Are we preventing VTE in patients with an infective exacerbation of chronic obstructive pulmonary disease - low adherence to VTE prophylaxis guidelines

Abstract Venous thromboembolism (VTE) is a significant cause of morbidity, mortality and increased healthcare costs. Chronic obstructive pulmonary disease (COPD) increases risk of thromboembolism, however, there is limited documentation on compliance with VTE prophylaxis guidelines in patients admitted with an infective exacerbation of COPD. Objective: Determine compliance with National Health and Medical Research Council (NHMRC) VTE prophylaxis guidelines in patients admitted with an infective exacerbation of COPD at a metropolitan hospital in Western Australia. Methods: A random sample of 40 patients with an infective exacerbation of COPD was audited for compliance with NHMRC VTE prophylaxis guidelines. Results: The audit highlighted nominal compliance with documentation of VTE prophylaxis risk assessment (2.5%), documentation of VTE prophylaxis contraindication (0%) and prescription of pharmacological prophylaxis (27.5%). Prophylaxis was prescribed and administered appropriately (correct agent, route & frequency) when it was considered suitable for a patient. Conclusions: There is nominal adherence to VTE prophylaxis guidelines in patients admitted with an infective exacerbation of COPD. VTE prophylaxis compliance rates are steadily increasing within the surgical specialities. This audit highlights the need for quality improvement interventions to increase VTE prophylaxis compliance in patients hospitalized with an infective exacerbation of patients.


ABOUT THE AUTHOR
Anmol Khanna is a medical doctor based in Western Australia. He is interested in research on venous thromboembolism. This article is part of a wider research comparing adherence to VTE prophylaxis guidelines within different medical specialities.

PUBLIC INTEREST STATEMENT
Blood clot in the lung increases healthcare costs and may be fatal. Patients with chronic obstructive pulmonary disease (COPD) are at a higher risk of developing clots in deep veins of arm, leg and pelvis. These clots are preventable. Experts have agreed on guidelines to prevent blood clots, however, there is limited research on compliance with these guidelines in COPD patients admitted with an infection. The research work in this paper identifies low adherence to these guidelines. This research informs policy makers that quality improvement interventions are needed to prevent blood clots in COPD patients admitted with an infection.

Introduction
Venous thromboembolism (VTE) is a significant cause of morbidity, mortality and increased health care costs (National Institute of Clinical Studies, 2003). A community-based study in Perth identified the incidence of VTE 0.83 (95% CI, 0.69-0.97) per 1,000 residents per year (Ho, Hankey, & Eikelboom, 2008). This is consistent with the incidence of VTE in United States (White, 2003). Chronic obstructive pulmonary disease (COPD) stage is associated with a 2-fold increased risk of VTE (Børvik, Braekkan, & Enga, 2016). Limited data is available on compliance with VTE prophylaxis guidelines in COPD patients. The objective of this study was to determine compliance with National Health and Medical Research Council (NHMRC) VTE prophylaxis guidelines in patients admitted with an infective exacerbation of COPD. Infections predispose patients to VTE due to increase in systemic inflammation. There is no evidence to support alteration of VTE risk based on infection type and the type of infection was outside the scope of this study.

Aim
This audit aims to assess whether quality control groups need to implement interventions for improving VTE prophylaxis and reducing morbidity and mortality of COPD patients.

Objective
Determine compliance with NHMRC VTE prophylaxis guidelines in patients admitted with an infective exacerbation of COPD at a metropolitan hospital in Western Australia.

Standard
A random sample of 40 patients admitted with an infective exacerbation of COPD was audited to verify compliance with NHMRC VTE prophylaxis guidelines. NHMRC develops healthcare standards in Australia. They identify acute chest infection as a risk factor for VTE and recommend that patients with an infective exacerbation of COPD should receive VTE prophylaxis (National Health & Medical Research Council, 2009). NHMRC guidelines are in agreement with the guidelines recommended by American College of Chest Physicians (American College of Chest Physicians, 2008).

Case selection
Patients admitted with an infective exacerbation of COPD between 1 September 2015 and 31 December 2015 were assigned a number based on their admission date. An excel script was used to generate 40 random numbers and the corresponding patients were audited.
Sample size of 40 patients was recommended by the respiratory physicians at the hospital. Approximately 250 patients are admitted to the hospital with an infective exacerbation of COPD every year. The sample size is approximately 16% of the yearly admissions with a confidence level of 90 and a 12% margin of error.

Case definition
Patients admitted 1 September 2015 and 31 December 2015 with an infective exacerbation of COPD.

Inclusion criteria
• Information from the most recent admission was used when a patient had multiple admissions.

Exclusion criteria
• Patients on therapeutic VTE therapy prior to admission.

Data collection
Information specified in Table 1 was collected from patient notes and medication chart and recorded in an excel spread sheet. Excel formulas were used to calculate the key outcomes.

Results
The audit highlighted nominal compliance with documentation of VTE prophylaxis risk assessment (2.5%), documentation of VTE prophylaxis contraindication (0%) and prescription of pharmacological prophylaxis (27.5%). Prophylaxis was prescribed and administered appropriately (correct agent, route and frequency) when it was considered suitable for a patient (Table 2).
Medication chart checkbox indicating completion of VTE prophylaxis risk assessment was marked for one out of 40 patients. None of the patients had contraindications to VTE prophylaxis documented in the medication chart or the patient notes. 11 out of 40 patients were prescribed VTE prophylaxis. 10 out of 11 patients were prescribed prophylaxis in the VTE prophylaxis section of the medication chart. One patient was prescribed it in the regular medication section of the medication chart. Pharmacological prophylaxis was appropriately administered to each of the 11 patients. Mechanical prophylaxis was not prescribed to any patient in the relevant section of the medication chart. Two patients were prescribed mechanical prophylaxis in patient notes.

Discussion
Results obtained from audits both in Australia as well as overseas demonstrate that adherence to VTE prophylaxis guidelines is lower for patients with an infective exacerbation of COPD when compared to other non-surgical/medical patients. Audit of 8,774 non-surgical patients across 15 hospitals in Australia identified 37.9% patients received appropriate thromboprophylaxis (Gibbs, Fletcher, Blombery, Collins, & Wheatley, 2011). Audit of 121 patients at Hôpital Tenon in Paris identified that 45.5% of medical patients received appropriate thromboprophylaxis (Fagot et al., 2001). The result of this audit (highlighting poor compliance with VTE guidelines) is in line with other audits in COPD patients indicating poor compliance with other international clinical guidelines (Lodewijckx et al., 2009;Sandhu et al., 2013). Physician disagreement with VTE guidelines, management of COPD patients by non-respiratory physicians and lack awareness that respiratory illness is a risk factor for VTE are the key reasons for poor compliance. Some physicians believe that VTE prophylaxis guidelines overstate the need for thromboprophylaxis in medical patients and expose them to unnecessary risk of bleeding (Millar, 2009). Respiratory physicians comply with VTE guidelines to a greater extent than general physicians (Lodewijckx et al., 2009;Sandhu et al., 2013), however, COPD patients are often managed by non-respiratory physicians.
Relatively small sample size was a limitation of this study and decreases reliability of the results. Despite this limitation, this study has several strengths. This is perhaps the first study determining compliance with VTE prophylaxis guidelines in COPD patients. It highlights the need for interventions to improve nominal adherence to VTE prophylaxis guidelines in COPD patients.

Conclusion
Hospitalized patients with an infective exacerbation of COPD patients are at an increased risk of developing a thrombotic event. VTE prophylaxis compliance is steadily increasing within the surgical specialities, however, there is nominal adherence to VTE prophylaxis guidelines in patients admitted with an infective exacerbation of COPD. Physician disagreement with the VTE guidelines in COPD patients, management of COPD patients by non-respiratory physicians and lack awareness that respiratory illness is a risk factor for VTE are the key reasons for poor adherence. This audit highlights the need for quality improvement interventions to increase compliance with VTE prophylaxis in hospitalized patients with an infective exacerbation of COPD. Pharmacological prophylaxis administered as per prescription 11 11 11/11 × 100 = 100

Funding
The author received no direct funding for this research.