Key result
The appropriate overall decision to prescribe or withhold low-molecular-weight heparin according to both local and international guidelines was made in 72.2% of medical admissions.
Why the study?
Venous thromboembolism frequently complicates medical admissions, prompting guidelines to promote safe thromboprophylaxis, but adherence to local and international recommendations in a South African hospital remained to be evaluated.
Observational (n=352)
No
In a South African medical cohort, overall adherence to VTE prophylaxis guidelines was 72.2%, though overuse in low-risk patients and incorrect dosing in renal dysfunction remain areas for improvement.
Incomplete VTE prophylaxis guideline adherence warrants caution in practice; leaves open whether targeted interventions improve outcomes.
BACKGROUND: Venous thromboembolism (VTE) complicates a significant proportion of medical admissions. As well as increasing patient morbidity, pulmonary embolism is one of the commonest preventable causes of in-hospital death. An increase in the use of pharmacological preventive measures has been advocated in recent years. South African (SA) and international guidelines have been published in an effort to promote the safe use of VTE prophylaxis. OBJECTIVES: To describe adherence to both local and international recommendations for VTE prophylaxis in an SA hospital with regard to appropriateness of the decision to prescribe or withhold low-molecular-weight heparin (LMWH), and to observe the practice of dose adjustment in special population groups. METHODS: This was a prospective, observational study, and data were collected from consenting adults admitted to the medical wards. We assessed the patients' VTE risk, bleeding risk and the presence of contraindications at the time of LMWH prescription as well as the dose prescribed, specifically taking into consideration adjustment for renal dysfunction and obesity. RESULTS: Three hundred and fifty-two patients were enrolled, of whom 51.4% were male and 58.5% received LMWH. Primary outcomes. The appropriate overall decision according to both SA and international guidelines was made in 254 cases (72.2%). The inappropriate decision according to both guidelines was made in 79 cases (22.4%) and the appropriate decision according to one guideline only was made in 18 cases (5.1%), while 1 case (0.3%) was not categorised. Contraindications to VTE prophylaxis were present in 35 patients (9.9%), but 9 of these patients nevertheless received LMWH. An incorrect dose was prescribed in 36 cases (17.5%), the most common reason being an inappropriate reduction in the dose in mild renal dysfunction. SECONDARY OUTCOMES: Other medications that may have increased bleeding risk were prescribed in 46 patients who received LMWH (22.3%). Mechanical prophylaxis was indicated in 25 (7.1%) of the total sample; however, none received this. CONCLUSIONS: Overall adherence to published guidelines for VTE prophylaxis has improved compared with other published reviews on the topic, but documentation of patients' VTE risk in files is poor. Overuse in low-risk patients may be an unintended consequence of the widespread advocacy of LMWH use in hospital, highlighting the importance of adequate VTE risk stratification. Incorrect dosing in special population groups is an issue that needs to be addressed, as is non-utilisation of mechanical prophylaxis methods.
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Plessis et al. (2020) conducted an observational in Medical admissions at risk for venous thromboembolism (n=352). Low-molecular-weight heparin (LMWH) prescription was evaluated on Appropriate overall decision to prescribe or withhold LMWH according to both South African and international guidelines. The appropriate overall decision to prescribe or withhold low-molecular-weight heparin according to both local and international guidelines was made in 72.2% of medical admissions.
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