Making safer preoperative arrangements for patients using vitamin K antagonists.

Use of vitamin K antagonists creates a risk for patient
health and safety. The Dutch framework “Nationwide
Standard Integrated Care of Anticoagulation”
propagates a shared plan and responsibility by surgeon
and anesthesiologist together in the preoperative
setting. In our institution, this framework had not been
implemented. Therefore, a quality-improvement project
was started at the Anesthesia Department to improve
perioperative safety.
After exploration of barriers, multiple interventions
were carried out to encourage co-workers at the
preoperative screening department to take shared
responsibility: distribution of prints, adjustments in
electronic patient records, introduction of a protocol
and education sessions. Efficacy was measured
retrospectively performing a before-after study
collecting perioperative data of patients using vitamin K
antagonists. The primary outcome measure was the
percentage of predefined safe preoperative plans.
Secondary outcome measures were (1) incidence of
postoperative bleeding and thrombo-embolic events
within the first 24 hours after intervention and (2)
necessity to preoperative correction of anticoagulation.
Before intervention 72 (29%) safe, 93 (38%)
partially unsafe and 83 (33%) unsafe arrangements
were made. After the intervention these numbers were
105 (80%), 23 (17%) en 4 (3%), respectively: a
significant 51% increase in safe preoperative plans
(P<0.001). We observed no significant difference
(P=0.369) regarding bleeding and thrombo-embolic
events: pre-intervention 12 (5%) cases of postoperative
bleeding were documented, vs. 6 (5%) post
intervention and the number of thrombo-embolic
events was 5 (2%) vs. 0. Also, no significant
differences concerning preoperative correction of
anticoagulation were observed: 11 (4%) vs. 8 (6%)
(P=0.489).
This quality improvement project demonstrates a
major improvement in safer preoperative arrangements
in our institution regarding vitamin K antagonists,
using the described interventions. A significant effect
on bleeding or thrombo-embolic events or necessity to
correction of anticoagulation could not be
demonstrated.