Becker's ASC Review

23 Executive Briefing: DVT Prevention for Orthopedic Surgery Sponsored by: H ealthcare is trending toward outpatient procedures, and technological advancements in surgical technique and pain management allow orthopedic surgeons to send their patients home within 24 hours of surgery. However, the pa- tient's needs and care don't end when they leave the hospital. DVT risks Orthopedic surgery patients run the risk of developing deep vein thrombosis if they don't follow best practices post-surgery, which includes compression therapy. The American Academy of Orthopaedic Surgeons and The Joint Commission, among other organizations, recommend performing a strategic risk as- sessment on all patients to mitigate DVT risk factors after patient discharge. According to the CDC, DVT/PE affects around 900,000 people per year in the United States and estimates suggest 60,000 to 100,000 Americans die of DVT/PE annually; although a single hospital or provider may only see a few patients with DVT per year. DVT is the third largest killer in the United States and can create lasting problems for the patient. Patients are at their peek for developing DVT during the first 14 days after surgical inter- vention and 10 percent to 30 percent of people die within one month of diagnosis. "Just undergoing total joint replacement surgery places the pa- tient automatically into a higher risk pool for DVT," says Mark Farrow, President and CEO of Compression Solutions. "When it comes to total joints, there should be no question that some sort of prophylactic care should be used." Other key factors heightening the risk for DVT, according to German physician Rudolph Virchow's Triad, include: • Endothelial injury — the actual trauma of surgery can com- promise the endothelia lining of the blood vessels, which impairs blood flow; • Stasis of blood flow — when patients have limited ambu- lation, there is limited pressure applied to the foot and a dynamic foot pump expedites the return of blood flow to the lower extremity; • Hypocoagulability — surgical trauma can impact the actual constitution of the blood. Orthopedic surgery patients aren't very mobile after surgery — they may have difficulty moving or standing — which places them at higher risk as well. Physicians can prescribe drugs, in- cluding anticoagulants, but there is still a chance the patient will develop a DVT; without the anticoagulants, the risk increases to 50 percent to 70 percent, according to a study published in Blood Coagulants Fibrinolysis. "Clinical anticoagulants have been prescribed for years to re- duce the risk of DVT," says Adolph Lombardi Jr., MD, President of Joint Implant Surgeons in New Albany, Ohio. "However, they carry with them one significant drawback and that is the pos- sibility of the development of postoperative wound hematoma with subsequent drainage. Unfortunately, the consequences of wound hematoma and subsequent drainage can lead to an infection which is obviously one of the more catastrophic com- plications of an orthopedic procedure that involves any type of hardware." Post-surgery patient compliance Compliance is an additional concern. Not all patients are able to take anticoagulants and rely only on intermittent compression, and patients aren't always reliable about taking their medica- tions. Some studies suggest only 25 percent of prescriptions are used to the full regimen. Patients aren't always compliant when they return home. "In an effort to find a safer solution, surgeons have gravitated to the use of aspirin and have combined this with pneumatic compression," says Dr. Lombardi. "The combination has been documented in multiple studies to be extremely beneficial. Pa- tients having orthopedic procedures performed in the ambu- latory surgery center, especially those undergoing arthroplasty of the hip and knee, should be considered for this combined prophylaxis of aspirin and pneumatic compression." Clinical studies published in professional medical journals show using anticoagulants on high risk patients can reduce DVTs by as much as 75 percent, and if you add intermittent compression, the risk factor drops below 1 percent to 3 percent. "Hospitals and ASCs are coming under fire for readmissions. Pa- tients are going home after outpatient surgery and then return- ing to the hospital with DVT, and hospitals aren't paid for the readmission," says Mr. Farrow. "Surgery centers with total joint replacements will start losing money if they don't have quality outcomes, and the physician pay will impacted in 2017. There is a huge push for outcomes-based medicine and making sure the total joint patient doesn't get readmitted." The Continuum From Surgery to Home: Key Thoughts on Post-Orthopedic Surgery DVT By Laura Dyrda

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