PREVENTABLE CAUSE OF DEATH Venous thromboembolism occurs when a blood clot forms in deep veins in the legs, travels to another part of the body and blocks blood flow to vital organs such as the lungs.

Concern spreads through the staff at Memorial University Medical Center in Savannah, Ga., if a patient doesn't get a sequential compression device or subcutaneous heparin before a case starts. Surgeons and staff have been conditioned to second-guess decisions to start cases that don't include some type of prophylaxis against deep venous thrombosis. "The culture here is such that if a patient is not being prophylaxed for DVT, we want to know why," says Carl R. Boyd, MD, FACS, Memorial's medical director of perioperative services. That bodes well for Memorial, because Medicare is now linking hospital reimbursements to how well facilities ensure recommended venous thromboembolism prophylaxis is administered.

Memorial wasn't always so vigilant about preventing blood clots from forming after surgery. It wasn't until the hospital began participating in the National Surgical Quality Improvement Program a few years ago that it made DVT prevention a top priority for performance improvement. Hospitals participating in NSQIP, a national benchmarking program administered by the American College of Surgeons, report on 9 categories of surgical complications, including pulmonary embolism and venous thrombosis. NSQIP reports back to hospitals how they're doing compared to national benchmarks.

'Heparin or hose'
There's nothing complicated about DVT prevention. An injectable anticoagulant, compression boots or elastic stockings alone or in combination are effective at keeping blood flowing and decreasing DVT risk.

"You have to have an index of suspicion to prevent DVT," says Edward Mackay, MD, FACS, RVT, RPVI, a vascular surgeon from St. Petersburg, Fla., of the several factors that will alert you to a patient who's at risk for clotting.

• Patient history. Screen patients based on age (risk rises steadily from age 40), obesity, malignancy, history of DVT or PE, immobilization (bed rest, paralysis of legs, plaster casts), pregnancy and puerperium, and oral contraceptive use. "Patients with acquired (cancer) or inherited (lupus) hypercoaguable states are at risk, says Dr. Mackay. "When the blood's not flowing well, clots can form," he says. Patients with inflammatory bowel disease (IBD) undergoing surgery are at increased risk for developing DVT or PE. The risk appears to be even higher for patients with IBD who are having non-intestinal surgery, according to a study in the February 2012 Archives of Surgery.

• Type of surgery. Hip and knee surgery, venous procedures, abdominal surgery, gynecological surgery (particularly in older women) and major surgery lasting longer than 30 minutes are associated with significant risk.

• Type of anesthesia. Recent studies have also suggested that the type of anesthesia used can influence the degree of thrombosis risk. Spinal and epidural anesthetics seem to be less thrombogenic than general anesthesia.

PREVENTION At least 90% of pulmonary emboli are thought to originate in major leg veins. Intermittent pneumatic leg compression enhances blood flow in the deep veins.

Fast Facts About Pulmonary Embolism

• Remains the most common preventable cause of death in hospitals.
• 80% of PE occurs without symptoms.
• Two-thirds of deaths occur within 30 minutes.

— Dan O'Connor

"If you've got a healthy 45-year old getting inguinal hernia repair, does he really need DVT prophylaxis? Yes, he does," says Dr. Boyd. "Too often, we think we don't need to do anything for these patients. 'It's just outpatient hernia,' we'll say. But we're not being diligent enough in identifying patients who need prophylaxis."