Enhancing venous thromboembolism prophylaxis compliance: a quality initiative for standardised risk assessment in a hospital setting

Venous thromboembolism (VTE), encompassing deep vein thrombosis and pulmonary embolism, poses a significant threat to hospitalised patients, affecting morbidity, mortality and healthcare costs. Despite the availability of effective prophylaxis, adherence rates remain inconsistent. At AlKhor Hospital in Qatar, only 40% of moderate-risk to high-risk patients initially received appropriate VTE prophylaxis within 24 hours of admission due to limited use of assessment tools and inconsistent documentation. To address this, a multidisciplinary team, including physicians, nurses, pharmacists and quality improvement officers, applied a quality improvement framework with multiple Plan-Do-Study-Act cycles to implement a standardised VTE risk assessment tool. Compliance rates for risk assessment completion and prophylaxis administration were monitored monthly, with hospital-acquired VTE and prophylaxis-related bleeding as balance measures. A comprehensive VTE risk assessment and prophylaxis form was integrated into the electronic medical records (EMR), and training sessions were conducted, supported by 'super users' in each department. The implementation resulted in an initial rise in compliance, with fluctuations following the EMR transition, ultimately stabilising and showing improved adherence across departments. Ongoing support and multidisciplinary champions were instrumental in sustaining these gains. Standardised assessment tools, EMR integration and regular training significantly enhanced compliance with VTE prophylaxis. This project underscores the value of structured, team-based approaches in preventing hospital-acquired VTE, providing a model for similar healthcare settings.