Introduction Venous thromboembolism (VTE) is a leading cause of preventable morbidity and mortality among hospitalized surgical patients. Despite the availability of evidence-based guidelines, real-world adherence to appropriate VTE prophylaxis remains suboptimal.

Need for the Project At our institution, baseline data from January to September 2024 revealed that only 37.8% of surgical inpatients received guideline-concordant VTE prophylaxis. This gap posed significant risks to patient safety and underscored the need for a structured intervention.

Aim To improve the appropriateness of VTE prophylaxis in surgical patients through a multifaceted, system-level intervention.

Methods The project was implemented across three tertiary hospitals under the National Guard Health Affairs in Riyadh: King Abdulaziz Medical City, King Abdullah Specialized Children's Hospital, and the Women's Health Hospital. All patients admitted under a surgical department for more than 48 hours were included, with no exclusions. We conducted iterative Plan–Do–Study–Act (PDSA) cycles as part of our quality improvement approach. The intervention began in October 2024 and included:

  • Education of Healthcare Providers Targeted education sessions were delivered to surgical teams focusing on proper VTE prophylaxis indications, dosing, and patient-specific considerations such as weight and bleeding risk.

  • Automated Data Extraction and Weekly Audit-Feedback Weekly automated reports were sent to the thrombosis quality specialist containing comprehensive data on all surgical inpatients, including weight, prophylaxis type and dose, and baseline characteristics. Manual chart audits were then conducted, and individualized feedback was emailed to the primary team to address deviations.

  • EHR Pop-Up Alert with Embedded VTE Prophylaxis Algorithm A real-time decision-support alert was integrated into the EHR. It appears each time a provider orders VTE prophylaxis (heparin or enoxaparin), displaying the institutional algorithm to guide correct agent and dosing based on weight, renal function, and VTE risk.

The pre-intervention period spanned January to September 2024, and the post-intervention period covered October 2024 to July 2025. Fisher's Exact Test was used for statistical analysis. Statistical Process Control (SPC) charts were constructed to assess process stability and identify special cause variation.

Results Among 11,246 audited surgical inpatients, at baseline, the main reasons for inappropriate prophylaxis were: incorrect choice between pharmacological and non-pharmacological prophylaxis (22.4%), inappropriate selection of pharmacological agent—unfractionated heparin (UFH) vs. enoxaparin—based on renal function (65.7%), and incorrect dosing based on patient weight (11.9%). The appropriateness of VTE prophylaxis improved from 37.8% to 54.8% post-intervention (p < 0.0001). SPC charts revealed special cause variation starting in October 2024, with multiple Nelson Rules triggered (Rules 1, 2, 3, and 4), confirming a sustained improvement.

Conclusion This quality improvement initiative significantly improved the appropriateness of VTE prophylaxis in surgical patients through a scalable, multifaceted approach. Real-time decision support, targeted education, and comprehensive audit-feedback contributed to a sustained improvement in adherence to prophylaxis guidelines. Future work will evaluate whether the intervention led to a reduction in actual VTE events, explore the use of artificial intelligence to predict risk and guide prophylaxis decisions, and focus on sustaining the improvement and scaling the model to other hospitals across the country.

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2025
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