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Abstract

Introduction

Deep Vein Thrombosis (DVT) poses a significantly preventable threat within healthcare, with compliance to prophylaxis lacking among medical practitioners. This study explores the role of Quality Improvement (QI) in improving DVT prophylaxis practices at a tertiary-care hospital in Pakistan.

Methods

A cross-sectional questionnaire assessing knowledge, attitudes, and practices on DVT prophylaxis was administered among medical officers (MOs) at a multi-specialty setup. A pre-session questionnaire was conducted, followed by three educational sessions from September 21, 2021, to June 7, 2022, and then a post-session questionnaire. Categorical variables were compared using the Chi-squared test. A P-value < .10 was considered significant.

Results

42 MOs participated in the pre-session questionnaire and educational sessions, of which 34 (81.0%) completed the post-session questionnaire. The majority were female (85.5%) and rotated in Medicine (75.0%). Initially, 32 participants (76.2%) were aware of guidelines at their home institution, and 27 (64.3%) did not prescribe prophylaxis as the risks outweigh the benefits. Following session administration, most participants prescribed DVT prophylaxis (P = .004) with educational sessions significantly improving the knowledge of participants regarding DVT risk following discharge (28.6% vs 52.9%; P = .03).

Conclusion

This QI study demonstrated improvements in DVT prophylaxis practices among MOs. Further development and intervention is needed to improve institute-wide DVT practices.

Keywords

venous thrombosis prophylaxis quality improvement medical education

Introduction

Deep Vein Thrombosis (DVT) poses a significantly preventable cause of mortality and morbidity within healthcare.¹ It is the formation of a blood clot within the deep veins of the body, most commonly of the lower limbs. The thrombus formed may break off and lodge in the pulmonary vasculature causing Pulmonary Embolism (PE), with a mortality rate of approximately 10%.² DVT and PE collectively comprise venous thromboembolism (VTE).

Numerous risk factors contribute to the development of DVT. The classic framework known as Virchow's Triad elucidates the three major components predisposing individuals to thrombosis: endothelial injury, venous stasis, and hypercoagulability.¹ Clinically, patients can be stratified using risk assessment tools such as the Wells score and the Padua Prediction Score based on their predisposition to DVT.³ Factors such as age, previous history of VTE, malignancy, obesity, certain medications, and immobility can affect the risk of thrombosis.⁴ These scoring criteria are invaluable for healthcare providers, aiding in the identification of high-risk individuals who require DVT prophylaxis to mitigate the disease's morbidity and mortality.

For hospitalized patients, especially those undergoing major surgery or those with significant immobility, pharmacological thromboprophylaxis is commonly used. Drugs such as low molecular weight heparin (LMWH), unfractionated heparin (UFH) and fondaparinux are commonly prescribed. Mechanical prophylaxis measures may also be used such as graduated compression stockings and intermittent pneumatic compression devices concomitantly or in patients where pharmacological measures are contraindicated.

In a lower-middle income country (LMIC) such as Pakistan there is a dearth of data regarding the incidence of DVT and adherence to DVT prophylaxis protocols. Studies have shown the incidence of VTE, DVT, or PE to range up to 12.8%.⁵ Additionally, the few studies that have been done show the adherence to DVT prophylaxis to be as low as 22%.⁶ Despite the significant financial burden and the associated morbidity and mortality, which can be prevented through pharmacological or mechanical methods, DVT/VTE is frequently neglected in our country. This oversight may be attributed to either insufficient awareness or a failure to adhere to established thromboprophylaxis protocols.

We conducted a cross-sectional questionnaire study with the aim of assessing the existing knowledge regarding DVT prophylaxis protocols within our institution. Subsequently, improvements to DVT knowledge and adherence to protocols following the implementation of educational sessions were assessed. Using this data, we aim to enhance both understanding and adherence to DVT prophylaxis protocols, while also allowing us to identify the most effective interventions for achieving this goal. Through Quality Improvement (QI) initiatives, we can leverage this information to refine our approach and ensure optimal implementation of DVT prophylactic measures.

Methods

Ethics Approval

This study was conducted following approval from the Ethics Review Committee at the Aga Khan University, Karachi, Pakistan (ERC # 2020-3297-8675).

Study Design and Cohort

This was a prospective QI study conducted between September 2021 and June 2023 that included medical officers (MOs) aged 18 and older practicing at a multi-speciality setup at the Aga Khan University Hospital, a tertiary medical center in Pakistan. All medical officers practicing at the setup were included. The aim of this study was to establish pre-existing knowledge regarding DVT prophylaxis protocols within the institute and evaluate improvement following implementation of educational sessions. This study was reported in accordance with the Standards for QI Reporting Excellence (SQUIRE) guidelines.

Sample Size Calculation

To calculate the sample size required for adequate statistical power, openepi.com was used.

The minimum calculated sample size was 41 participants, assuming a precision of 5%, and an anticipated frequency of adherence to DVT prophylaxis ranging from 22-63.3%. At the time of study of conduction, a total of 45 medical officers were practicing within the multi-speciality set-up.

Implementation of QI Intervention

A model for improvement plan was conducted using the Donabedian model of change. In September 2021, a pre-session questionnaire was administered to evaluate Medical Officers’ (MOs) knowledge regarding DVT prophylaxis and hospital policies. Subsequently, three informational sessions were conducted during protected didactic time for house officers stationed in the department. These sessions were held at monthly intervals, October, November, and December 2021. Each session lasted two hours and included a structured lecture followed by a presentation. The educational content, adapted from pre-existing guidelines, was also disseminated via official institutional emails following each session.

Data Collection Tool

To conduct data collection, a questionnaire was developed using pre-existing literature and institutional guidelines. A previously published study conducted in a similar clinical setting was referenced, and the questionnaire used in that study served as the foundational framework.⁷ Permission to adapt and utilize the questionnaire was obtained from the original author. The content for the educational sessions and questionnaire items was initially adapted from previously validated material and subsequently revised to align with institutional VTE prophylaxis guidelines, ensuring relevance to our hospital context. These guidelines are developed by an internal expert committee, formulated in accordance with international standards, and reviewed periodically to reflect evolving best practices.

Following its construction, the questionnaire underwent internal validation. It was piloted among eight individuals with relevant clinical backgrounds to assess clarity, comprehensibility, and content validity. Any issues identified during this phase were addressed, and appropriate corrections were made before dissemination.

To maximize total data collected, pre-testing was omitted. Questionnaires were disseminated prior to session administration via anonymous Google surveys. Prior to commencing the survey, participants were provided with a detailed informed consent form explaining the scope of the study, their extent of participation, and their right to withdraw at any given point in time. Questionnaires were re-administered following session administration among the same sample population.

The final questionnaire consisted of four components as follows: (1) Demographics of study participants (2): Knowledge regarding pre-existing guidelines at AKUH (3): Knowledge regarding common indications and contraindications of DVT Prophylaxis (4): Knowledge regarding various tools used in evaluating DVT Prophylaxis.

Statistical Analysis

Categorical variables were described as frequencies and percentages. The χ² test for categorical variables was used to compare the answers of individual questions among the pre-test and post-test cohorts.

Data analysis and management were performed using Stata V15. Statistical significance was assessed at two-sided P-value <.05. Due to the small nature of the sample, P-values < .10 was considered as trending towards statistical significance.

Results

Demographics and Participant Characteristics

A total of 42 participants completed the pre-test questionnaires; of which 34 participants (81.0%) completed the post-test questionnaire. Most participants were female (85.5%) and rotated in the Medicine service line (75.0%). Most participants were in their second year of service (35.5%), with only 13.2% having been employed for five or more years at the set-up (Table 1).

Table 1.

Demographics of Participants.

Category	Pre-test (%)	Post-test (%)	Total (%)	P-value
Gender
Male	5 (11.9)	6(17.7)	11 (14.5)	.479
Female	37 (88.10)	28(82.4)	65 (85.5)	.479
Service line
Medicine	31 (73.8)	26 (76.5)	57 (75.0)	.79
Surgery	11 (26.2)	8 (23.5)	19(25.0)	.79
Year of Employment
First	6 (14.3)	10 (29.4)	16(21.1)	.111
Second	18 (42.9)	9 (26.4)	27(35.5)
Third	10 (23.8)	4 (11.8)	14(18.4)
Fourth	5 (11.9)	4 (11.8)	9(11.8)
Fifth (or higher)	3 (7.1)	7 (20.6)	10(13.2)

Key:

• P-value reported for Chi-squared test of independence.

• Significant P-values denoted in bold.

Opinions Regarding DVT Prophylaxis

Among the 42 participants completing the pre-test questionnaire, 76.2% of participants (n = 32) were aware of the guidelines at their home institution, with most participants (85.7%) believing DVT prophylaxis to be extremely important. Low-molecular weight heparin was the most prescribed method of prophylaxis (n = 33) with 18 participants (42.9%) unaware that heparin was derived from animal products. When inquired regarding reasons for not prescribing DVT prophylaxis regularly, 40/42 participants (95.2%) responded, with 27 participants (64.3%) believing the risks outweigh the benefits (Table 2).

Table 2.

Opinions Regarding DVT Prophylaxis Among Participants.

Category	Pre-test (%)	Post-test (%)	P-value
Are you aware of the current guidelines at your home institute?
Yes	32(76.2)	27(79.4)	.738
No	10 (23.8)	7 (20.6)	.738
How important is DVT prophylaxis, based on your clinical perspective?
Moderately important	6 (14.3)	4 (11.8)	.746
Extremely important	36 (85.7)	30 (88.2)	.746
What prophylaxis do you most commonly prescribe?
Unfractionated Heparin	15 (35.7)	14 (41.2)	.626
Low-Molecular Weight Heparin	33 (78.6)	28 (82.4)	.596
Fondaparinux Sodium	1 (2.4)	1 (2.9)	.879
Anti-embolic Stockings	17 (40.5)	19 (55.9)	.181
Are you aware that Heparin is an animal product?
Yes	24 (57.1)	25 (73.5)	.138
No	18 (42.9)	9 (26.5)	.138
If you do not prescribe DVT prophylaxis regularly, what is the reason?
I do not regularly prescribe DVT prophylaxis because it feels unimportant.^$	4 (9.5)	0 (0.0)	.064^$
I do not regularly prescribe DVT prophylaxis because the risks outweigh the benefits.	27 (64.3)	0 (0.0)	0
I do not regularly prescribe DVT prophylaxis because it is expensive.	1 (2.4)	4 (11.8)	.101
I do not regularly prescribe DVT prophylaxis because it is not relevant to our setup.	0 (0.0)	1 (2.9)	.263
I do not regularly prescribe DVT prophylaxis because seniors have told me not to,	5 (11.9)	2 (5.9)	.367
I do not regularly prescribe DVT prophylaxis because patients have contraindications.	3 (7.1)	0 (0.0)	.282

Key:

• P-value reported for Chi-squared test of independence.

• Significant P-values denoted in bold.

• ^$: Trending towards statistical significance (P-value < .10).

Following educational session interventions, participants were resurveyed regarding opinions on DVT prophylaxis. Of the 34 respondents, 27 (79.4%) participants were now aware of institutional guidelines (P = .738), with 88.2% of participants believing DVT prophylaxis to be extremely important (P = .746). Low-molecular weight heparin remained the most utilized method of prophylaxis, however, 73.5% of participants were now aware that heparin was an animal product (P = .138). Regular prescription of DVT prophylaxis improved significantly from 2/42 participants to 27/34 participants ( P = .004).

Knowledge Regarding DVT Prophylaxis

Of the 42 participants completing the pre-test questionnaire, 32 participants (76.2%) were aware that UFH was the preferred prophylaxis in renal failure, and 26 (61.9%) were aware that no prophylaxis was prescribed for patients with bleeding disorders. Following post-test administration, these numbers decreased to 23 participants (67.6%; P = .27) and 18 participants (52.9%, P = .558), respectively (Supplementary Table 1).

Awareness regarding the Padua Prediction Score (PPS) and Caprini score, two commonly utilized scores in DVT risk assessment), was present among 23.8% and 28.6% participants during pre-test administration. Following educational session administration, awareness regarding the PPS improved to 38.2% (16 participants; P = .17), and awareness regarding the Caprini score demonstrated trends towards statistical significance (47.1%, 20 participants; P = .097). Of the PPS criteria, significant reductions in identification of the following individual criteria were noted: Bedridden/immobilized patients for > 3 days (38 vs 26 participants; P = .096); pregnant patients (28 vs 15 participants; P = .049); and patients with previous history of DVT (38 vs 23 participants; P = .05 (Supplementary Table 1).

Among the 42 pre-test participants, 28.6% (12 participants) were aware that a significant number of hospitalized patients develop DVT following discharge, while 37 participants (88.1%) were aware of the contraindications of DVT prophylaxis. Administration of educational sessions improved contraindication awareness to 94.1% (32 participants; P = .367), with a significant increase in the number of participants aware of DVT risk following discharge (28.6% vs 52.9%; P = .031). All participants were aware of the platelet cutoff associated with bleeding risk prior to session administration, with 81% (34 participants) aware of the subsequent management in such patients. Educational interventions resulted in a significant increase in this knowledge, with 94.1% (32 participants) being aware following session administration (P = .091) (Supplementary Table 1).

Discussion

DVT is a significant cause of morbidity and mortality; however, proper prophylaxis is known to reduce this burden.⁸ Improving the knowledge of healthcare professionals regarding DVT prophylaxis is crucial to enhance patient safety and reduce the incidence of this potentially life-threatening complication. By assessing the knowledge and practice of DVT prophylaxis among healthcare professionals at AKUH, this study aimed to identify areas for improvement, implement targeted educational interventions and assess their effectiveness.

The findings of the study reflected a lack of awareness regarding certain aspects of DVT prophylaxis among the surveyed medical officers. Despite a high percentage of participants expressing the belief that DVT prophylaxis is extremely important, 23.8% of participants were initially unaware of the guidelines present at their home institution. This low level of knowledge is not unique to our setting; similar findings have been reported in other countries. For instance, Tang et al found in China that 60% of the medical staff were not aware of the VTE prophylaxis guidelines, whether domestically or internationally.⁹ Similarly, notable gaps in knowledge were observed, such as the indications and contraindications of various prophylactic methods and scoring and risk stratifying criteria of DVT. These observations align with similar studies conducted in other LMICs, where a lack of knowledge regarding details of DVT prophylaxis has been reported, and may represent a significant gap in medical education delivery.¹⁰

The implementation of educational interventions resulted in a notable improvement in several areas of knowledge. There was a slight increase in awareness of institutional guidelines and the shift towards a greater understanding of different prophylactic methods, their implications, and contraindications. There was a significant improvement in the regular prescription of DVT prophylaxis indicating that targeted interventions such as holding educational sessions can impact clinical practices.¹¹ These findings suggest that regular educational interventions may offer an avenue for viable improvement in trainee knowledge, thus allowing for effective implementation of DVT prophylaxis.

However, the post-test results revealed that knowledge and awareness regarding specific criteria remained suboptimal and improvement in most areas was not significant. The lack of significant improvement in most areas following the post-test may stem from the passive approach of intervention. Studies indicate varying degrees of effectiveness among different intervention types for improving VTE prevention, with passive learning often ranking as less effective.^8,12 Conversely, active mandatory tools are more likely to yield positive outcomes. Evidence suggests that integrating information technology tools like alerts and computerized clinical decision support systems into provider workflow can significantly enhance prophylaxis practices and mitigate the risk of VTE-related patient harm.

In Pakistan the prevalence of DVT remains elevated, yet the utilization of thromboprophylaxis among at-risk patients is notably low.¹³ These observations may be attributable to a demanding workload in the context of limited resources often seen in low-income countries. Additionally, this oversight could stem from the absence of standardized treatment protocols and reduced standardized clinical documentation, exacerbated by the absence of electronic health records (EHRs). Introducing educational initiatives on DVT prophylaxis and implementing EHRs with computerized clinical decision support systems could improve adherence to prophylaxis protocols. Such measures hold the potential to reduce DVT rates and ultimately enhance patient outcomes.

The present study carries several key implications for clinical practice and healthcare delivery. First and foremost, it underscores the effectiveness of targeted educational interventions in enhancing healthcare professionals’ knowledge and adherence to DVT prophylaxis guidelines. This finding suggests that continued educational efforts could serve as a cost-effective means of reducing preventable complications, such as pulmonary embolism, thereby improving patient safety. Other studies also have shown educational interventions have resulted in an improvement in adherence to VTE prophylaxis guidelines.¹⁴ Furthermore, the study emphasizes the need for standardized protocols for DVT prophylaxis, especially in low-resource settings like Pakistan, where adherence to such protocols remains inconsistent. Importantly, this QI model holds promise for broader application in similar healthcare environments, providing a framework for policy development aimed at standardizing DVT prevention practices across institutions in LMICs such as Pakistan.

These findings additionally demonstrate potential for replication in other healthcare institutions through systemic enhancements. Even in resource-limited settings, implementing institutional process improvements can significantly augment adherence to prophylaxis protocols. Integrating validated risk assessment tools into EHRs with automated clinical decision support has been shown to reduce postoperative VTE events by 39%-58% through standardized risk stratification and prophylaxis recommendations.^15,16 Such systems overcome knowledge gaps by embedding guidance directly into clinical workflows, particularly valuable in environments with high patient volumes and variable provider experience such as where this study was conducted. Complementary strategies like automated alerts for prophylaxis omissions have demonstrated 4.3%-5.3% absolute increases in appropriate ordering within 6-24 h of admission or patient transfers.¹⁷ Periodic audit-feedback cycles create accountability through performance monitoring. When combined with targeted educational interventions like those implemented in our study, these systemic approaches form a multifaceted solution; EHR tools address knowledge to practice gaps, automated alerts prevent oversight during care transitions, and audits ensure sustained compliance. Future initiatives should explore phased implementation of these evidence-based strategies, particularly in LMIC settings where EHR adoption is growing but clinical decision support remains underutilized.

Several limitations of this study must be acknowledged. The relatively small sample size, confined to a single tertiary care hospital, may limit the generalizability of the results, as the limited observations preclude meaningful stratified analysis based on various factors including years of experience and participant educational backgrounds. Further research is necessitated to evaluate these practices in a larger cohort, thus enabling greater understanding of practices in similar setups. Additionally, the absence of a control group makes it challenging to definitively attribute the observed improvements solely to educational interventions. The short follow-up period also raises questions regarding the sustainability of these improvements in the long term and whether they will translate into tangible changes in patient outcomes. However, the primary objective of this study was to highlight the existing knowledge gaps and demonstrate the feasibility and benefit of structured educational sessions in improving DVT prophylaxis awareness. Long-term follow-up efforts are currently underway within the institution to assess whether these sessions, in combination with additional system-level interventions, translate into sustained improvement in clinical practice and VTE prevention outcomes. The questionnaire used may not have captured all dimensions of DVT prophylaxis knowledge, potentially overlooking other areas where knowledge gaps persist in clinical practice. Additionally, adoption of a more stringent adherence to VTE prophylaxis may be achieved better by implementation of active interventions rather than passive ones, as suggested by Michota et al.¹⁸

Conclusion

DVT carries significantly preventable risk to individuals in healthcare settings, particularly in lower-middle income countries. Targeted QI strategies, aimed at improving healthcare provider understanding, allow for an effective and implementable method to improve adherence to DVT prophylactic practices, thus reducing the risk of this entity.

Supplemental Material

sj-docx-1-cat-10.1177_10760296251345474 - Supplemental material for Evaluating and Improving Knowledge of DVT Prophylaxis Among Healthcare Professionals at a Tertiary Care Hospital in Karachi, Pakistan: A Quality Improvement Study

Supplemental material, sj-docx-1-cat-10.1177_10760296251345474 for Evaluating and Improving Knowledge of DVT Prophylaxis Among Healthcare Professionals at a Tertiary Care Hospital in Karachi, Pakistan: A Quality Improvement Study by Aahan Arif, Muzamil Hamid Hussain, Faheem Shaikh, Shihyeon Kim and Muhammad Haroon Khan in Clinical and Applied Thrombosis/Hemostasis

Supplemental Material

sj-docx-2-cat-10.1177_10760296251345474 - Supplemental material for Evaluating and Improving Knowledge of DVT Prophylaxis Among Healthcare Professionals at a Tertiary Care Hospital in Karachi, Pakistan: A Quality Improvement Study

Supplemental material, sj-docx-2-cat-10.1177_10760296251345474 for Evaluating and Improving Knowledge of DVT Prophylaxis Among Healthcare Professionals at a Tertiary Care Hospital in Karachi, Pakistan: A Quality Improvement Study by Aahan Arif, Muzamil Hamid Hussain, Faheem Shaikh, Shihyeon Kim and Muhammad Haroon Khan in Clinical and Applied Thrombosis/Hemostasis

Supplemental Material

sj-docx-3-cat-10.1177_10760296251345474 - Supplemental material for Evaluating and Improving Knowledge of DVT Prophylaxis Among Healthcare Professionals at a Tertiary Care Hospital in Karachi, Pakistan: A Quality Improvement Study

Supplemental material, sj-docx-3-cat-10.1177_10760296251345474 for Evaluating and Improving Knowledge of DVT Prophylaxis Among Healthcare Professionals at a Tertiary Care Hospital in Karachi, Pakistan: A Quality Improvement Study by Aahan Arif, Muzamil Hamid Hussain, Faheem Shaikh, Shihyeon Kim and Muhammad Haroon Khan in Clinical and Applied Thrombosis/Hemostasis

Footnotes

ORCID iDs

Aahan Arif

Muzamil Hamid Hussain

Ethical Considerations and Consent to Participate

This study was conducted following approval of the Ethics Review Committee (ERC) at the Aga Khan University, Karachi, Pakistan (ERC # 2020-3297-8675). Prior to administration of the questionnaire, informed consent was taken from all participants detailing the nature of this study, the scope, and their right to withdraw from the study at any time.

Author Contributions

Aahan Arif: Data curation; conceptualization; formal analysis; methodology; writing- original draft. Muzamil Hamid Hussain: Data curation; conceptualization; methodology; writing- original draft. Faheem Shaikh: Data curation; conceptualization; writing- reviewing and editing. Shihyeon Kim: Data curation. Haroon Khan: Conceptualization; methodology; supervision; writing- reviewing and editing.

All authors have read and approved the final manuscript.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

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Supplementary Material

Please find the following supplemental material available below.

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Evaluating and Improving Knowledge of DVT Prophylaxis Among Healthcare Professionals at a Tertiary Care Hospital in Karachi,Pakistan: A Quality Improvement Study

Abstract

Introduction

Methods

Results

Conclusion

Keywords

Introduction

Methods

Ethics Approval

Study Design and Cohort

Sample Size Calculation

Implementation of QI Intervention

Data Collection Tool

Statistical Analysis

Results

Demographics and Participant Characteristics

Opinions Regarding DVT Prophylaxis

Knowledge Regarding DVT Prophylaxis

Discussion

Conclusion

Supplemental Material

sj-docx-1-cat-10.1177_10760296251345474 - Supplemental material for Evaluating and Improving Knowledge of DVT Prophylaxis Among Healthcare Professionals at a Tertiary Care Hospital in Karachi, Pakistan: A Quality Improvement Study

Supplemental Material

sj-docx-2-cat-10.1177_10760296251345474 - Supplemental material for Evaluating and Improving Knowledge of DVT Prophylaxis Among Healthcare Professionals at a Tertiary Care Hospital in Karachi, Pakistan: A Quality Improvement Study

Supplemental Material

sj-docx-3-cat-10.1177_10760296251345474 - Supplemental material for Evaluating and Improving Knowledge of DVT Prophylaxis Among Healthcare Professionals at a Tertiary Care Hospital in Karachi, Pakistan: A Quality Improvement Study

Footnotes

ORCID iDs

Ethical Considerations and Consent to Participate

Author Contributions

Funding

Declaration of Conflicting Interests

Supplemental Material

References

Supplementary Material