Utilizing Clinical Pharmacy Services to Improve Rates of Venous Thromboembolism in Total Joint Replacement Surgery
MaryAnne Cronin, Pharm.D., Timothy Hill, R.Ph., M.H.A., Brian Pinard, M.D., Eugene S. Krauss, M.D.
Glen Cove Hospital, Glen Cove, New York
Randomized clinical trials have exhibited a 40−60% rate of asymptomatic deep vein thrombosis (DVT) and a 10−30% rate of proximal DVT when no prophylaxis was administered for 7 to 14 days following major orthopedic surgery. Even in recent years with the use of thromboprophylaxis, rates of symptomatic venous thromboembolism (VTE) range from 1.5−10% within 3 months of surgery.1 When a Clinical Pharmacist was added to our institution’s Orthopedic Surgical Team in 2004, opportunities to decrease VTE rates by revising the thromboprophylaxis practice were revealed.
All cases of DVT, pulmonary embolism (PE), and DVT and PE diagnosed at our institution were reviewed retrospectively in 2005. Following data analysis, a Thromboprophylaxis Team, consisting of representatives from the departments of Medicine, General Surgery, Orthopedic Surgery, Anesthesia, Hematology, Rehabilitative Medicine, Pharmacy, Nursing, and Quality Management was established and first convened in February 2006. The team created a Thromboprophylaxis Risk Factor Assessment / Prescriber Order Sheet, reflecting the American College of Chest Physicians (ACCP) guidelines for venous thromboprophylaxis. These recommendations were implemented in the Department of Orthopedic Surgery in April 2006. As part of the implementation process, the Clinical Pharmacist reviewed patient charts daily and attended patient care rounds twice weekly with the Orthopedic Team.
Our 2006 review of VTE in the total joint replacement population revealed that the changes made in clinical practice led to a 48% reduction in overall VTE, from 4.6% to 2.4%. Epidural anesthesia and analgesia (EAA) offer recognized benefits in reducing the risk of VTE irrespective of manual or chemical prophylaxis.2-5 Rates of VTE for 2005 were 4% in the EAA group and 8.7% in the non-epidural group. In 2006, rates were 2.2% in the EAA group and 3.3% in the non-epidural group. We experienced a 45% reduction in VTE in the epidural group and a 62% reduction in the non-epidural group. Incidence of PE overall fell from 0.9% in 2005 to 0.4% in 2006, a 57% reduction. Our most significant reduction in VTE , a 60% decrease, was seen in patients who received warfarin alone as prophylaxis.. Patients receiving warfarin therapy should be bridged with a low molecular weight heparin until the INR is safely in therapeutic range to prevent a protein C deficiency prothrombotic state.6
The Clinical Pharmacist is an indispensable member of the patient care team, and was able to facilitate a significant improvement in rates of VTE in our total joint replacement surgical population.
- Geerts WH, Pineo GF, Heit JA et al. Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004; 126(Suppl 3):S338-400.
- Farag E, Dilger J, Brooks P et al. Epidural analgesia improves early rehabilitation after total knee replacement. J Clin Anesth. 2005; 17:281-5.
- Rodgers A, Walker N, Schug S et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ. 2000; 321:1493.
- Grass, J. The role of epidural anesthesia and analgesia in postoperative outcome. Anesthesiol Clin North America. 2000; 18:407-28, viii.
- Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002; 183:630-41.
- Choueiri T, Deitcher SR. Why shouldn’t we use warfarin alone to treat acute venous thrombosis? Cleve Clin J Med. 2002; 69:546-8.
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