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Implementation of a Perioperative Venous Thromboembolism Prophylaxis Program for Patients Undergoing Radical Cystectomy
Philip J. Cheng, MD, Valerie Haines, RN, MSN, Jill Steinberg, RN, MPH, Peter A. Najjar, MD, MBA, Graeme S. Steele, MD, Quoc-Dien Trinh, MD, Jairam R. Eswara, MD, Steven L. Chang, MD, MS, Adam S. Kibel, MD, Matthias F. Stopfkuchen-Evans, MD, Mark A. Preston, MD, MPH.
Brigham and Women's Hospital, Boston, MA, USA.
BACKGROUND: Patients who undergo radical cystectomy are at high risk for venous thromboembolism (VTE). Prophylactic anticoagulation is routinely used post-operatively following radical cystectomy; however, the rate of deep venous thrombosis and pulmonary embolism remains high. Our enhanced recovery after surgery (ERAS) protocol includes more extensive measures for VTE prevention, including preoperative and post-discharge pharmacologic prophylaxis and early ambulation coupled with mechanical prophylaxis.
METHODS: We utilized the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) to perform a single-institution, retrospective, pre- and post-intervention analysis of a systematic VTE prophylaxis program. The primary end point was 30-day post-operative symptomatic DVT or PE. Our pre-intervention cohort received post-operative pharmacologic and mechanical prophylaxis while our post-intervention ERAS cohort also underwent pre-operative pharmacologic prophylaxis, early ambulation, and—for a majority of the patients—post-discharge prophylaxis for 30 days.
RESULTS: Among 310 patients who underwent radical cystectomy from July 2011 to January 2017, 219 (71%) were in the pre-intervention cohort and 91 (29%) were in the post-intervention cohort, which began in June 2015. Compared with the pre-intervention cohort, patients in the post-intervention cohort demonstrated a significantly lower post-operative VTE rate (6.4%, n = 14 pre-intervention vs 1.1%, n = 1 post-intervention; p = 0.048). The one VTE event in the post-intervention cohort occurred prior to initiation of 30-day post-discharge prophylaxis. There was no increase in bleeding events among the post-intervention cohort.
CONCLUSIONS: VTE prophylaxis should consist of preoperative, post-operative, and post-discharge prophylaxis. A systematic VTE prophylaxis program, including local guideline adaptation, bedside medication delivery, and patient education, was associated with significantly fewer post-operative VTE events among patients undergoing radical cystectomy.
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