P0655 VTE thromboprophylaxis in patients with inflammatory bowel disease admitted to hospital; can we increase adherence with guidelines?
Authors: Das A , Florez C S , Leslie F 
Published: January 2025

Abstract

Background
Incidence of venous thromboembolism (VTE) increases two to three folds in patients with inflammatory bowel disease (IBD), with hospitalisation, active disease and surgery as the major risk factors. VTE risk assessment and low molecular weight Heparin (LMWH) is recommended in all patients with IBD admitted to hospital1,2. The aim of the quality improvement project was to look at our practice, audit our adherence with guidance and where possible improve practice.

Methods
A tertiary centre audit was conducted from 1 September 2023 to 30 November 2023, to include all IBD patients ≥ 18 years, admitted for one day or more. Relevant data on VTE risk assessment, prescribing VTE prophylaxis, any missed doses and reasons were collected from electronic patient records. Patient identifiable details were omitted, and the audit was registered with institutional audit department. Audit outcomes were identified, interventions were implemented and a re-audit was conducted from 1 June 2024 to 30 June 2024.

Results
Out of 107 patients, VTE risk assessment was done in 61(57%) and LMWH was started in 79 (74%). Among 45 patients admitted with IBD flare, LMWH was started in 36 (80%). Among 28 patients where LMWH was not started, rectal bleeding(n=6) and ‘declined by patients’ (n=5) were the most common reasons. Other reasons highlighted included subdural haematoma (2), fall and suspected brain haemorrhage (1), major trauma (1), razor blade ingestion (1), diverticular bleed (1), lymphoma and low platelets (1), metastatic cancer and end of life (1). In patients started on LMWH (n=79), 76 (96%) received the first dose on Day 1, while 47 (59%) received all the recommended doses. ‘Declined by the patient’ was the most common reason for any missed dose (47%).
The findings were disseminated with the relevant medical teams at team education sessions with opportunities to discuss the guidelines, wider issues including importance of giving LMWH despite rectal bleeding, and any concerns explored.
After these initiatives, a re-audit was conducted. Out of 51 admissions, 45 (88.2%) had VTE risk assessments, and 44 (86.25%) started on LMWH, showing improvement in practice. Among 16 patients admitted with IBD flare, all had VTE risk assessment and started on LMWH.
No thromboembolic events were identified during either of the audit periods.

Conclusion
Low compliance with thromboprophylaxis in IBD inpatients is commonly driven by fear of aggravating rectal bleeding and patient’s declining administration. Communication and raising awareness by education with relevant medical & nursing teams and patients can improve practice and thus prevent thromboembolic events.

References
1.Hannah Gordon, Johan Burisch, Pierre Ellul, et al. ECCO Guidelines on Extraintestinal Manifestations in Inflammatory Bowel Disease,Journal of Crohn’s and Colitis, Volume 18, Issue 1, January 2024, Pages 1–37, https://doi.org/10.1093/ecco-jcc/jjad108
2.Olivera, P.A., Zuily, S., Kotze, P.G. et al. International consensus on the prevention of venous and arterial thrombotic events in patients with inflammatory bowel disease.Nat Rev Gastroenterol Hepatol 18, 857–873 (2021). https://doi.org/10.1038/s41575-021-00492-8