cath removal /02/10 62 F B2 Ortho 21/02/10 25/02/10 e coli esbl NO NO 23/02/10 NOT DOCU cefa/piptaz Not meetingthe criteria.no symptoms documented other than fever.organism count cfu/ml. per NSQUIP must have 2 symptoms to meet criteria /05/10 75 M C1 General 17/5/10 30/05/11 Candida NO NO 18/5,25/5 25/5,31/5 NO Not uti, No symptoms documented,only cath removed-consider colonisation /05/10 58 M C1 General 20/5/10 31/05/10 Klebsiella Pneumoniae NO NO 20/05/10 NOT DOCU NO No symptoms documented.no treatment documented, need 2 other symptoms to meet criteria.no cath on situ at the time of culture /05/10 53 F B2 Ortho 03/06/10 07/06/10 pseudomonas NO NO 04/06/10 06/09/2010 NO No symptoms documented,ua done normal. no treatment documented /06/10 58 M B3 Ortho 29/06/10 28/07/10 E.coli NO NO N/A N/A Nitrofurantoin C/S done in outpatients. Does not meet NSQIP criteria, afebrile, no S & S documented

31 Risk assessment was identified as a major problem in our surgical patients: A compulsory paper based risk assessment tool (Caprini et al) was introduced. A hard stop for surgery patients and for all admissions.

32 t was identified as a major problem in medical & su A compulsory paper based risk assessment tool (Caprini et al) was introduced. A hard stop for surgery patients and for all admissions.

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34 1,152 cases were done at BMI Abu Dhabi compared to 65,693 cases at ACS NSQIP bariatric surgery programs. 626 (LRYGB) compared to (LRYGB 32, (LSG) compared to (33,563) LSG

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36 Comparison of outcomes of 967 patients compared to ACS NSQIP Bariatric Surgery Programs Presented as an abstract IFSO Rio 2016

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43 2.50% 2.00% VTE rates at BMI Abu Dhabi and ACS NSQIP % ACS NSQIP 1.50% 1.00% 0.90% 0.95% 0.50% 0.00% 0.45% 0.45% 0.45% 0% 0.50% 0.25% 0.35% 0.40% 0.30% 0.30%

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46 Odds Ratio of DVT/PE in the division of General & Vascular Surgery at SKMC High outlier Series Exemplery

47 Odds Ratio of DVT/PE in the department of Surgery at SKMC High outlier Series

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53 Take Home Message Morbidly obese patients area at a high risk of VTE and 80% of VTE happened after discharge. Switching from SQ heparin to LMWH, mandatory risk assessment of patients and sending high risk patients on LMWH for 2 weeks led to lower rates of VTE in LSG and RYGB. The highest risk patients need higher doses of LMWH and their anti factor Xa measured for a goal of IU.

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