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May 2013 Vol 97 No 5 • AORN Connections | C7 http://dx.doi.org/10.1016/S0001-2092(13)00396-7 © AORN, Inc, 2013 VTE Continued on C8 R esearch from the UC Davis Medical Center, Sacramento, Calif., recently published electronically by the Journal of Surgical Research, offers clinicians hope of predicting which patients are at the highest risk for developing postoperative venous thromboembolism (VTE). 1,2 Associate Professor of Surgery Dr. Robert Canter and his team used the medical histories of more than 470,000 surgical patients from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data File to establish factors that increase VTE risk. 3,4 Next, they created a nomogram, a type of graphical calculating device, 5 to assist clinicians in 30-day VTE risk predictions for individual perioperative patients. Based on the extent of data analyzed and the unique application of the nomogram, the study provides a more logical and in-depth approach to predicting VTE than has been applied in previous studies. The incidence of VTE in the United States continues to be high, despite efforts directed toward its reduction. 6 Postoperative VTE, including both deep vein thrombosis and pulmonary embolism, is increasingly considered a quality of care metric and a preventable cause of morbidity and mortality by The Joint Commission, as well as the Centers for Medicare & Medicaid Services. 7,8 Postoperative VTE is reportable under the Surgical Care Improvement Project 9,10 and it is one of the Patient Safety Indicators of the Agency for Healthcare Research & Quality’s Clinical Practice Guidelines. 11 It also qualifies as a serious morbidity variable in the ACS NSQIP profile. In an effort to prevent postoperative VTEs in general surgery patients, the American College of Chest Physicians outlined risk stratification strategies in 2008, categorizing patients as being at low, intermediate, and high risk for VTE. 12 Although helpful, the lack of individualized patient assessment of postoperative VTE risk limited the ability to generalize strategies across other surgical populations. However, the opposite approach of not using any risk-assessment tool left clinicians with the option of adopting an unsatisfactory one-size-fits-all approach. There have been several aempts to address this issue, 13,14 but prior to the UC Davis study, no one had so comprehensively examined the variety of factors that contribute to VTE risk. 2,3 The UC Davis team’s goal was to identify VTE events within 30 days of surgery, both pre- and post-discharge. Elements, such as individual patient demographics and medical history specifics (e.g., age, elevated body mass index, preoperative infection, cancer), were factored into the study. Other elements included surgical approach, specific procedure type, and major postoperative complications. 2,3 One unexpected and significant finding was that the risk indicated by the UC Davis study deviated distinctly from Joint Commission risk appraisals. Under The Joint Commission’s current guidelines, patients having emergency hernia repair and cancer patients having laparoscopic hemicolectomies would be considered at equal risk. However, using UC Davis’ nomogram to calculate risk, the hernia patient would have a less than 5 percent risk of developing a postoperative VTE, whereas the cancer patient would have a 10 percent risk. 1,3,8 Calculating postoperative VTE risk using the nomogram could allow clinicians the opportunity to precisely respond to each patient individually in a manner that achieves patient safety and advances robust patient outcomes. The research needs further validation, but New research offers hope of predicting postoperative VTE risk Margaret Wasserman, BSN, RN
