Background: The timing of holding direct acting oral anticoagulants (DOACs) prior to surgery and restarting after surgery is crucial to minimize the risks of thromboembolism and bleeding. To reduce these risks hospitals and practices often implement protocols based on the best available evidence and guidelines, such as by the American College of Chest Physicians (1-3). However, the degree to which evidence-based protocols are adhered to in practice is unknown. We performed an administrative database review and random chart abstraction to determine the adherence with the perioperative DOAC protocol at our institution over a five-year period.
Methods: An administrative database review was performed for patients on treatment-dose DOAC undergoing surgery from September 2018 to October 2023 at an urban tertiary care hospital. Data captured included the number of days the DOAC was held pre- and post-operatively, type of surgery, whether spinal anesthesia was utilized, and renal function. The number of days the DOAC was held was compared to the number of days recommended by our institution’s perioperative DOAC protocol. The protocol incorporates the invasiveness of the procedure (minor vs major surgery), renal function, and whether spinal anesthesia was used. The protocol is available on the hospital’s internal web-based policy platform and Pre-Op App. Nonadherence was defined as a ≥1 day deviation from the protocol. Post-operative data on time to resume the DOAC was available for the subset of patients who were admitted after the procedure. Patients undergoing cardiovascular surgery were excluded. A random sample of 50 charts where nonadherence was noted was performed to assess rationale and documentation for deviating from the protocol.
Results: A total of 1073 procedures for patients on treatment-dose DOAC undergoing surgery from September 2018 to October 2023 were examined. Pre-operative renal function was available for 786 (66.1%) patients. Adherence to the protocol was low. Adherence was noted for 194 of 523 (37.1%) procedures preoperatively and 38 of 354 (10.7%) procedures postoperatively. Documentation of a rationale for nonadherence was identified less often in the pre-operative than postoperative period, 25.0% vs 59.5%, respectively. For those patients with documentation of a rationale, preoperative causes leading to holding the DOAC longer than recommended included (1) a plan for spinal anesthesia and (2) patients having multiple procedures over a brief time span. Postoperative causes leading to holding the DOAC longer than recommended included (1) serosanguinous or bloody drainage, (2) awaiting surgical clearance, and (3) using prophylaxis dose rather than treatment dose anticoagulation. Limitations to the administrative database review included misclassification of prophylactic-dose anticoagulation and DOAC orders that are “held” as resuming full anticoagulation.
Conclusions: Adherence to an evidence-based protocol for the peri-operative management of DOACs was low in both the pre-operative and post-operative periods. Pre-operative documentation of a rationale for nonadherence was rare. Real-time electronic guidance and other tools should be considered by hospitals and practices to promote adherence with evidence-based guidelines.