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
Disclosures Source of Funding: Washington University Institute of Clinical and Translational Sciences grant UL1 TR000448 from the National Center for Advancing Translational Sciences and National Institute of Diabetes and Digestive and Kidney Diseases Clinical Investigator Award (1K08DK097302-01A1 - SAS)
HHS Blog- 1/26/2015
HHS Blog- 1/26/2015
HHS Blog- 1/26/2015
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%
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
Cystectomy Bundle Decision was made to enact urology cystectomy surgical bundle Decrease VTE Decrease length of stay Decrease readmissions Decrease SSI
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
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
Timeline of Implementation Prior to 2013- Business as Usual Starting January 2013- Epidural Placement March 1, 2014- Surgical implementation of pathway October 1, 2014- Full pathway implementation
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, % 2 3 4 39.3 58.9 0.9 Conduit, % Ileal Conduit Neobladder Indiana pouch Prior chemotherapy, % No Yes Procedure, % Open Robotic 79.3 17.1 3.6 60.5 39.5 67.6 32.4
12 Barnes Jewish Length of Stay (Days) 10 10.2 9.6 8 7.7 6 6 4 2 0 Jan 2012- Dec 2012 Jan 2013- Feb 2014 March 2014- Sept 2014 Oct 2014 to present Number of Patients 89 79 41 59
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.
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!
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
Risk Reduction 55% relative risk reduction 7.2% absolute risk reduction
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 76.0 76.9 92.6 91.7 85.5 Postoperative compliance, % LMWH given subcutaneously daily, starting by end of DOS 51.9 64.3 46.4 77.8 60.0
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
Questions? John A. Brockman brockmanj@wudosis.wustl.edu
Readmission Rate Time Period Intervention Patients Readmission Jan- Dec 2012 84 22.7% Jan 2013-Feb 2014 March- September 2014 Oct 2014 to present Epidurals Added 79 35.1% Surgical Pathway Full Pathway Implemented 41 40% 59 27.6%