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Keywords:

  • prevention;
  • quality improvement;
  • thromboprophylaxis;
  • venous thromboembolism

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Prophylaxis modalities
  5. Prophylaxis guidelines – ACCP
  6. Prophylaxis use/adherence with the guidelines
  7. Strategies to increase the appropriate use of thromboprophylaxis
  8. Disclosure of Conflict of Interests
  9. References
  10. Some excellent additional resources

Summary.  It is more than 50 years since the first publication of a study showing that symptomatic and fatal venous thromboembolism could be reduced with the use of thromboprophylaxis. Furthermore, it is 23 years since the first evidence-based guidelines recommended routine use of thromboprophylaxis for most hospitalized patients. However, despite the overwhelming evidence that thromboprophylaxis safely and inexpensively reduces thromboembolic complications associated with acute illness and surgery, there continue to be large gaps in the provision of this key patient safety intervention and even larger gaps in the provision of optimal thromboprophylaxis. The implementation of quality improvement strategies, both at the national level and in local hospitals, are able to increase awareness of thromboembolic risks, to increase adherence to thromboprophylaxis guidelines, and to decrease both clinically important thromboembolic events and hospital costs. Therefore, the objective is for every hospitalized patient to receive appropriate thromboprophylaxis based on their thromboembolic and bleeding risks.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Prophylaxis modalities
  5. Prophylaxis guidelines – ACCP
  6. Prophylaxis use/adherence with the guidelines
  7. Strategies to increase the appropriate use of thromboprophylaxis
  8. Disclosure of Conflict of Interests
  9. References
  10. Some excellent additional resources

In 1959, the publication of a controlled trial of thromboprophylaxis demonstrated that an oral anticoagulant administered to patients who had surgical repair of hip fractures reduced symptomatic venous thromboembolism (VTE) and death without an increase in clinically important bleeding [1]. Over the half century since then, several hundred studies of thromboprophylaxis have been carried out and many new prophylaxis options have been evaluated, used and, in some cases, replaced by more effective or safer methods. Since 1986, more than 25 evidence-based guidelines recommending routine thromboprophylaxis in the majority of hospitalized patients have been published [2,3]. It is appropriate not only to celebrate the efforts and accomplishments of a large number of researchers, clinicians and champions in the area of thromboprophylaxis but also to consider some of the remaining challenges related to the prevention of VTE.

The frequency of thromboembolic complications in hospital patients, the adverse consequences of these events and their economic impact strongly justify consideration of thromboprophylaxis as a key patient safety priority for all general hospitals. Sixty to seventy percent of the entire population burden of VTE is related to hospitalization [4–7]. As VTE is one of the most common complications of hospital stay and is associated with substantial short-term and long-term morbidity and with death, prevention is the key to reducing the burden of this condition. Several hundred clinical trials confirm the effectiveness, safety and cost-effectiveness of thromboprophylaxis for various patient groups. The use of recommended thromboprophylaxis has been shown to decrease the risk of deep vein thrombosis (DVT), proximal DVT, pulmonary embolism (PE), and fatal PE by more than 60% in a broad spectrum of patients with a very low risk of adverse effects [3,8–10].

The Agency for Healthcare Research and Quality (AHRQ) systematically evaluated and ranked 79 safety practices based on the strength of evidence supporting each intervention and on its impact on patient outcomes. They determined that the appropriate use of thromboprophylaxis was ‘the number one patient safety practice’ for hospitals [11].

Prophylaxis modalities

  1. Top of page
  2. Abstract
  3. Introduction
  4. Prophylaxis modalities
  5. Prophylaxis guidelines – ACCP
  6. Prophylaxis use/adherence with the guidelines
  7. Strategies to increase the appropriate use of thromboprophylaxis
  8. Disclosure of Conflict of Interests
  9. References
  10. Some excellent additional resources

Multiple, proven thromboprophylaxis options are currently available to clinicians. Nonpharmacologic methods of thromboprophylaxis, including graduated compression stockings, intermittent pneumatic compression devices and venous foot pumps, have each been shown to reduce asymptomatic DVT in one or more patient groups [3,12]. While these mechanical prophylaxis methods do not increase the bleeding risk, there are many fewer studies of these devices and they appear to be less efficacious than pharmacologic prophylaxis at least in some groups. Furthermore, a substantial effort is required to ensure that optimal compliance with these nonpharmacologic methods is achieved in order to prevent VTE. Based on current evidence, mechanical prophylaxis options are best reserved for patients at high risk for bleeding or possibly combined with anticoagulant prophylaxis to try to enhance effectiveness [3]. In the high bleeding risk setting, anticoagulant prophylaxis can be substituted for or added to the mechanical method when the bleeding risk decreases.

The landmark International Multicentre Trial led by Professor VV Kakkar demonstrated that heparin 5000 units, administered subcutaneously three times a day, reduced DVT from 25% in the unprophylaxed control group to 8% and decreased fatal PE 8-fold in patients undergoing major surgical procedures [13]. A subsequent meta-analysis of 46 randomized trials including more than 15 000 surgical patients demonstrated a greater than 60% reduction in both asymptomatic DVT and fatal PE as well as a significant decrease in all-cause mortality with low dose heparin [8]. There have been no direct comparisons of BID and TID heparin. However, meta-analysis data suggest that TID heparin is more effective than BID. Furthermore, among patients undergoing hip arthroplasty or gynecologic surgery for malignancy, TID heparin appears to more efficacious than BID heparin based on indirect comparisons. For these reasons, TID heparin has been recommended over BID heparin as a prophylaxis option for patients undergoing cancer surgery [3]. Although low-dose heparin has been the mainstay of thromboprophylaxis for much of the past 30 years and remains a recommended option for most at-risk patients, it has a number of disadvantages, including the need for multiple daily injections, greater risk of heparin-induced thrombocytopenia, and lower efficacy in high-risk patients.

The low molecular weight heparins (LMWHs) have emerged as the most effective prophylaxis option for the greatest spectrum of patients and there is an ongoing trend towards LMWHs replacing unfractionated heparin [3,9]. The LMWHs have a rapid onset of action, short half-life (3–5 h), predictable dose–response effect (and, therefore, little variability among patients), low rates of heparin-induced thrombocytopenia, once daily dosing, and, in many countries, relatively low cost. Disadvantages include the need for subcutaneous injections and, in some countries, higher cost than unfractionated heparin. Any differences in clinically-important bleeding with the LMWHs compared with other methods of prophylaxis are either absent or small [9,14]. Although there are well-established chemical differences between the various LMWHs, there are few direct comparisons of these agents. Many experts consider the LMWHs to be interchangeable (as long as the doses are roughly similar). As with low dose unfractionated heparin, there is also a dose–response for efficacy of the LMWHs. For most at risk patients, the high prophylaxis dose (sometimes known as the ‘orthopedic dose’) is appropriate. A lower than usual dose should be considered in patients with body weight <40 kg. It is also reasonable to give a higher than usual dose for obese patients [15,16]. For example, we double the usual prophylaxis dose of LMWH in patients with body weight >100 kg. Others have proposed incremental dosing based on body weight [17]. In the presence of renal dysfunction, there does not appear to be a need to reduce the prophylaxis doses of LMWH at least for dalteparin and tinzaparin [18,19]. For enoxaparin, it is reasonable to reduce the dose with severe renal dysfunction as suggested by the manufacturer.

The synthetic indirect Factor Xa inhibitor, fondaparinux, has been shown to be more efficacious than LMWH in more than 7000 orthopedic surgery patients in the regimens that were used in the trials [20]. Fondaparinux was also efficacious in prophylaxis studies in general surgery and medical patients [21,22]. Disadvantages of this agent include: strong renal clearance, a long half-life (17–21 h) and possible increased bleeding risks.

The oral vitamin K antagonists such as warfarin have been used as thromboprophylaxis in major orthopedic surgery for several decades and, when used optimally, are effective at reducing the occurrence of VTE. However, the disadvantages of these agents as thromboprophylaxis include their delayed onset of action for several days after surgery, reduced efficacy compared with LMWH (with similar bleeding rates), marked variability in dose among patients, need for frequent laboratory monitoring, increased rates of bleeding with extended duration of prophylaxis, and the complexity of both in-patient and post-discharge supervision [3,12,23–25].

A number of multimodal thromboprophylaxis strategies are likely to be effective (for example, the combination of epidural anesthesia plus pneumatic compression devices plus elastic stockings plus aspirin plus anticoagulant prophylaxis in patients considered to be at particularly high risk). However, they are not included in prophylaxis guidelines because there are few randomized trials comparing these regimens to any of the recommended options and they may not be more effective and are more complex and costly than single modality options [26–29].

Recently, a number of oral direct inhibitors of Factor Xa or thrombin that are given in fixed doses without laboratory monitoring have been developed [30]. Two of these, rivaroxaban and dabigatran etexilate, have already been approved in some countries for the prevention of VTE following elective hip and knee arthroplasty. The Factor Xa inhibitor, rivaroxaban, has been assessed in four large, Phase III trials of thromboprophylaxis in elective hip and knee replacement surgery. This RECORD program demonstrated significant risk reductions in VTE rates compared with enoxaparin given either as 40 mg once daily or as 30 mg BID [31]. Dabigatran etexilate is an oral, direct thrombin inhibitor that has been shown to be approximately as efficacious and safe as LMWH in hip and knee arthroplasty patients [32,33]. The simplicity of these new oral agents overcomes many of the logistic limitations of alternative options for thromboprophylaxis.

A majority of symptomatic thromboembolic events that occur in surgical patients are diagnosed after the patient has left hospital. The increased risk of VTE continues for up to 3 months after THR and up to 1 month after TKR [34,35]. Multiple studies in major orthopedic surgery have compared the in-hospital use of thromboprophylaxis with prophylaxis that extended for 4–6 weeks after surgery. A meta-analysis of nine randomized trials, that included 4000 patients who underwent major orthopedic surgery, demonstrated a 51% risk reduction for venographic DVT and a 61% risk reduction for symptomatic VTE with extended prophylaxis without an increase in bleeding [36]. The extended use of fondaparinux in hip fracture patients essentially eliminated both asymptomatic DVT and symptomatic VTE compared with fondaparinux that was given in hospital for approximately 7 days [37]. As there is currently no method to identify reliably the orthopedic surgery patients who will develop post-discharge VTE, extended prophylaxis is recommended for all patients undergoing THR, TKR and HFS [3]. Although 4–6 weeks of prophylaxis is clearly superior to in-hospital prophylaxis, the optimal duration of prophylaxis between 2 weeks and 6 weeks is uncertain; this remains a local policy decision for the unit or for the individual patient. In two studies of patients who had undergone major cancer surgery, extended prophylaxis for 4 weeks with LMWH was shown to reduce the DVT rate compared with one week of prophylaxis [38]. At this time, because of the limited number of studies and uncertainty about which patients might benefit, the use of post-discharge prophylaxis in non-orthopedic surgical and medical patients should be individualized.

Prophylaxis guidelines – ACCP

  1. Top of page
  2. Abstract
  3. Introduction
  4. Prophylaxis modalities
  5. Prophylaxis guidelines – ACCP
  6. Prophylaxis use/adherence with the guidelines
  7. Strategies to increase the appropriate use of thromboprophylaxis
  8. Disclosure of Conflict of Interests
  9. References
  10. Some excellent additional resources

Since 1986, the American College of Chest Physicians (ACCP) has sponsored and published what are generally considered the most comprehensive and most commonly utilized evidence-based guidelines on the management and prevention of VTE. The 2008 ACCP Antithrombotic Guidelines are discussed in 23 chapters in a 900-page supplement to the journal CHEST [39]. The ACCP Guidelines are prepared by multidisciplinary, international groups of clinician-methodologists who adhere to the principles of guideline development. Extensive literature reviews are performed which lead to recommendations that are based on available evidence, patient and societal values and preferences as well as economic considerations. After extensive formal peer review, the primary principle of the ACCP guidelines is to have a transparent link between the evidence and the subsequent recommendations.

The 2008 ACCP Guidelines on the Prevention of VTE include discussions of the risks of VTE separately for 23 patient groups as well as the evidence for thromboprophylaxis with particular emphasis on randomized clinical trials [3]. For each patient group, graded recommendations for (or against) thromboprophylaxis are provided. It is recommended that every general hospital develop a formal, hospital-wide policy on the prevention of VTE and that thromboprophylaxis be administered to most hospitalized patients.

A summary of the 2008 ACCP Guidelines on the Prevention of VTE is found in Table 1. Most non-orthopedic surgery patients and sick medical patients have a moderate risk of VTE; the guidelines recommend the routine use of LMWH, low dose heparin, or fondaparinux. Patients who have undergone hip or knee arthroplasty or hip fracture surgery or patients who are recovering from major trauma have a high VTE risk and the guidelines recommend the routine use of LMWH, fondaparinux or warfarin (target INR 2.0–3.0). Most hospital patients at risk for VTE should continue thromboprophylaxis until discharge and not stop as soon as they start to ambulate. For major orthopedic surgery, the recommended duration of prophylaxis is at least 10 days with a strong recommendation to continue for up to 5 weeks.

Table 1.   Patient groups and recommended thromboprophylaxis options*
Patient groups and examplesThromboprophylaxis options
  1. *The recommended options may differ somewhat for specific patient groups based on available evidence. See the 8th ACCP guidelines on the prevention of VTE for more details [3].

Low VTE Risk
 Medical – fully mobile, brief admission, no additional risk factorsNo prophylaxis Early and frequent ambulation
 Surgical – procedure <30 min, mobile, no additional risk factors 
Moderate VTE Risk
 Acute medical illnessLow molecular weight heparin
 Major general surgeryLow dose heparin
 Major gynecologic surgeryFondaparinux
 Major urologic surgery  Thoracic surgeryCombinations of a physical method and an anticoagulant
 Bariatric surgery 
High VTE Risk
 Hip or knee arthroplastyLow molecular weight heparin
 Hip fracture surgeryFondaparinux
 Major trauma, spinal cord injuryRivaroxaban or dabigatran Warfarin (target INR 2–3) Combinations of a physical method and an anticoagulant
High bleeding risk
 Physical method of prophylaxis (GCS, PCD, VFP)
Consider anticoagulant prophylaxis when bleeding risk decreases

Prophylaxis use/adherence with the guidelines

  1. Top of page
  2. Abstract
  3. Introduction
  4. Prophylaxis modalities
  5. Prophylaxis guidelines – ACCP
  6. Prophylaxis use/adherence with the guidelines
  7. Strategies to increase the appropriate use of thromboprophylaxis
  8. Disclosure of Conflict of Interests
  9. References
  10. Some excellent additional resources

Despite the overwhelming evidence supporting thromboprophylaxis for most hospital patients, the rates of prophylaxis use are far from optimal [5,6,40–47]. In fact, audits demonstrate that the majority of medical, surgical and cancer patients do not receive appropriate thromboprophylaxis [5,6,40–47]. There is a strong link between suboptimal prophylaxis rates and both symptomatic VTE and increased costs of care [47–50]. For example, cancer patients receiving thromboprophylaxis that was partially compliant with the ACCP guidelines had a higher risk of VTE and higher total hospital costs than patients whose prophylaxis was fully adherent with the guidelines [50].

A high proportion of patients who develop VTE after a hospital admission have not received adequate prophylaxis during that admission. For example, among 1375 patients admitted with acute DVT within 3 months of a non-orthopedic surgical procedure, only 44% had received any form of thromboprophylaxis [51]. Among 567 Swiss patients who developed acute VTE during or within 30 days after a hospital admission, 42% had not received any prophylaxis (30% of the surgical patients and 52% of the medical patients) [47]. An international, cross-sectional audit of 35 000 inpatients at risk for VTE found that only 59% of surgical patients and 40% of medical patients received recommended prophylaxis [46]. There were striking differences in prophylaxis use among the 32 participating countries. Similarly, an international registry of thromboprophylaxis use in medical patients found that only 37% of at-risk patients received any prophylaxis [43]. Another audit of almost 86 000 surgical discharges from 225 American hospitals found that 73% of patients received some thromboprophylaxis, but appropriate thromboprophylaxis was provided to only 32% [45].

Strategies to increase the appropriate use of thromboprophylaxis

  1. Top of page
  2. Abstract
  3. Introduction
  4. Prophylaxis modalities
  5. Prophylaxis guidelines – ACCP
  6. Prophylaxis use/adherence with the guidelines
  7. Strategies to increase the appropriate use of thromboprophylaxis
  8. Disclosure of Conflict of Interests
  9. References
  10. Some excellent additional resources

A large number of strategies, both system-wide and local, have been developed to increase the appropriate use of thromboprophylaxis (Table 2) [52,53]. The availability of high-quality clinical practice guidelines is very helpful because they summarize an extensive and sometimes complex literature and provide evidence-based recommendations that can be broadly applied. However, even excellent guidelines do not improve patient safety unless these guidelines are incorporated into clinical practice.

Table 2.   Strategies to increase appropriate use of thromboprophylaxis
StrategiesExamples*
  1. *The examples are not intended to be comprehensive – there are other national and local strategies to improve thromboprophylaxis use

System-wide (national) strategies
 Excellent quality, evidence-based guidelinesACCP Guidelines on the Prevention of VTE
International Consensus Statement
 National standards of careThe Joint Commission/National Quality Forum – USA
National Institute for Health and Clinical Excellence (NICE) – UK
 Endorsement by national bodiesUS Surgeon General “Call-to-Action”
Society of Hospital Medicine (SHM)
American Society of Clinical Oncology (ASCO)
National Comprehensive Cancer Network (NCCN)
American College of Obstetricians and Gynecologists (ACOG)
Royal College of Obstetricians and Gynaecologists of England (RCOG)
Eastern Association for the Surgery of Trauma (EAST)
 Hospital accreditationThe Joint Commission – USA
Healthcare Commission – UK
 National or international quality improvement campaignsSurgical Care Improvement Project (SCIP) – USA
IHI 5 Million Lives Campaign – USA
WHO Surgical Safety Checklist – international
National Institute for Health and Clinical Excellence (NICE) implementation support program – UK
Safer Healthcare Now!– Canada
 Public reporting of thromboprophylaxis adherencehttp://www.hospitalcompare.hhs.gov
Premier
Leapfrog
 Pay-for-reporting and pay-for-performanceCenters for Medicare and Medicaid Services (CMS)
Surgical Care Improvement Project (SCIP)
Physician Quality Reporting Initiative (PQRI)
Blue Cross
 ‘No pay’ for complicationsCenters for Medicare and Medicaid Services (CMS)
 Medical-legal influencesConcerns about litigation
Local strategies
 Hospital leadership to support and participateCommitment to support evidence-based standardization of care
Senior leadership – CEO, program heads, department heads
Hospital boards
Clinical champions, opinion leaders
 Provider education/awareness raisingOf physicians, pharmacists, nurses
During undergraduate education
During postgraduate training
Grand rounds, newsletters
Dissemination of guidelines or other educational materials
Involve hospital media relations department
Interactive education sessions/educational outreach
 Implement written policy/care pathway/decision supportHospital-wide preferred
Clinical program or specific patient care unit
 Routine VTE risk assessment and protocol-driven thromboprophylaxisDone by admitting physician using a simple paper or electronic risk assessment model
Embedded in the hospital computerized patient information system
Done by other health professionals after admission (pharmacists, nurses)
 Hospital patient safety initiativesAHRQ VTE Prevention Quality Improvement Guide
Society of Hospital Medicine Guide for Effective Quality Improvement
 Audit and feedbackIndividual provider feedback
Small scale – local unit
Hospital wide
Local public reporting
 Provider reminder systemsPocket cards, posters, computer screensavers
Daily pharmacist review of patients
Daily nursing review of patients
Targeted computer alerts
 Order setsPaper pre-printed order sets
Mandated by the hospital
Computerized provider order entry (CPOE)
 Default policyOpt-out for prophylaxis orders
 Financial and other incentivesPatient safety measures linked to renumeration
 Involve patients Education
Encourage questioning of staff about safety practices
 Sentinel event investigation, reportingSystem review for fatal and symptomatic events

At the national or system-wide level, a number of countries have created incentives or legislation to induce hospitals to implement various patient safety practices, including thromboprophylaxis. For example, in the United States, the Surgical Care Improvement Project (SCIP), with the financial leverage of the Centers for Medicare and Medicaid Services (CMS), uses the strategy of pay-for-reporting to encourage hospitals to provide guidelines-recommended thromboprophylaxis to the vast majority of surgical patients in the country [54]. SCIP is assessing whether thromboprophylaxis, as recommended by the ACCP guidelines, has been ordered and commenced within 24 h after surgery for approximately 1 million surgical patients every year. Rates of adherence with VTE prophylaxis have been steadily increasing since this initiative began. The Joint Commission/National Quality Forum collaboration has also developed a series of standards of care as well as performance measures to evaluate the practices of hospitals in the prevention of VTE [55]. In 2005, they endorsed 30 evidence-based, safe practices for better healthcare, including Safe Practice 17 which recommends that every hospitalized patient be evaluated on admission, and regularly thereafter, for their risk of developing VTE and that the patients at-risk be given appropriate evidence-based thromboprophylaxis. The performance measures assess whether or not thromboprophylaxis has been started within 24 h of hospital admission or they require documentation of reasons why thromboprophylaxis is not indicated or is contraindicated. Other system-wide strategies include the public reporting of hospital thromboprophylaxis rates, the requirement of documentation of a prophylaxis policy for hospital accreditation, and a number of national or international patient safety initiatives including the Institute for Healthcare Improvement 5 Million Lives Campaign and the World Health Organization Surgical Safety Checklist.

Local interventions have also been assessed with respect to their impact on thromboprophylaxis use [52,56–59]. Passive dissemination of guidelines or thromboprophylaxis policies is ineffective as a single intervention [52]. Group educational activities alone may have some benefit, but the effects of this are generally short-lived [52,60]. Similarly, providing forms that include a VTE risk assessment and prophylaxis suggestions has limited impact unless strategies are implemented to ensure that these forms are actually completed [60,61]. Adapting evidence-based practice guidelines into local policies and protocols has been shown to increase significantly the proportion of at-risk patients receiving appropriate thromboprophylaxis [62,63]. The use of order sets that have thromboprophylaxis recommendations embedded among the other admission or postoperative orders is a particularly useful tool for improving thromboprophylaxis rates because they save time for physicians, nurses and pharmacists, they can be used in every patient group and implemented without extensive education or process redesign, lead to dramatic improvements in prophylaxis rates, can be used to easily audit adherence with prophylaxis use, and are readily upgraded as new evidence becomes available [42,61]. The impact of audit and feedback has also been demonstrated to substantially improve thromboprophylaxis use [52].

Computerized VTE risk assessment, based on the electronic medical record, and subsequent automatic physician alerts have been shown to both improve thromboprophylaxis use (from 14.5% to 33.5%) and reduce thromboembolic complications at 90 days (from 8.2% to 4.9%) in a randomized clinical trial in 2500 at-risk hospital patients who were not initially ordered prophylaxis [64]. Another study also demonstrated that a computer alert program resulted in increased use of thromboprophylaxis as well as reduced in-hospital VTE [65]. The increasing role of hospital patient information systems to alert physicians about VTE risk and to recommend thromboprophylaxis is a very powerful tool to increase the use of thromboprophylaxis and to decrease the rates of nosocomial VTE. These modalities can be designed in a manner to require clinicians to order thromboprophylaxis or to document the reason why prophylaxis is not needed or is contraindicated [66]. Accumulating evidence about improving the quality of thromboprophylaxis suggests that system changes are required as well as multifaceted interventions including provider education, reminders that are integrated with work flow, and default (or ‘opt out’) order entry supplemented by periodic, ongoing audit and feedback [59,67–70]. For example, a multifaceted quality improvement initiative based on the use of preprinted admission order sets, provider education, reminders, and audit and feedback, increased thromboprophylaxis use from 63% to 95% and reduced hospital-acquired DVT from 2.6 per 1000 discharges to 0.2 [59].

On the 50-year anniversary of the publication of the first clinical trial of thromboprophylaxis, it is appropriate to reflect on the great progress that has been made in this area of patient safety as well as on the substantial challenges that remain. Several hundred trials of thromboprophylaxis have been conducted and numerous evidence-based guidelines have been published since 1986 that identify at-risk patient groups and confirm the effectiveness, safety and cost-effectiveness of thromboprophylaxis. Despite this massive body of evidence, VTE remains an important cause of nosocomial morbidity and death, not because proven methods of prevention are not available, but rather, because a high proportion of patients do not benefit from the accumulated knowledge in this field. Both individual practitioners and health care organizations have responsibilities to provide thromboprophylaxis, the highest ranked patient safety intervention for hospitalized patients. Only when thromboprophylaxis is incorporated into the culture of routine care will every hospitalized patient receive thromboprophylaxis that is appropriate to their thromboembolic and bleeding risks. This requires, not only selection of an evidence-based option, but also starting the prophylaxis in a timely manner in relation to the thromboembolic risk, providing a correct dose if an anticoagulant is used, ensuring optimal compliance, and continuing the prophylaxis for the period of risk.

Disclosure of Conflict of Interests

  1. Top of page
  2. Abstract
  3. Introduction
  4. Prophylaxis modalities
  5. Prophylaxis guidelines – ACCP
  6. Prophylaxis use/adherence with the guidelines
  7. Strategies to increase the appropriate use of thromboprophylaxis
  8. Disclosure of Conflict of Interests
  9. References
  10. Some excellent additional resources

WHG has acted as a consultant for and/or received honoraria for speaking engagements from: Bayer Healthcare, Boehringer Ingelheim, Covidien, Pfizer, and Sanofi Aventis.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Prophylaxis modalities
  5. Prophylaxis guidelines – ACCP
  6. Prophylaxis use/adherence with the guidelines
  7. Strategies to increase the appropriate use of thromboprophylaxis
  8. Disclosure of Conflict of Interests
  9. References
  10. Some excellent additional resources
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Some excellent additional resources

  1. Top of page
  2. Abstract
  3. Introduction
  4. Prophylaxis modalities
  5. Prophylaxis guidelines – ACCP
  6. Prophylaxis use/adherence with the guidelines
  7. Strategies to increase the appropriate use of thromboprophylaxis
  8. Disclosure of Conflict of Interests
  9. References
  10. Some excellent additional resources