Standardizing VTE prophylaxis in the inpatient setting: A quality improvement project

Abstract Introduction: Venous thromboembolism (VTE) is a major preventable cause of morbidity and mortality in hospitalized patients. Pharmacologic VTE prophylaxis is the mainstay of prevention, but its implementation is inconsistent, often leading to both underuse in high-risk patients and overuse in low-risk populations. The cost of pharmacologic prophylaxis in a standard medical admission in the United States ranges from $200 to $300 per patient, excluding downstream costs of complications. With rising healthcare costs, value-based care, and safety initiatives, real-world evaluations of VTE prophylaxis practices are essential. We present a real-world analysis from a 381-bed community hospital in Central Massachusetts, aiming to describe current DVT prophylaxis practices in a general medicine population, identify patients at risk of inappropriate treatment and develop a hospital-wide protocol to standardize VTE prophylaxis. Methods: We conducted an electronic health records-based retrospective review of all adult patients admitted to the inpatient medicine service between November and December 2023. Demographics, admission diagnoses, comorbidities, and VTE risk factors were collected. VTE risk stratification was performed using the Padua Scale. Inappropriate use was defined as administration of pharmacologic prophylaxis in patients with Padua scores <4 or in the presence of major bleeding contraindications, as well as omission of prophylaxis in high-risk patients without contraindications. Outcomes assessed included frequency of appropriate and inappropriate prophylaxis, prevalence of complications during hospitalization, and distribution of individual Padua risk factors. Results: We reviewed 1,574 medical inpatients (median age 70 years; 49.6% male, 50.4% female). The most common admission diagnosis was urinary tract infection. The mean Padua Prediction Score was 2.61. VTE prophylaxis was administered to 70.7% of patients, though only 59.2% of all patients received it appropriately. Among patients with a Padua score <4 (n=1,097), 245 patients (22.3%) received pharmacologic prophylaxis inappropriately. Conversely, eight patients with a Padua score ≥4 and major contraindications (e.g., active bleeding or high bleeding risk) still received prophylaxis. The mean length of hospital stay was 5.1 days. Breakdown of Padua score components revealed the following prevalence: age ≥70 years (69.4%), obesity (36.3%), active cancer (11.5%), reduced mobility ≥3 days (10.7%), previous VTE (6.9%), and recent trauma/surgery (6.4%). Documented bleeding complications occurred in 0.5% of patients, while VTE events during hospitalization were rare (0.3%). Conclusion: These findings reveal significant discrepancies between guideline-recommended and actual prophylaxis practices in a community hospital setting. Over one-fifth of low-risk patients received unnecessary anticoagulation, while a small but important subset of high-risk patients with bleeding contraindications still received treatment. These patterns reflect not only gaps in risk stratification but also potential over-reliance on defensive medical practices. This real-world data presents an opportunity to optimize VTE prophylaxis through the implementation of a standardized institutional protocol and a focused quality improvement initiative tailored to reduce both overuse and underuse within our hospital.