DVT prevention in ASCs: Mobile compression post-discharge as the next frontier

Pulmonary embolism is the second leading cause of death in the United States, right behind heart disease. Around 300,000 people die each year due to pulmonary embolism, and deep vein thrombosis impacts more than 2 million Americans annually, however; many of these cases are preventable.

Healthcare providers know the importance of preventing DVT and associated complications. It has become the standard of care at hospitals to use compression devices such as those offered by Midwest Medical, in addition to best practices for patients to prevent post-surgical blood clots.

Now, with more ambulatory surgery centers hosting higher acuity orthopedics cases, DVT prevention protocol is more important than ever. The compression technology traditionally was expensive and cumbersome, but with procedures moving quickly into the outpatient setting, the technology is evolving to include products such as Midwest Medical’s DVTLite/Venowave that improve on the following:

• Fewer wires
• Easier portability
• Bedside accessibility
• Cost-effectiveness

Standard of care
The DVT protocols and prevention are relatively new for ambulatory surgery centers. A decade ago, DVT prevention wasn't the standard of care and providers only used the compression devices with high-risk cases, which often weren't performed in the ASC. Now, however, new studies show compression devices are important for all at risk patients and accrediting bodies are demanding them for around 85 percent of admission.

"The only ones who aren't getting compression are the small number of patients who are not at risk for DVT," says Midwest Medical CEO Richard Parker. "Accrediting agencies would like to see every patient scored with the Caprini risk assessment tool. The AAAHC has a patient safety toolkit and within the toolkit is this DVT risk assessment tool. AAAHC is encouraging ASCs to assess every patient upon admission."

There are around 30 risk factors and most patients present with three to five of the factors, meaning compression would be within the best practices. There are several guidelines built around DVT risk assessment and prevention from organizations such as the American College of Chest Physicians and American Academy of Orthopaedic Surgeons.

Hospitals are paying even more attention to DVTs over the past few years since Medicare placed DVT on the "Never Events" list. Medicare won't reimburse for items on the "Never Events" list, so hospitals lose money treating patients with those conditions.

"It's gotten to the point that Medicare won't pay for the readmission of DVT because they say it should never happen for certain orthopedic procedures," says Mr. Parker. "The big insurers are saying they won't pay either. That's really driving the market because hospitals don't like to pay penalties. What was once a profit center — readmissions for DVTs — is now a cost. ASCs understand that as well and they don't want to risk penalties in the future."

High-risk patients
According to the Centers for Disease Control, around one-half of the people who have DVT have long term complications, including swelling, pain, discoloration and scaling in the affected limb. Around 33 percent of the patients with DVT/PE have recurrence within 10 years.

The Nationwide Inpatient Sample developed through the Agency for Healthcare Research and Quality's Healthcare Cost Utilization Project found venous thromboembolism diagnosis was 2.4 percent overall among adult hospitalizations.

There are higher rates of VTE are seen among these groups:

• Adults 80 years of age or older
• Male
• Black
• Medicare insurance as the primary payer
• No previous operating room procedures of any kind
• Urban hospitals

In addition to DVT risk assessment and compression, providers are also charged with educating patients about DVT risks and prevention.

"With the move of total joints into surgery centers, they will have to develop DVT prevention protocol post-discharge," says Mr. Parker. "We are seeing just about every center interested in total joints and they are looking for devices to send home with patients. The mobile devices we have can go home with patients and combined with aspirin, many physicians are beginning to move away from an anticoagulant regimen post-discharge.”

Making compression mobile
In addition to refining the technology to prevent DVT, providers are concerned with the continuum of care. They want to move patients out of the hospital with excellent homecare that will prevent post-surgical complications and readmissions.

"All the manufacturers and industry personnel recognize the next thing we need to look at is compression devices in the home," says Mr. Parker. "DVTs occur at home after surgery in most cases. To date, the standard of care for post-discharge DVT Prevention has been drugs — anticoagulants. But orthopedists don't like anticoagulants namely for their risk of bleeding complications."

In 2012, compression became an accepted guideline by Association of periOperative Registered Nurses and ACCP standards, and now Compression Devices alone are an accepted standard for preventing DVT. As a result, orthopedic surgeons are now prescribing at-home compression devices to prevent DVT and don’t have to worry about the risk of bleeding that is associated with anticoagulants. Compression devices are also less expensive than the anticoagulant regimen, however; it is most important to use a Mobile Compression Device post-discharge. Patients cannot take home the hospital-designed devices; they are bulky and don't allow patient mobility and ultimately they are not patient compliant, versus their self-contained, 1/2 pound, Mobile Compression Device comparisons, like the DVTLite/Venowave carried by Midwest Medical.

The DVTlite Venowave Compression Device is a tubeless, cordless, battery-operated device. It feels like the patient is being massaged when they wear it and they often feel the benefit. The device’s peristaltic wave plate continuously moves blood up the calf, which is very different from the pneumatic pumps that squeeze the calf once per minute.

"It's easy for the surgeon to see the difference," says Mr. Parker. "Because there is continuous blood movement, there aren't any opportunities for pooling or stasis. If we don't allow the blood to stop moving, there isn't a platform for clots."

Midwest Medical's compression device has undergone a flagship study and the results were good enough for Blue Cross Blue Shield and Healthnet to create medical policy around it. There is good national insurance coverage for the DVTLite/Venowave device post-discharge and ASC’s are now looking at this protocol especially for their discharge Total Joint cases and also high-risk DVT patients.

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