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MP92-01 SAFETY AND EFFICACY OF POST-OPERATIVE EXTENDED-DURATION VENOUS THROMBOEMBOLISM PROPHYLAXIS IN HIGH-RISK UROLOGIC ONCOLOGY PATIENTS
THE JOURNAL OF UROLOGYâ
e1226
Vol. 197, No. 4S, Supplement, Tuesday, May 16, 2017
General & Epidemiological Trends & Socioeconomics: Quality Improvement & Patient Safety II Moderated Poster 92 Tuesday, May 16, 2017
7:00 AM-9:00 AM
MP92-01 SAFETY AND EFFICACY OF POST-OPERATIVE EXTENDED-DURATION VENOUS THROMBOEMBOLISM PROPHYLAXIS IN HIGH-RISK UROLOGIC ONCOLOGY PATIENTS Russell Terry*, Mohit Gupta, Michael Blute, Paul Crispen, Gainesville, FL INTRODUCTION AND OBJECTIVES: Patients undergoing major urologic oncology surgery are at risk for post-operative venous thromboembolic events (VTE). The development of VTE following surgery often presents clinically after discharge and is associated with potentially significant morbidity and mortality. At present there is little published data on the safety and efficacy of extended duration venous thromboembolism prophylaxis (EDVTP) beyond the time of hospital discharge in urologic oncology patients. In this study, we evaluate the use of EDVTP for post-operative high-risk urologic oncology patients. METHODS: All patients undergoing major urologic oncology surgery by a single surgeon at our institution from April 2015 to present were evaluated for their risk for VTE using the Caprini risk assessment model. Patients considered high-risk (Caprini score 5) were discharged on post-operative EDVTP according to 2012 ACCP guidelines. 28 days of postoperative subcutaneous enoxaparin was considered the standard of care in eligible patients. These patients were prospectively monitored for the development of clinically symptomatic VTE within 30 days postoperatively and for adverse effects of EDVTP. RESULTS: 150 patients who underwent major urologic oncology surgery were considered to be at high VTE risk based on Caprini score of 5. Average patient age was 63.3 years and 68% of the patients were male. Surgical procedures performed included 39% radical cystectomy, 29% nephrectomy, 16% partial nephrectomy and 16% other. Average Caprini score was 7. Of these, 75% were candidates to receive a 28 day course of enoxaparin EDVTP. The most common reasons for the 25% of patients not receiving standard enoxaparin EDVTP included renal insufficiency (31%), atrial fibrillation requiring oral anticoagulation (26%), and previously diagnosed VTE requiring therapeutic anticoagulation (16%). Adherence to guidelines was not associated with any VTE prophylaxis complications. There were also no noted complications from the use of enoxaparin. The rate of observed 30-day symptomatic VTE in this population was 0%, with an anticipated rate of >5% based upon Caprini score. CONCLUSIONS: Post-operative use of EDVTP appears to be a safe and effective way to decrease the risk of VTE in high-risk urologic oncology patients. Additional data from larger registries is needed to evaluate and confirm the benefit gained and need for use of EDVTP in this patient population. Source of Funding: None
MP92-02 BPA ALERT EFFECT ON CAUTIS HOSPITAL-WIDE AT UIHC Colette Gnade*, Douglas Storm, Patrick Ten Eyck, Iowa City, IA INTRODUCTION AND OBJECTIVES: Catheter associated urinary tract infections (CAUTIs), the most common hospital-acquired
infection, increase hospital cost, length of stay, morbidity/mortality and time/wages lost for patients. In an effort to reduce the CAUTI rate, our hospital instituted a Best Practice Alert (BPA) reminder within our inpatient electronic medical record system in 2013. To determine the effect of this BPA, we compared the CAUTI rate and number of urinary catheter days before and after 2013, hypothesizing that this BPA reduced both variables. METHODS: A retrospective review was performed utilizing our institution0 s inpatient database from 2011-2016. All CAUTIs were defined using the 2013 CDC guidelines. Generalized linear mixed modeling was used to estimate the effects of variables of interest on catheter utilization (CU) and CAUTI rates. CU and CAUTI rates were measured using a binomial distribution with a logit link and were also compared between ICU, general adult and general pediatric wards. RESULTS: Data from 1,102,803 patient days accounting for 227,256 catheter days was evaluated. Between 2011 and 2013, there was a 1.9% decrease per month (p value < 0.0001) in CU rates. Comparing the years of 2013 to 2016, there was less significant decrease at 1.3% per month (p value < 0.0001) in CU rates. Between 2012 and 2016, there was not a significant decrease in CAUTIs despite a decrease in CU rates (0.01% per month, p value 0.846). We also found a lower relative rate in overall CU rate in pediatrics (-3.14, p value < 0.001) as compared to adult units and a higher rate in overall CU rates in the ICU setting (2.04, p value 0.003) as compared to the nonICU setting. CONCLUSIONS: Our study shows that there is a decrease in CU rates, but no effect on CAUTI rates with the BPA alert. This suggests that factors resulting in CAUTIs are multifactorial and not just limited to length of catheter use. These additional factors may be difficult to control, and perhaps are intrinsic to the patient and their disease process, making some CAUTIs difficult to prevent, despite limiting catheter use. This may result in a plauteau in a hospital0 s overall CAUTI rate, despite following recommended best practices. Source of Funding: None
MP92-03 TRANSVERSUS ABDOMINIS PLANE BLOCKADE AS PART OF A MULTIMODAL POSTOPERATIVE ANALGESIA PLAN IS ASSOCIATED WITH IMPROVED POSTOPERATIVE OUTCOMES IN RADICAL CYSTECTOMY PATIENTS Richard Matulewicz*, Mehul Patel, Jacqueline Morano, Brendan Frainey, Yasin Bhanji, Anton Nader, Shilajit Kundu, Joshua Meeks, Chicago, IL INTRODUCTION AND OBJECTIVES: Enhanced recovery protocols (ERP) after radical cystectomy (RC) focus heavily on GI recovery since prolonged postoperative ileus is associated with an increased risk of complications and longer length of stay (LOS). Recently, novel multimodal pain management plans have been used in conjunction with ERPs to either reduce the use of narcotics postoperatively or prevent their side effects. We examine the benefits of continuous transversus abdominis plane (TAP) blockade with a local anesthetic as part of a post-RC pain regiment. METHODS: A retrospective comparison of consecutive patients undergoing RC over a 4-year period was conducted. Patients were designated as having RC during either the pre-TAP or TAP era. Patient demographics, operative details, and perioperative outcomes were compared between the two cohorts. Median days to flatus, bowel movement (BM), LOS, and narcotic usage (converted to milligrams of morphine equivalents) were compared using the Mann-Whitney Test. RESULTS: In total, 171 patients were included: 100 pre-TAP and 71 TAP. There were no differences in age, smoking status, operative approach (robot vs. open), or urinary diversion type between the two cohorts. The TAP group had fewer men (69% vs. 83%, p¼0.03) and more patients who received neoadjuvant chemotherapy (38% vs. 21%, p¼0.015). The TAP cohort had significantly better GI
e1226
Vol. 197, No. 4S, Supplement, Tuesday, May 16, 2017
General & Epidemiological Trends & Socioeconomics: Quality Improvement & Patient Safety II Moderated Poster 92 Tuesday, May 16, 2017
7:00 AM-9:00 AM
MP92-01 SAFETY AND EFFICACY OF POST-OPERATIVE EXTENDED-DURATION VENOUS THROMBOEMBOLISM PROPHYLAXIS IN HIGH-RISK UROLOGIC ONCOLOGY PATIENTS Russell Terry*, Mohit Gupta, Michael Blute, Paul Crispen, Gainesville, FL INTRODUCTION AND OBJECTIVES: Patients undergoing major urologic oncology surgery are at risk for post-operative venous thromboembolic events (VTE). The development of VTE following surgery often presents clinically after discharge and is associated with potentially significant morbidity and mortality. At present there is little published data on the safety and efficacy of extended duration venous thromboembolism prophylaxis (EDVTP) beyond the time of hospital discharge in urologic oncology patients. In this study, we evaluate the use of EDVTP for post-operative high-risk urologic oncology patients. METHODS: All patients undergoing major urologic oncology surgery by a single surgeon at our institution from April 2015 to present were evaluated for their risk for VTE using the Caprini risk assessment model. Patients considered high-risk (Caprini score 5) were discharged on post-operative EDVTP according to 2012 ACCP guidelines. 28 days of postoperative subcutaneous enoxaparin was considered the standard of care in eligible patients. These patients were prospectively monitored for the development of clinically symptomatic VTE within 30 days postoperatively and for adverse effects of EDVTP. RESULTS: 150 patients who underwent major urologic oncology surgery were considered to be at high VTE risk based on Caprini score of 5. Average patient age was 63.3 years and 68% of the patients were male. Surgical procedures performed included 39% radical cystectomy, 29% nephrectomy, 16% partial nephrectomy and 16% other. Average Caprini score was 7. Of these, 75% were candidates to receive a 28 day course of enoxaparin EDVTP. The most common reasons for the 25% of patients not receiving standard enoxaparin EDVTP included renal insufficiency (31%), atrial fibrillation requiring oral anticoagulation (26%), and previously diagnosed VTE requiring therapeutic anticoagulation (16%). Adherence to guidelines was not associated with any VTE prophylaxis complications. There were also no noted complications from the use of enoxaparin. The rate of observed 30-day symptomatic VTE in this population was 0%, with an anticipated rate of >5% based upon Caprini score. CONCLUSIONS: Post-operative use of EDVTP appears to be a safe and effective way to decrease the risk of VTE in high-risk urologic oncology patients. Additional data from larger registries is needed to evaluate and confirm the benefit gained and need for use of EDVTP in this patient population. Source of Funding: None
MP92-02 BPA ALERT EFFECT ON CAUTIS HOSPITAL-WIDE AT UIHC Colette Gnade*, Douglas Storm, Patrick Ten Eyck, Iowa City, IA INTRODUCTION AND OBJECTIVES: Catheter associated urinary tract infections (CAUTIs), the most common hospital-acquired
infection, increase hospital cost, length of stay, morbidity/mortality and time/wages lost for patients. In an effort to reduce the CAUTI rate, our hospital instituted a Best Practice Alert (BPA) reminder within our inpatient electronic medical record system in 2013. To determine the effect of this BPA, we compared the CAUTI rate and number of urinary catheter days before and after 2013, hypothesizing that this BPA reduced both variables. METHODS: A retrospective review was performed utilizing our institution0 s inpatient database from 2011-2016. All CAUTIs were defined using the 2013 CDC guidelines. Generalized linear mixed modeling was used to estimate the effects of variables of interest on catheter utilization (CU) and CAUTI rates. CU and CAUTI rates were measured using a binomial distribution with a logit link and were also compared between ICU, general adult and general pediatric wards. RESULTS: Data from 1,102,803 patient days accounting for 227,256 catheter days was evaluated. Between 2011 and 2013, there was a 1.9% decrease per month (p value < 0.0001) in CU rates. Comparing the years of 2013 to 2016, there was less significant decrease at 1.3% per month (p value < 0.0001) in CU rates. Between 2012 and 2016, there was not a significant decrease in CAUTIs despite a decrease in CU rates (0.01% per month, p value 0.846). We also found a lower relative rate in overall CU rate in pediatrics (-3.14, p value < 0.001) as compared to adult units and a higher rate in overall CU rates in the ICU setting (2.04, p value 0.003) as compared to the nonICU setting. CONCLUSIONS: Our study shows that there is a decrease in CU rates, but no effect on CAUTI rates with the BPA alert. This suggests that factors resulting in CAUTIs are multifactorial and not just limited to length of catheter use. These additional factors may be difficult to control, and perhaps are intrinsic to the patient and their disease process, making some CAUTIs difficult to prevent, despite limiting catheter use. This may result in a plauteau in a hospital0 s overall CAUTI rate, despite following recommended best practices. Source of Funding: None
MP92-03 TRANSVERSUS ABDOMINIS PLANE BLOCKADE AS PART OF A MULTIMODAL POSTOPERATIVE ANALGESIA PLAN IS ASSOCIATED WITH IMPROVED POSTOPERATIVE OUTCOMES IN RADICAL CYSTECTOMY PATIENTS Richard Matulewicz*, Mehul Patel, Jacqueline Morano, Brendan Frainey, Yasin Bhanji, Anton Nader, Shilajit Kundu, Joshua Meeks, Chicago, IL INTRODUCTION AND OBJECTIVES: Enhanced recovery protocols (ERP) after radical cystectomy (RC) focus heavily on GI recovery since prolonged postoperative ileus is associated with an increased risk of complications and longer length of stay (LOS). Recently, novel multimodal pain management plans have been used in conjunction with ERPs to either reduce the use of narcotics postoperatively or prevent their side effects. We examine the benefits of continuous transversus abdominis plane (TAP) blockade with a local anesthetic as part of a post-RC pain regiment. METHODS: A retrospective comparison of consecutive patients undergoing RC over a 4-year period was conducted. Patients were designated as having RC during either the pre-TAP or TAP era. Patient demographics, operative details, and perioperative outcomes were compared between the two cohorts. Median days to flatus, bowel movement (BM), LOS, and narcotic usage (converted to milligrams of morphine equivalents) were compared using the Mann-Whitney Test. RESULTS: In total, 171 patients were included: 100 pre-TAP and 71 TAP. There were no differences in age, smoking status, operative approach (robot vs. open), or urinary diversion type between the two cohorts. The TAP group had fewer men (69% vs. 83%, p¼0.03) and more patients who received neoadjuvant chemotherapy (38% vs. 21%, p¼0.015). The TAP cohort had significantly better GI