Achieving durable compliance with venous thromboembolism prophylaxis in bariatric surgery: 3-year data from a major academic medical center

Danny Mou; Elissa Falconer; Melissa Majumdar; Tori Delgado; Katherine Fay; Carrie E Hall; Carla Smach; Shanza Ashraf; Sydnee Levett; Edward Lin; Scott Davis; Ankit Patel; Jamil Stetler; Federico Serrot; Jahnavi Srinivasan; Omobolanle Oyefule; Maggie Diller; Elizabeth Hechenbleikner

doi:10.1016/j.soard.2023.08.008

Achieving durable compliance with venous thromboembolism prophylaxis in bariatric surgery: 3-year data from a major academic medical center

Surg Obes Relat Dis. 2024 Jan;20(1):72-79. doi: 10.1016/j.soard.2023.08.008. Epub 2023 Aug 16.

Authors

Danny Mou¹, Elissa Falconer², Melissa Majumdar², Tori Delgado², Katherine Fay², Carrie E Hall², Carla Smach³, Shanza Ashraf⁴, Sydnee Levett⁵, Edward Lin², Scott Davis², Ankit Patel², Jamil Stetler², Federico Serrot², Jahnavi Srinivasan², Omobolanle Oyefule², Maggie Diller², Elizabeth Hechenbleikner²

Affiliations

¹ Department of Surgery, Emory University, Atlanta, Georgia. Electronic address: Danny.mou@emory.edu.
² Department of Surgery, Emory University, Atlanta, Georgia.
³ Department of Surgery, Emory University, Atlanta, Georgia; Emory University School of Nursing, Atlanta, Georgia.
⁴ Department of Surgery, Emory University, Atlanta, Georgia; Emory University Office of Quality, Atlanta, Georgia.
⁵ Department of Surgery, Emory University, Atlanta, Georgia; University of Miami, Miami, Florida.

PMID: 37684191
DOI: 10.1016/j.soard.2023.08.008

Abstract

Background: Metabolic and bariatric surgery (MBS) venous thromboembolism (VTE) prescribing practices vary widely. Our institutional VTE prophylaxis protocol has historically been unstandardized.

Objectives: To create a standardized MBS VTE prophylaxis protocol, track protocol compliance, and identify barriers to protocol compliance and address them with Plan-Do-Study-Act (PDSA) cycles.

Setting: Single Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program-accredited academic hospital.

Methods: We conducted a retrospective study for all patients undergoing MBS (January 2019 to September 2022). A multidisciplinary group of bariatric clinicians reviewed literature and developed the following standardized VTE prophylaxis protocol: 5000 units preoperative subcutaneous (SC) heparin within 60 minutes of anesthesia induction and postoperative 40 mg SC low molecular weight heparin (LMWH) within 24 hours of surgery. This protocol was distributed to relevant clinical stakeholders. We assessed monthly compliance rates through chart review. Goal compliance was ≥90%. We identified sources of noncompliance and addressed them with PDSA methodology.

Results: A total of 796 patients were included. Preoperative heparin administration increased from a mean of 47% (107/228) preintervention to 96% (545/568) postintervention (P < .0001), and postoperative LMWH administration increased from 71% (47/66) to 96% (573/597, P = .0002). These compliance rates were sustained for 3 years. Barriers to protocol noncompliance included order set timing errors (n = 45), surgeon error (n = 44), surgeon discretion (n = 40), and nursing error (n = 20). No change in bleeding or VTE rates was observed.

Conclusions: Developing a standardized VTE prophylaxis protocol, monitoring process measures, and engaging relevant stakeholders in PDSA cycles resulted in drastic and durable improvement in VTE prophylaxis compliance rates.

Keywords: Bariatric surgery; Compliance; Pulmonary embolus; Quality improvement; Venous thromboembolism prophylaxis.

MeSH terms

Academic Medical Centers
Anticoagulants / therapeutic use
Bariatric Surgery*
Heparin / therapeutic use
Heparin, Low-Molecular-Weight / therapeutic use
Humans
Postoperative Complications / drug therapy
Postoperative Complications / prevention & control
Retrospective Studies
Venous Thromboembolism* / etiology
Venous Thromboembolism* / prevention & control

Substances

Heparin, Low-Molecular-Weight
Anticoagulants
Heparin