Naji Isaid Emad, Joudeh Anwar I, Shereef Nijab, Sirjuddin El Hareth, Aboubaker Naseera, Abdelfattah-Arafa Eiman, Mohammad Rehab, Charles Hemalatha, Macalimbon Joseph, Ghadban Wissam
General Medicine, Alkhor hospital, Hamad Medical Corporation, Doha, Qatar.
Internal Medicine Department AlKhor hospital, Hamad Medical Corporation, Doha, Qatar
BMJ Open Qual. 2025 Jun 23;14(2):e003239. doi: 10.1136/bmjoq-2024-003239.
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.
静脉血栓栓塞症(VTE),包括深静脉血栓形成和肺栓塞,对住院患者构成重大威胁,影响发病率、死亡率和医疗成本。尽管有有效的预防措施,但依从率仍然参差不齐。在卡塔尔的阿尔霍尔医院,由于评估工具使用有限和记录不一致,只有40%的中高危患者在入院24小时内最初接受了适当的VTE预防措施。为了解决这个问题,一个包括医生、护士、药剂师和质量改进人员在内的多学科团队应用了一个带有多个计划-执行-研究-行动循环的质量改进框架,以实施标准化的VTE风险评估工具。每月监测风险评估完成率和预防措施给药率,以医院获得性VTE和与预防相关的出血作为平衡指标。一份全面的VTE风险评估和预防表格被整合到电子病历(EMR)中,并在每个部门的“超级用户”支持下开展了培训课程。实施导致依从率最初上升,在EMR转换后出现波动,最终稳定下来并显示各部门的依从性有所提高。持续的支持和多学科倡导者对维持这些成果起到了重要作用。标准化评估工具、EMR整合和定期培训显著提高了VTE预防的依从性。该项目强调了结构化的、基于团队的方法在预防医院获得性VTE方面的价值,为类似的医疗环境提供了一个模式。