Early Ambulation Reduces the Risk of Venous Thromboembolism After Total Knee Replacement. Introduction/Background. Research Team.

Transcription

1 Research Team Early Ambulatio Reduces the Risk of Veous Thromboembolism After Total Kee Replacemet Marily Szekedi, PhD, RN Baafsheh Sadeghi, MD, PhD, School of Medicie, Uiversity of Califoria Davis Patrick S. Romao, MD, MPH, School of Medicie, Uiversity of Califoria Davis Gregory Mayard, MD, MS, School of Medicie, Uiversity of Califoria Sa Diego Amy L. Slater, MPH, MBA, UHC Laurie Hesley, MHA, UHC Julie Cerese, RN, MSN, UHC Richard H. White, MD, FACP, School of Medicie, Uiversity of Califoria Davis ANA 7 th Aual Nursig Quality Coferece, February 3 Ageda Itroductio/Backgroud Methods Results Discussio Itroductio/Backgroud 2 Study Objectives The Extet of the Problem Although widely recogized as a potetially prevetable complicatio, symptomatic VTE is a frequet complicatio followig TKR. This case-cotrol study was performed to aalyze the associatio betwee acute symptomatic VTE ad potetial risk factors: Patiet factors Age Geder BMI Type of TKR (uilateral vs. simultaeous bilateral) Guidelie-based itervetios Delivery of pharmacologic Delivery of mechaical Duratio of immobility Acute VTE is diagosed after TKR i approximately 2% of patiets who receive recommeded pharmacologic TKR is the pricipal coditio used to study the effectiveess of ew aticoagulats VTE leads to icreased LOS ad higher costs, ad may lead to complicatios such as fatal PE, post-thrombotic sydrome, ad aticoagulat-related bleedig. Blachard J, Meuwly JY, Leyvraz PF, et al. Prevetio of deep vei thrombosis after total kee replacemet: Radomized compariso betwee a low-molecular-weight hepari (adropari) ad mechaical with a foot-pump system. J Boe Joit Surg Br. 999;8(4): Jauel JM, Che G, Ruffieux C, et al. Symptomatic i-hospital deep vei thrombosis ad pulmoary embolism followig hip ad kee arthroplasty amog patiets receivig recommeded : a systematic review. JAMA. 2; 307(3):

2 Evidece-Based Cliical Practice Guidelies Guidelie Accepted VTE Prophylaxis Defied Risk America College of Chest Oe of the followig for 0-4 days Total kee surgeries are Physicias: Atithrombotic LMWH started 2 h before or after surgery cosidered high risk for VTE, Therapy ad Prevetio of Low-dose ufractioated hepari regardless of age, activity level, or Thrombosis, 9 th ed. Factor Xa ihibitor (fodapariux, apixaba, comorbidities rivaroxaba) Warfari Guyatt GH, Akl EA, Crowther M. Executive summary: Evidece- Dabigatra Based Cliical Practice Guidelies. Recommeds agaist the use of aspiri aloe for Chest. 2;4(2 suppl):7s-47s. Geerts WH, Bergquist D, Pieo GF, ay group I patiets with elevated bleedig risk: et al. Prevetio of veous Itermittet peumatic compressio device (8 thromboembolism. Chest. 08;33(6):38S-43S. America Academy of hours daily) Pharmacologic as above Total kee surgeries are Orthopedic Surgeos Mechaical for patiets with elevated cosidered stadard risk for PE. bleedig risk: Bleedig risk defied as: Peumatic compressio devices History of a bleedig disorder Foot ad leg pumps History of recet gastroitestial bleed History of recet hemorrhagic es/vte/vte_guidelie.asp stroke Surgical Care Improvemet LMWH Orthopedic surgeries with surgical Project Factor Xa ihibitor (fodapariux) time > 60 mi ad LOS > 3 days Warfari Itermittet peumatic compressio devices Veous foot pump Research Methods 7 Case-Cotrol Study Cases: Uilateral or bilateral TKR October 08-March 0 > 40 y Code for VTE withi 90 days of surgery Cotrols: Uilateral or bilateral TKR October 08-March 0 > 40 y No code for VTE withi 90 days of surgery Radom selectio Data Collectio ad Aalysis Fiftee voluteer academic medical ceters participated. Up to cases ad up to 40 cotrols i each hospital were abstracted. VTE = PE (4.,4.9); DVT (43.4x) plus 4., 4.9, 4.2, 4.8, 43.2, 43.8, 43.9 No other TKR or hip replacemet withi previous 90 days No idex hospitalizatio pricipal diagosis of VTE No idex hospitalizatio VTE with POA = Y No pregacy, childbirth, or puerperium Excluded hospital that screeed with ultrasoud UHC collected ad maaged the data for data aalysis. UCD team performed data aalysis. 8 9 VTE Performace Measures Percetage of TKR patiets who were started o appropriate* before surgery Percetage of TKR patiets who received appropriate* postop after surgery * Appropriate subset icluded percetage of patiets who received: Appropriate aget Appropriate aget with recommeded dosig Appropriate aget at recommeded times Appropriate aget cotiued postdischarge Percetage of TKR patiets who were prescribed cotiued after discharge after idex admissios (all agets) Results Percetage of TKR patiets who ambulated i room 24 h after surgery (with or without the use of a cae or walker) Media time postop util ambulatig i room (with or without the use of a cae or walker) Percetage of TKR patiets w/idex or late DVT idetified by routie screeig (i.e., tests performed i all patiets idepedet of documeted cliical cocer for PE or VTE i particular patiets) 0 2

3 Study Sample Sample Characteristics 93 TKA Chart Abstracted 3 Cases 462 Cotrols Cofirmed VTE No VTE Female 63% Media age = 63 y Cases vs Cotrols: No differeces with regard to geder, race, payer type, or comorbidities Age by Rage (y) 28 = = 326 = Had DVT Aloe Had PE 3 Had DVT + PE Race/Ethicity % () White 72% (428) Payer % () Medicare/Mgd Care 48% (286) Upper Extremity Subclavia 2 Superficial Sapheous Vei 70 Lower Extremity DVT Black 8% (0) Hispaic 6% (3) Asia 2% (2) Other 2% (2) Ukow % (6) Native America/ Eskimo 0.8% () Private 34% (0) Medicaid/Mgd Care 9% () Other % (28) Ukow 3% (8) US/State/Local Govt % (6) Noe/Uis/Self-pay 0.7% (4) 2 3 Comorbidities Pharmacologic ad Mechaical Prophylaxis i Cases ad Cotrols Top Comorbidities Cases With VTE, (%) Cases Without VTE (%) Hypertesio 92 (70%) 3 (67%) Diabetes 29 (22%) 00 (22%) History of maligacy 0 (8%) 3 (2%) Prior history of DVT or PE 7 (%) 2 (9%) Curret eoplasm 4 (3%) 9 (7%) Documeted history/risk of bleedig 3 (2%) 7 (%) Pharmacologic Prophylaxis LMWH/ hepari Eoxapari/daltepari/fodapariux, ufractioated hepari subcutaeous VTE = Yes = 29 VTE = No = % 48% Warfari aloe (o LMWH) 33% 3% BMI Rage Cases With VTE (3), (%) Cases Without VTE (462), (%) 30 2 (40%) 9 (4%) (6%) 9 (%) (8%) 93 (%) (22%) 74 (6%) No data 6 (%) 3 (3%) Mechaical Prophylaxis Itermittet peumatic compressio device, graduated compressio stockigs/foot pump The umbers are mutually exclusive withi each stratum. 2% % No Percetage of Patiets Receivig Appropriate* Postoperative Prophylaxis Percetage of Patiets Who Ambulated i Room 24 h After Surgery (With or Without Cae or Walker) 4.9% (272/93) of TKR patiets received appropriate postop Hospital Performace: Mea: 48% SD: 27.9% Media: 2% Rage: 2.4%-90.% As defied by ACCP guidelies for postop : Cases with documetatio that eoxapari was give 30 mg q2 SC started withi 2-24 h post surgery; fodapariux 2. mg SC started withi 8 h post surgery; ad/or warfari 2-0 mg PO started withi2 h post surgery, prescribed postdischarge. 6.% (267/437) of TKR patiets ambulated i room 24 h after surgery Hospital Performace: Mea: 4.9% SD: 2.2% Media: 9.7% Rage: 0.0%-8.4% *For postoperative appropriateess, aget, dose, timig, ad prescribed post discharge were cosidered. Percetage of Patiets Receivig Appropriate Prophylaxis After Surgery 00% % % Media 28 40% 2 27 % % 00% 80% 60% 40% % 0% Media 2 23 Percetage Who Ambulated i Room 24 h After Surgery (With or Without the Use of a Cae or Walker) Numbers above bars idicate the umber of cases with available time data. Numbers above bars idicate the umber of cases with data available

4 Percetage of Cases Time to Ambulatio Process Effects o Outcomes Withi 2 hours 2 up to up to up to up to to 96 hours Greater tha 96 hours hours hours hours hours With VTE Evet Without VTE Evet Pharmacologic Prophylaxis Patiets receivig appropriate pharmacologic Patiets ot receivig appropriate pharmacologic Ambulatio (42.7%) 26 (46.8%) 32 7 (7.3%) 246 (3.2%) Patiets ambulatig 24 h (36.6%) 29 (47.4%) Patiets ambulatig > 24 h (32.8%) 27 (27.%) Patiets w/o date/time of ambulatio documeted 6 40 (30.%) 6 (2.%) First Postop Prophylaxis Timig Patiets receivig st postop dose withi 24 h (62.6%) 326 (70.6%) Patiets receivig st postop dose h 4 2 (9.2%) 29 (6.3%) Patiets receivig st postop dose > 36 h 4 0 (7.6%) 4 (0.9%) Isufficiet date/time data or o postop (.6%) 03 (22.3%) 8 9 Multivariate Aalysis Fidigs Prophylaxis Rates by Surgical Case Load Multivariate adjusted odds ratios ad 9% cofidece itervals Outcome: Ay VTE evet diagosed day 2 after surgery or later Excluded hospital that screeed TKR patiets routiely for VTE 86 surgeos performed the 93 total kee surgeries i this study. Predictive Factor Odds Ratio (9% CI) P Value Age.02 ( ).2 Geder (ref: male).40 ( ).2 Ambulatio (ref: o ambulatio) Takig steps day or 2 Takig steps after day 2 Type of TKR (ref: uilateral TKR) 0.30 ( ) 0.67 ( ) <.0.6 Bilateral TKR 3.30 ( ) <.0 Pharmacological (ref: oly mechaical ) 0.0 (0.-.09).07 BMI 3 (ref: BMI < 3) 0.94 ( ).82 No. of Cases per Surgeo No. of Surgeos i This No. of Patiets Who Received Appropriate Postop Prophylaxis No. of Cases i This Rate of Appropriate Prophylaxis i This % % % % or more % 2 Discussio Expected fidig: Not developig VTE was associated with receivig pharmacologic thrombo. (OR = 0., P = 0.07) Discussio Iterestig but ot uexpected fidigs: Bilateral TKR was associated with higher odds of VTE. (OR = 3.3, P = <0.0) Early mobilizatio was associated with lower odds of VTE. (OR = 0.3, P = <0.0) Uexpected fidig: Prophylaxis was as effective i morbidly obese as i less obese patiets

5 Key Take-Aways Ambulatio withi 48 hours was associated with a 70% reductio i the risk of VTE. Although is typically the focus of VTE prevetio strategies, this fidig demostrates that early ambulatio, a ursig ad physical therapy fuctio, directly affects this importat health care outcome. Prophylactic regimes vary widely across physicia practices ad orgaizatios. Orgaizatios are ot followig guidelie-drive for TKR surgery patiets. Drivers to Improve Outcomes Istitute a protocol for early ambulatio of TKR patiets (withi 24 hours postop) Focus o timig of first postop dose of pharmacologic Reduce orgaizatioal variatio Stadardize guidelies withi your orgaizatio Itegrate stadardizatio ito order sets 24 2 Cotact: Marily Szekedi, PhD, RN szekedi@uhc.edu