Barriers to Venous Thromboembolism Prophylaxis
A critical step in translating evidence into practice is to understand local culture and where barriers to implementation may lie.
Review your VTE prophylaxis process from risk assessment and prescription order to administration and documentation. Assess what is already in place and whether it meets current standards.
This section describes barriers the implementation team has experienced when helping sites implement the intervention. Use it as a general guide to help you consider where barriers may lie.
Organizational/Health System/Hospital Policies
Identify policies or protocols implemented when a prescribed medication is not given due to 1) patient refusal or 2) other reasons.
- Dig deep; information may be buried in appendices or in manuals
- Review content to assess if recommendations are congruent with current clinical guidelines
- Evaluate inter-policy or protocol alignment
- Confer with appropriate policy sponsor to address inconsistencies, for example, risk management, pharmacy, nursing
Data Collection and Analytics Infrastructure
The electronic health record (EHR) system enables collecting data regarding VTE risk assessment, prescription and administration of VTE prophylaxis.
- Work with an EHR data specialist (e.g., report writer or clinical informatician) to identify what data are currently being captured in the EHR regarding VTE prevention
- Develop a standardized report to routinely (e.g., monthly) capture data regarding VTE risk assessment, VTE prophylaxis prescription and administration, and VTE outcomes
- Use data to identify specific opportunities to improve VTE prevention practice, which may include improving VTE risk assessment, improving VTE prophylaxis prescription or administration of prescribed prophylaxis
Barrier: The absence of an EHR system to facilitate data collection
Barrier: Identifying IT professionals who can assist with pulling data from the EHR system
In addition to organizational level barriers, review the steps in implementation of best practice VTE prophylaxis. Barriers may reside in each of the individual areas that impact prescription to administration.
- Identify training process for VTE risk assessment and appropriate prophylaxis orders
- Evaluate communication of guidelines for appropriate reasons to hold doses and required EHR documentation
- Review the process to best impact patient refusals
- Utilize decision support tools to optimize prescription 
Barrier: Culture that inappropriately supports VTE prophylaxis holds for procedures; for example, PICC line placement, surgical procedures and other reasons not backed by evidence, such as holds for patients ambulating. 
- Review all VTE prophylaxis education, including online, in-person and other methods, to assess alignment with current guidelines and practice
- Identify unit culture that may affect administration 
- Avoid presenting ambulation as a substitute for prescribed pharmacologic VTE prophylaxis [3, 4]
Barrier: Inconsistent messaging
Most patients are not aware of their increased risk of VTE while hospitalized, nor the safety measures used to reduce that risk. [5,6]
- Identify education offerings on VTE prevention
- Assess content of materials given to patients to determine if congruent with current clinical guidelines
- Evaluate content for health literacy criteria (layout, lay person language) [7,8,9]
Barrier: Use of educational offerings that inappropriately emphasize ambulation as a substitute for pharmacologic prophylaxis.
Barrier: Inconsistent messaging from staff members regarding importance of pharmacologic prophylaxis may lead to non-adherence.
- Determine what role your pharmacist plays in unit-based patient education, for example first dose education and side effects
- Evaluate consistency of messaging across disciplines
Barrier: Medication access may impact missed doses related to pharmacy review and approval prior to medications release.
Barrier: Some medication stations may have inadequate supply to meet the demand of administration.
Education for Other Clinical Team Members
- List all staff who interact with patients, for example, clinical technicians, associates, physical and occupational therapists
- Review any education offerings for congruency with current clinical guidelines
- Assess knowledge of best practices for VTE prophylaxis
- Dispel myths: ambulating a substitute for prescribed VTE prophylaxis including mechanical prophylaxis (Sequential compression device and thromboembolic deterrent stockings)
Barrier: Inconsistency with messaging of evidence based VTE prophylaxis measures may influence patient adherence.