Current practice of venous thromboembolic prophylaxis in newly admitted medical Patients at Kenyatta National Hospital

Abstract

BACKGROUND Venous thromboembolism (VTE) prophylaxis has been shown to be safe and effective. Underutilization of this intervention results in avoidable morbidity, readmissions, and mortality. The underutilization of VTE prophylaxis occurs despite there being evidencebased guidelines on VTE prophylaxis from various medical societies. Information on the prevalence of risk in the acute medical hospital care setting is scarce. The evaluation of VTE prophylaxis administration will aid in identifying possible gaps in administration of this life saving measure. OBJECTIVE OF THE STUDY The objective of this study was to determine the level of risk for VTE and prescription of thromboprophylaxis in medical in-patients and assess the knowledge and practice of senior house officers’ (SHO) in the Department of Clinical Medicine and Therapeutics at Kenyatta National Hospital in regard to VTE prophylaxis. STUDY DESIGN Cross sectional descriptive study PARTICIPANTS AND STUDY SITE Eligible newly admitted medical in-patients on their third post admission day at Kenyatta National Hospital, a tertiary referral hospital, and SHOs in the Department of Clinical Medicine and Therapeutics in the University of Nairobi. METHODS Four hundred eligible study patients were selected using a random number generator. They were scored using the Padua Prediction Score and classified as low or high risk. Their medical files were reviewed for thromboprophylaxis prescription. Consenting senior house officers in the Department of Clinical Medicine and Therapeutics in the University of Nairobi training at the Kenyatta National Hospital were invited to fill a validated questionnaire on VTE prophylaxis. DATA MANAGEMENT The data was analyzed using SPSS version 21.0. Descriptive statistics were used to present the results. RESULTS Two hundred and sixty eight (67%) out of 400 were found to be in the high-risk category of VTE. Ninety-eight (36.6%) out of 268 had no prescription of VTE prophylaxis. Seventyeight (19.5%) out of 400 had increased risk for bleeding. Most [164 (71.9%)] were offered unfractionated heparin while 64 (28.1%) were offered enoxaparin with correct prescription in 54 of those patients. Eleven (16.9%) of the residents were unaware of the ACCP 2012 guidelines for VTE prophylaxis. Sixty percent had either never had formal updates or had updates more than a year ago while eleven (16.9%) had not undertaken self-directed updates. In addition, while most (83.2%) felt that a patient who is entitled to VTE prophylaxis should receive it, 81.5%felt that VTE risk assessment was not incorporated into the work flow and 92.3% felt that they were left to make the decision on their own. The preferred agent for VTE prophylaxis was LMWH by 89.2%. This was however not observed in their prescriptions. CONCLUSION A majority of medical patients were at high risk for VTE with only slightly more than half receiving the appropriate action. The residents faced challenges in VTE prophylaxis prescription such as the lack of both VTE risk assessment models, guideline implementation into the workflow of patient care and updates on the existing international guidelines. Key words: Venous thromboembolism, acutely ill medical patients, thromboprophylaxis