title: Barriers and facilitators of thromboprophylaxis for medical-surgical intensive care unit patients: a multicenter survey.
abstract: BACKGROUND
  The objective of this study was to identify the self-reported barriers to and facilitators of prescribing low-molecular-weight heparin (LMWH) thromboprophylaxis in the intensive care unit (ICU).
  
  
  METHODS
  We conducted an interviewer-administered survey of 4 individuals per ICU (the ICU director, a bedside pharmacist, a thromboprophylaxis research coordinator, and physician site investigator) regarding LMWH thromboprophylaxis for medical-surgical patients in 27 ICUs in Canada and the United States. Items were generated by the research team and adapted from previous surveys, audits, qualitative studies, and quality improvement research. Respondents rated the barriers to LMWH use, facilitators (effectiveness, affordability, and acceptability thereof), and perceptions regarding LMWH use.
  
  
  RESULTS
  Respondents had 14.5 (SD, 7.7) years of ICU experience (response rate, 99%). The 5 most common barriers in descending order were as follows: drug acquisition cost, fear of bleeding, lack of resident education, concern about bioaccumulation in renal failure, and habit. The top 5 rated facilitators were preprinted orders, education, daily reminders, audit and feedback, and local quality improvement committee endorsement. Centers using preprinted orders (mean difference [P<.01]) and computerized physician order entry (P<.01) compared with those centers not using those tools reported higher affordability for these 2 facilitators. Compared with physicians and pharmacists, research coordinators considered ICU-specific audit and feedback of thromboprophylaxis rates to be a more effective, acceptable, and affordable facilitator (odds ratio, 6.67; 95% confidence interval, 1.97-22.53; P<.01). Facilitator acceptability ratings were similar within centers but differed across centers (P≤.01).
  
  
  CONCLUSIONS
  This multicenter survey found several barriers to use of LMWH including cost, concern about bleeding, and lack of resident knowledge of effectiveness. The diversity of reported facilitators suggests that large scale programs may address generic barriers but also need site-specific interprofessional knowledge translation activities.
authors.affiliation: Department of Medicine, McMaster University, Hamilton, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada. Electronic address: debcook@mcmaster.ca.
authors.forename: Deborah
authors.initials: D
authors.lastname: Cook
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada; Department of Pediatrics, McMaster University, Hamilton, Canada.
authors.forename: Mark
authors.initials: M
authors.lastname: Duffett
authors.affiliation: Centre de recherche FRQS du Centre hospitalier affilié universitaire de Québec, Axe Traumatologie - urgence - soins intensifs, Division de soins intensifs adultes, départements de médecine et d'anesthésiologie, Université Laval, Quebec, Canada.
authors.forename: Francois
authors.initials: F
authors.lastname: Lauzier
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.
authors.forename: Chenglin
authors.initials: C
authors.lastname: Ye
authors.affiliation: Division of Critical Care Medicine and Center for Health Evaluation and Outcome Sciences, St Paul's Hospital and University of B.C., Vancouver, Canada.
authors.forename: Peter
authors.initials: P
authors.lastname: Dodek
authors.affiliation: Section of Critical Care Medicine, Department of Internal Medicine, University of Manitoba, Winnipeg, Canada.
authors.forename: Bojan
authors.initials: B
authors.lastname: Paunovic
authors.affiliation: Department of Medicine and Department of Critical Care Medicine, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada.
authors.forename: Rob
authors.initials: R
authors.lastname: Fowler
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada; School of Rehabilitation Science, McMaster University, Hamilton, Canada.
authors.forename: Michelle E
authors.initials: ME
authors.lastname: Kho
authors.affiliation: Division of Critical Care Medicine, Vancouver General Hospital, Vancouver, Canada.
authors.forename: Denise
authors.initials: D
authors.lastname: Foster
authors.affiliation: Department of Critical Care Medicine, Institute of Public Health, University of Calgary, Calgary, Canada.
authors.forename: Tom
authors.initials: T
authors.lastname: Stelfox
authors.affiliation: Department of Medicine and Department of Critical Care Medicine, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada.
authors.forename: Taz
authors.initials: T
authors.lastname: Sinuff
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.
authors.forename: Nicole
authors.initials: N
authors.lastname: Zytaruk
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.
authors.forename: France
authors.initials: F
authors.lastname: Clarke
authors.affiliation: Department of Anesthesia, Vancouver Island Health Authority, Victoria, Canada; Department of Critical Care, Vancouver Island Health Authority, Victoria, Canada.
authors.forename: Gordon
authors.initials: G
authors.lastname: Wood
authors.affiliation: Department of Pulmonary and Critical Care, St John's Mercy Hospital, St Louis, MO, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Cox
authors.affiliation: Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.
authors.forename: Jim
authors.initials: J
authors.lastname: Kutsiogiannis
authors.affiliation: Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.
authors.forename: Michael
authors.initials: M
authors.lastname: Jacka
authors.affiliation: Department of Critical Care, Thunder Bay Regional Health Sciences Centre, Division of Clinical Sciences, Northern Ontario School of Medicine, Thunder Bay, Canada; Department of Internal Medicine, Thunder Bay Regional Health Sciences Centre, Division of Clinical Sciences, Northern Ontario School of Medicine, Thunder Bay, Canada.
authors.forename: Marios
authors.initials: M
authors.lastname: Roussos
authors.affiliation: Department of Surgery, Saint John Regional Hospital, St John, Canada; Department of Critical Care, Saint John Regional Hospital, St John, Canada.
authors.forename: Hari
authors.initials: H
authors.lastname: Kumar
authors.affiliation: Department of Medicine, McMaster University, Hamilton, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.
authors.forename: Gordon
authors.initials: G
authors.lastname: Guyatt
mesh_terms: D000925:Anticoagulants / Q000191:economics / Q000493:pharmacokinetics / Q000627:therapeutic use*; D002170:Canada; D003422:Critical Care; D016527:Drug Costs; D005239:Fear; D019538:Health Care Surveys; D006470:Hemorrhage / Q000139:chemically induced / Q000523:psychology; D006495:Heparin, Low-Molecular-Weight / Q000191:economics / Q000493:pharmacokinetics / Q000627:therapeutic use*; D006801:Humans; D007362:Intensive Care Units; D051437:Renal Insufficiency / Q000378:metabolism; D057566:Self Report; D013927:Thrombosis / Q000517:prevention & control*; D014481:United States
chemical_list: D000925:Anticoagulants; D006495:Heparin, Low-Molecular-Weight
keywords: Critical illness; Interview; Survey; Thromboprophylaxis; Venous thromboembolism