Every Day Counts: Interventions to Improve VTE and Length of Stay in Patients Undergoing Radical Cystectomy

Transcription

1 Every Day Counts: Interventions to Improve VTE and Length of Stay in Patients Undergoing Radical Cystectomy John A. Brockman, Steven B. Brandes, Arnold D. Bullock, Robert L. Grubb III, Gurdarshan Sandhu, Vicky Peck, Rachel Stratman Wolfe, Cory Hess, Jacob Groenendyk, and Seth A. Strope

2 Disclosures Source of Funding: Washington University Institute of Clinical and Translational Sciences grant UL1 TR from the National Center for Advancing Translational Sciences and National Institute of Diabetes and Digestive and Kidney Diseases Clinical Investigator Award (1K08DK A1 - SAS)

3 HHS Blog- 1/26/2015

4 HHS Blog- 1/26/2015

5 HHS Blog- 1/26/2015

6 Barnes Jewish Hospital and NSQIP Barnes Jewish Hospital Urology joined NSQIP in 2012 First full year of data available was 2013 VTE rate on Urology Service in 2013 was 2.6% National rate only 1.2%

7 2013 NSQIP Data- Deeper Dive 50% of VTE events (8/16) occurred in cystectomy patients (61 total patients). VTE events occurred during initial hospital admission in 5/8 patients. All patients received SCDs in the OR and post-op and appropriate pharmacologic DVT prophylaxis post-op

8 Cystectomy Bundle Decision was made to enact urology cystectomy surgical bundle Decrease VTE Decrease length of stay Decrease readmissions Decrease SSI

9 Implementation of the BJH Protocol Epidural placed pre-operatively 5000 units of SQ Heparin one hour after epidural placement Enoxaparin to be started at 2000 on POD #0. Enoxaparin to be continued for 4 weeks postoperatively

10 Implementation of the BJH Protocol Pre-op bowel prep Clear liquids up to 3 hours before surgery Alvimopan Clean closure protocol No nasogastric tubes leaving the OR Early feeding post-operatively Standardized epidural management Restricted use of fluids in the OR

11 Timeline of Implementation Prior to Business as Usual Starting January Epidural Placement March 1, Surgical implementation of pathway October 1, Full pathway implementation

12 Patient Characteristics Age, mean (SD), y 68.1 (10.6) BMI, mean (SD) 29.2 (5.9) Male/Female 81%/19% Length of stay, mean (SD), d 6.5 (2.9) ASA score, % Conduit, % Ileal Conduit Neobladder Indiana pouch Prior chemotherapy, % No Yes Procedure, % Open Robotic

13 12 Barnes Jewish Length of Stay (Days) Jan Dec 2012 Jan Feb 2014 March Sept 2014 Oct 2014 to present Number of Patients

14 2013 NSQIP Data- Review VTE rate on Urology Service of 2.6% 50% of VTE events (8/16) occurred in cystectomy patients (61 total patients). VTE events occurred during initial hospital admission in 5/8 patients.

15 BJC Data 13.1% (8/61) VTE rate in 2013 pre-intervention 101 cystectomies since March 1, 2014 when DVT bundle rolled out 6 Cases of VTE (5.9%) All six were on protocol!

16 VTE Cases 2 upper extremity DVT associated with central lines 2 Pulmonary Embolism seen on CT scan of abdomen Both incidental findings, patients were asymptomatic 1 symptomatic posterior tibial DVT 1 embolism lodged in patent PFO requiring cardiac surgery

17 Risk Reduction 55% relative risk reduction 7.2% absolute risk reduction

18 Making it Stick Table 2: Protocol Compliance Quartile, by DOS (n) 1 (27) 2 (28) 3 (28) 4 (28) Overall Preoperative compliance, % Heparin given >60 min prior to surgery Postoperative compliance, % LMWH given subcutaneously daily, starting by end of DOS

19 Conclusion Our quality improvement program substantially reduced the DVT/PE rate in a high risk pelvic surgery. Despite excellent compliance with the protocol, some patients will still experience adverse events. There is a continued need for leadership to ensure protocol compliance

20 Questions? John A. Brockman

21 Readmission Rate Time Period Intervention Patients Readmission Jan- Dec % Jan 2013-Feb 2014 March- September 2014 Oct 2014 to present Epidurals Added % Surgical Pathway Full Pathway Implemented 41 40% %