Thromboprophylaxis for hospitalized medical patients: a multicenter qualitative study.
BACKGROUND
Observational studies have documented that medical patients infrequently receive venous thromboembolism (VTE) prevention.


OBJECTIVE
To understand the barriers to, and facilitators of, optimal thromboprophylaxis.


METHODS
Hospitalized medical patients.


METHODS
We conducted in-depth interviews with 15 nurses, 6 pharmacists, 12 physicians with both clinical and managerial experience, and 3 hospital administrators.


METHODS
One university-affiliated and 2 community hospitals.


METHODS
Interviews were audiotaped and transcribed verbatim. Transcripts were reviewed and interpreted independently in duplicate.


METHODS
Analysis was conducted using grounded theory.


RESULTS
Physicians and pharmacists affirmed that evidence supporting heparin is strong and understood. Clinicians, particularly nurses, reported that mobilization was important, but were uncertain about how much mobilization was enough. Participants believed that depending on individual physicians for VTE prevention is insufficient. The central finding was that multidisciplinary care was also perceived as a barrier to effective VTE prevention because it can lead to unclear accountability by role confusion. Participants believed that a comprehensive, systems approach was necessary. Suggestions included screening and risk-stratifying all patients, preprinted orders at hospital admission that are regularly reevaluated, and audit and feedback programs. Patient or family-mediated reminders, and administrative interventions, such as hiring more physiotherapists and profiling thromboprophylaxis in hospital accreditation, were also endorsed.


CONCLUSIONS
Universal consideration of thromboprophylaxis finds common ground in multidisciplinary care. However, results of this qualitative study challenge the conviction that either individual physician efforts or multidisciplinary care are sufficient for optimal prevention. To ensure exemplary medical thromboprophylaxis, clinicians regarded coordinated, systemwide processes, aimed at patients, providers, and administrators as essential.
Cook
Deborah
D
Department of Medicine, McMaster University, Hamilton, Ontario, Canada. debcook@mcmaster.ca
Tkaczyk
Andrea
A
Lutz
Kristina
K
McMullin
Joseph
J
Haynes
R Brian
RB
Douketis
James
J
D000328:Adult; D000925:Anticoagulants / Q000627:therapeutic use; D002985:Clinical Protocols; D005260:Female; D006493:Heparin / Q000627:therapeutic use; D006801:Humans; D007297:Inpatients; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D009864:Ontario; D010564:Personnel, Hospital; D054556:Venous Thromboembolism / Q000517:prevention & control*
D000925:Anticoagulants; D006493:Heparin