John R. Tongue, MD
In May, the American Academy of Orthopaedic Surgeons adopted a new set of clinical guidelines addressing the prevention of symptomatic pulmonary embolism (PE) in patients undergoing total hip or knee arthroplasty (see page 10). To help assess the impact of the new guidelines, AAOS Now Executive Editor G. Jake Jaquet spoke with John R. Tongue, MD, a member of the Council on Education who is in private practice in Portland, Ore.
Jaquet: Dr. Tongue, what do you feel will be the overall impact of the new AAOS clinical guidelines on prevention of symptomatic PE in total hip and total knee arthroplasty?
Tongue: Thes guidelines should have a major impact on the practice of orthopaedic surgery. They are much needed and timely because they are based on the best available evidence. They also provide us with a more reasonable alternative to earlier, widely disseminated protocols. These previous protocols have been distributed by well-intended hospital-based quality assurance (QA) committees. We now need to bring these new AAOS guidelines to QA committees. Otherwise, we risk giving implicit acceptance to earlier protocols, which—in my opinion—are not in the best interest of our orthopaedic patients.
Jaquet: How so?
Tongue: In Portland, two large private hospital systems have recently approved and distributed deep vein thrombosis (DVT) prophylaxis protocols. I believe these protocols were strongly influenced by the American College of Chest Physicians (ACCP) guidelines, and promulgated by the National Quality Forum (NQF). Our new AAOS evidence-based guidelines challenge the validity of these previous guidelines, particularly for arthroplasy patients. Our members are now empowered to open a necessary discussion at the community hospital level.
The AAOS guidelines appropriately address symptomatic PE prophylaxis, not DVT prophylaxis. This distinction is important because reducing the incidence of DVT has not been proven to reduce the incidence of fatal PEs. We must emphasize this point in our conversations with hospital QA committees.
Another problem with previous protocols is that they’ve been promoted as single standards that cross all surgical specialties. Currently, the key decision-makers at my hospital are not orthopaedic surgeons. They lack our understanding of the risks of bleeding, hematoma, postoperative anemia, transfusion, wound dehiscence, and infection in arthoplasty patients, particularly when low molecular weight heparin is used. We need to address PE prophylaxis with them, particularly with respect to our choices of anticoagulation agents, because previous guidelines restricted our choices of these medications.
We also need to ask and define who qualifies as a “high-risk” patient. Controversy exists regarding patient risk factor classifications. Some protocols basically state that anyone having a total joint replacement is a high-risk patient, even though some published orthopaedic series consider only about 10 percent of the arthroplasty patients to be high-risk.
Other factors in written PE prophylaxsis protocols may include dosage levels, timing, optimal laboratory test controls levels, and the duration of treatment. In attempting to reduce risks for all surgical patients, earlier protocols are often very specific, despite a lack of Level 1 evidence to support those recommendations.
So, we have a complex issue with diverse, conflicting protocols or guidelines. We should now open a dialogue across all surgical specialties at the medical staff level of our hospitals. Orthopaedic surgeons need to share our perspectives for balancing the risks of peri-operative anticoagulation before previously disseminated protocols become accepted as standard regimens—or perceived as standards of care. These earlier protocols do not protect the best interests of our orthopaedic patients—and their legal implications are potentially quite serious for us as well.
Jaquet: Would you characterize the situation in Portland as being common across the country?
Tongue: I brought this issue up at an open mike session during this year’s National Orthopaedic Leadership Conference. I asked, “How many of you are aware that other protocols have already been distributed in your hospital?” About a third raised their hands, and I suspect many more just didn’t know it had happened.
The existing protocol at my primary hospital system appears to have been written by an individual hospital-based physician, supported by subsequent hospital QA committees, and distributed to our medical staff in the mail. It appears to be have been carefully worked out. I met with the chair of our QA committee to explain my serious concerns regarding this protocol, emphasizing the need to consider changes that will reduce perioperative risks for orthopaedic patients.
I think this issue has been “under the radar” for a lot of medical staffs. They may have seen the protocols and been uncomfortable, but they did not fully realize that an important precedent was being established.
The new AAOS guidelines are a terrific resource, providing us with an orthopaedic-specific, evidence-based protocol we can use in discussions with our individual hospital QA committees. Otherwise, our patients are not well served and our liability exposure, in my mind, increases significantly.
Jaquet: On a practical level, what do you think the effect of going back to those committees will be?
Tongue: I don’t expect a lot of resistance. I think there just hasn’t been a lot of good information available. The AAOS guidelines represent helpful information that should be welcomed. One simple option is to present the AAOS guidelines as an alternative to existing protocols. I think that will be a pretty easy “sell.” But there also should be an open discussion across surgical specialties so other surgeons and all QA committee members understand how our AAOS guidelines improve the balance of risks for our orthopaedic patients. I expect additional patient-care protocols to be developed in the future, resulting from national concerns for reducing medical errors. Although such efforts are well-intended, we need to be involved in discussions that affect orthopaedic patient care.
Jaquet: What do you see as the best strategy for fueling discussion of the new guidelines?
Tongue: I think we have to address it both from the top—with the AAOS presenting the guidelines to national medical organizations and all hospitals—and from the bottom—with individual orthopaedic surgeons presenting and discussing the AAOS guidelines with their institutions. We need to create awareness about the controversy surrounding existing protocols. This is a very important issue because it affects patient care. It is also important for managing our liability exposure.
Jaquet: Is there a role for state societies or specialty societies in this dialog?
Tongue: Because decisions are made at the individual hospital or hospital-system level, specialty societies may play an appropriate role. Certainly their involvement would be helpful. Although this is not an issue that is legislated on a state-wide basis, state societies may also have a role by educating their members of existing local hospital protocols.
Jaquet: And your thoughts looking forward?
Tongue: Once surgeons are made aware of the importance of this issue, they will be interested and concerned enough to act on it. We must keep the dialogue constructive and realize that everyone is trying to do the best thing for the patient. I expect great success getting hospitals to support these AAOS guidelines.
Initially, we face an uphill task, but we must make the effort. Earlier overdrawn protocols have already been widely distributed and adopted. The trick is to open a dialogue—not to try to solve the problem immediately, which can generate resistance. Also, give credit to the hospital QA committees for recognizing patient safety issues, and then help those committees to improve them. Keeping the discussion positive is very important.
After polling other orthopaedic surgeons regarding their usual practices regarding PE prophylaxis at my primary hospital, I have met with our QA committee chairman. We will next meet with our hospital’s surgery committee, medical executive com-mittee, and finally with others within our corporate hospital system. This will all take some time. But, I think everyone wants to do the right thing.