Closing the Gap in Thromboprophylaxis: A Multidisciplinary Quality Improvement Approach Among Medical Inpatients

ABSTRACT

Objectives: To evaluate the impact of a multidisciplinary quality improvement (QI) framework on guideline-directed venous thromboembolism (VTE) prophylaxis adherence among hospitalized patients.

Study Design: A prospective, pre-post interventional study conducted in internal medicine wards with historically low baseline prophylaxis rates.

Methods: Following a retrospective baseline assessment, a multicomponent QI initiative was executed across 2 Plan-Do-Study-Act cycles in adult internal medicine wards at a university hospital between September and November 2022. Interventions included the following: (1) physician education on the Padua Prediction Score and International Medical Prevention Registry on Venous Thromboembolism Bleeding Risk Score; (2) implementation of an electronic health record clinical decision-support tool prompting VTE risk assessments; and (3) integration of clinical pharmacists into daily multidisciplinary rounds to provide active audit and feedback.

Results: At baseline, 62.1% of high-risk patients received guideline-recommended VTE prophylaxis. Post intervention, this rate increased to 79.1% in the first cycle and 82.1% in the second cycle (P = .006). Among clinical pharmacists' 27 recommendations, 70.4% were accepted and implemented. The multidimensional strategy demonstrated sustained improvements in guideline adherence with minimal adverse events.

Conclusions: Implementing a multidisciplinary QI framework significantly enhanced guideline-directed VTE prophylaxis use among hospitalized patients. This collaborative approach underscores the value of electronic decision support, clinical audit-feedback loops, and pharmacist-physician integration in driving patient safety. Ultimately, this system-level strategy provides a scalable model for improving preventive care protocols across diverse hospital settings.

Am J Manag Care. 2026;32(10):In Press

doi:10.37765/ajmc.2026.90031

Takeaway Points

Venous thromboembolism (VTE) remains a leading preventable cause of harm in hospitalized patients, yet prophylaxis gaps persist. Results of this study show that closing these gaps requires coordinated change across education, workflow, and oversight to ensure long-term sustainability.

• Coordinated workflows combining electronic decision-support tools with audit-and-feedback sessions significantly increased guideline-concordant VTE prophylaxis in internal medicine wards.
• Integrating clinical pharmacists into multidisciplinary teams served as a key driver of workflow adaptation, achieving a recommendation acceptance and implementation rate of more than 70%.
• Sustained institutional oversight can be maintained long term by embedding VTE protocols into the residency curriculum and incorporating quality indicators into routine hospital audits.

Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary thromboembolism, poses significant risks to hospitalized patients, particularly those with certain medical conditions or prolonged immobility.^1,2 VTE is responsible for 5% to 10% of hospital mortality among medical inpatients and remains a primary preventable factor.^3-5 Effective risk assessment and appropriate prophylaxis are essential for improving outcomes.

Guidelines for VTE management across various health care settings emphasize thorough risk assessment and prophylaxis for high-risk patients in medical and nonsurgical settings.^6-9 However, the ENDORSE study revealed that although41.5% of hospitalized medical patients were at VTE risk, and only 39.5% of these received ACCP-recommended prophylaxis.¹⁰Conversely, other studies have shown that 33% to 74% of low-risk patients receive unnecessary thromboprophylaxis.^11-14

Our institution’s experience mirrors these findings: A 2019 study found that only 30.2% of high-risk medical inpatients received guideline-recommended thromboprophylaxis, which improved modestly to 53.9% by 2021.^15,16 Interestingly, this improvement occurred when formal VTE initiatives were interrupted by the COVID-19 pandemic—a phenomenon we termed the “collateral benefit of pandemics,” as heightened awareness of VTE risks in patients with COVID-19 appeared to reduce clinicians’ hesitation to prescribe prophylaxis more broadly.¹⁶

Despite this unintended improvement, our prophylaxis rates remained suboptimal (30%-54%).^15,16 To address this persistent gap, we redesigned a structured approach based on evidence that multidisciplinary teams can enhance thromboprophylaxis through quality improvement (QI) initiatives that combine education, decision support, and audit-feedback loops.^10,17-21

This study evaluated the impact of a comprehensive QI initiative integrating physician education, audit and feedback, and clinical pharmacist involvement on the implementation of guideline-recommended VTE prophylaxis among hospitalized medical inpatients, excluding those admitted to surgical and oncology wards. Our interventions aimed to improve guideline-concordant prophylaxis rates over a 6-month period through 2 Plan-Do-Study-Act (PDSA) cycles.

METHODS

This study was conducted at a 1100-bed tertiary-care academic hospital and employed a multidisciplinary QI framework to improve guideline-recommended VTE prophylaxis use among hospitalized internal medicine patients. The internal medicine wards comprise 120 beds. The study consisted of a retrospective analysis to establish a baseline, followed by a prospective intervention that applied 2 PDSA cycles for iterative improvement.¹⁵ Following the baseline assessment, the allocation of hospital resources was revised, and the hospital’s electronic health record (EHR) system was prepared for planned implementation.

Study Design and Participants

The retrospective analysis evaluated adherence to guideline-recommended VTE prophylaxis (eAppendix Table 1 [eAppendix available at ajmc.com]) in medical inpatients hospitalized in general internal medicine wards (excluding surgical and oncology wards) between March 21 and September 21, 2021, aiming to quantify the extent of misalignment between guideline recommendations and actual practice at our institution. The prospective phase was initiated on June 1, 2022, with 2 PDSA cycles; each cycle lasted 3 months, followed a defined strategy, and was conducted in the same general internal medicine wards (excluding surgical and oncology wards).

Eligible patients were those 18 years or older admitted for medical reasons to the internal medicine ward during the study period. Exclusion criteria included pregnancy, current anticoagulant therapy including home-based regimens, a VTE diagnosis, a hospitalization lasting less than 24 hours, the duration of interventions during hospitalization (if unplanned surgical or invasive procedures were required), a history of bone marrow transplantation, or refusal to provide informed consent. Informed consent was obtained from all participants included in the prospective part of the study. Patients who previously had VTE and their families were not involved in defining the research question or the outcome measures. However, their experiences were integral to the design and implementation of the intervention.

We collected data on demographics, the Padua Prediction Score (used to estimate VTE risk), the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) Bleeding Risk Score, comorbidities, and reasons for hospitalization. The Padua Prediction Score was assessed within 24 hours of hospital admission by the admitting medical resident through the EHR system and independently verified by the clinical pharmacist during daily rounds. Patients with a Padua Prediction Score of 4 or higher were categorized as high risk for VTE. The IMPROVE Bleeding Risk Score was calculated by the clinical pharmacist within 24 hours of admission, and patients with a score of 7 or higher were classified as high risk for bleeding.

Guideline adherence was assessed according to the use of recommended prophylaxis (pharmacological or mechanical through the assessment of the patient’s bleeding risk) with regard to the assessed risk of the patients.^6,7,9 Prophylaxis was classified as “inappropriate” for patients who did not receive guideline-recommended thromboprophylaxis despite being at high risk and for patients who received thromboprophylaxis despite being at low risk (eAppendix Table 1). Patients were evaluated within 24 hours for mobility risks, taking their prehospital baseline into account. Those who were bedridden and older or physically disabled were generally immobile, and it was determined that they were also immobile before hospital admission. Patients were assessed daily during their hospital stay, and their prophylaxis regimen was revised as necessary when changes in mobility were observed. In patients with chronic kidney disease, doses were adjusted based on creatinine clearance estimated with the Cockcroft-Gault formula. Suboptimal low doses (< 10,000 IU of unfractionated heparin daily or a lower adjusted dose of enoxaparin [Lovenox]) or failure to administer mechanical prophylaxis (compression stockings, pneumatic compression) were considered inappropriate VTE prophylaxis.

QI Strategy

The QI initiative began with a retrospective analysis to establish baseline performance, followed by 2 prospective PDSA cycles. Our approach integrated 3 key strategies: provider education, clinical decision support (through clinical pharmacists and EHR-based tools), and audit-feedback loops. These interventions were implemented synchronously.

Provider Education. Educational interventions occurred at multiple levels. Biannual 1-hour lectures were integrated into the internal medicine residency curriculum as mandatory sessions. However, for this specific QI initiative, these lectures were delivered at the beginning of each 3-month PDSA cycle. These lectures included guideline summaries for senior and junior medical residents, emphasizing the Padua Prediction Score and IMPROVE Bleeding Risk Score systems, the importance of guideline-recommended VTE prophylaxis (including drug selection, dose adjustments, pharmacological/nonpharmacological treatment selection according to risk stratification [eAppendix Table 1]), and reviews of cornerstone studies. Absolute contraindications to anticoagulant prophylaxis—including active bleeding; severe bleeding diathesis; acute intracranial hemorrhage; high-risk surgical procedures performed within the last 3 weeks; or lumbar puncture, epidural, or spinal anesthesia within the previous 4 hours or expected in the next 12 hours—were explicitly reviewed during these educational sessions.

Additionally, monthly small-group sessions on VTE prophylaxis were conducted for ward-assigned medical residents (approximately 10 residents per group). These sessions focused on guideline-based risk assessment and prophylaxis strategies. The content evolved based on feedback from both the clinical pharmacist and medical residents, addressing frequently observed issues such as “irrational fear of bleeding complications” and “inappropriate dose reductions.”

Consultants, defined as specialist-physicians responsible for inpatient care, were also informed about the initiative and requested to verify each patient’s bleeding and VTE risk assessment during routine ward rounds, checking for mismatches between calculated scores and assigned prophylaxis regimens. The Padua Prediction Score was embedded in the EHR and required completion by admitting medical residents as part of routine admission workflows. Attending physicians (consultants) were expected to review these entries during ward rounds; however, their verification or correction was not always documented in the EHR, as this depended on individual practice patterns. As part of the QI intervention, the clinical pharmacist independently recalculated both the Padua Prediction Score and IMPROVE Bleeding Risk Score during daily rounds. Because pharmacists did not have EHR documentation privileges, risk-score corrections or discrepancies were communicated verbally to the attending physician, who incorporated the information into the clinical plan when appropriate.

Clinical Decision Support. A clinical pharmacist participated in daily patient care rounds and conducted comprehensive reviews. During these reviews, the pharmacist assessed patients’ VTE and bleeding risks by evaluating relevant laboratory parameters (eg, platelet count, coagulation studies, creatinine/estimated glomerular filtration rate), potential drug interactions, and medication dosing. All new admissions were assessed within 24 hours of arrival. If the patient was admitted on a holiday or weekend, the assessment was performed on the following weekday.

Using the Padua Prediction Score and IMPROVE Bleeding Risk Score tools, the pharmacist identified high-risk patients and provided recommendations during rounds with consultants or directly to medical residents managing patient care. For example, the pharmacist would highlight high-risk features such as active cancer or reduced mobility and suggest guideline-recommended pharmacological prophylaxis or dose adjustments. Similarly, the pharmacist used the IMPROVE Bleeding Risk Score to guide the selection of prophylaxis modality. For high–VTE-risk patients with high bleeding risk (IMPROVE score ≥ 7), recommendations favored mechanical prophylaxis (intermittent pneumatic compression devices) or closer monitoring if pharmacological prophylaxis was clinically indicated. For high–VTE-risk patients with low bleeding risk (IMPROVE score < 7), the pharmacist advocated for pharmacological prophylaxis when it had been inappropriately withheld.

On days without medical ward rounds, the pharmacist continuously provided feedback on VTE risk assessments and reviewed medication orders during medical resident patient management sessions. Any discrepancies identified during these sessions were escalated to morning consultant rounds for resolution. Recommendations included initiating prophylaxis, adjusting anticoagulant doses, and discontinuing unnecessary therapy.

The Padua Prediction Score was also integrated into the hospital’s EHR system as a mandatory pop-up prompt that appeared before the first medical order could be entered. This ensured that all patients underwent VTE risk assessment during admission. Occasional scoring inaccuracies (eg, incorrect assignment of points) were identified and corrected in real time through direct feedback or escalated to the attending consultant during ward rounds. The importance of accurate scoring was further emphasized during the educational sessions.

Audit-Feedback Loops. Patient data were collected daily, and review reports were examined to determine whether recommendations had been implemented in subsequent medication orders. Feedback was provided directly to consultants and through weekly reports submitted to the field investigator (MÖ).

Audits served not only to monitor adherence to guidelines but also to resolve conflicts, such as instances in which medical residents perceived the initiative as intrusive on their workflow. Constructive feedback emphasized the program’s collaborative nature, highlighted the principle of endorsement over enforcement, and aimed to improve staff acceptance.

Implementation Through PDSA Cycles

The initiative was implemented over 2 PDSA cycles, with adjustments between cycles based on observed outcomes and feedback.

Cycle 1 (June-August 2022; 3 months): Initial implementation of interventions and data collection. This cycle mainly focused on provider education and the integration of clinical pharmacists into medical admission assessment rounds on VTE risk assessment and prophylaxis, with ward nurses supporting by monitoring prophylaxis administration.

Cycle 2 (September-November 2022; 3 months): Adjustments based on feedback. This cycle focused on audit and feedback (eg, emphasizing mechanical prophylaxis as an adjunct rather than an alternative to pharmacological prophylaxis for high-risk patients and removing mild thrombocytopenia [platelet counts > 50 × 10⁹/L] as a contraindication) and clinical decision support through clinical pharmacist involvement.

At the end of each cycle, the rate of guideline-recommended VTE prophylaxis was evaluated by the number (%) of patients at high risk and at low risk who received guideline-recommended prophylaxis (eAppendix). Moreover, the adherence rate to the guideline was evaluated as a composite metric encompassing the number (%) of patients who received guideline-recommended prophylaxis, whether at high risk or at low risk. A comparative analysis was conducted to assess the rates across the designated study periods.

Outcomes

The primary outcome was the rate of guideline-recommended VTE prophylaxis among high-risk patients across the 3 study periods. Secondary outcomes included the rate of guideline-recommended prophylaxis among low-risk patients; the composite guideline adherence rate (encompassing both high- and low-risk patients); the clinical pharmacist’s recommendation acceptance rate; and the incidence of VTE, heparin-induced thrombocytopenia, and clinically significant bleeding during the study period.

Statistical Analysis

Sample size was calculated using Cohen h to quantify effect size, which was then applied to the standard sample size formula for comparing 2 independent proportions. The study was powered to detect an increase in the guideline-recommended prophylaxis rate from a previously reported 60%¹⁶ to a target of 75%, with 80% power and a 5% margin of error. This yielded a minimum sample of 153 patients per group, for a total of 306 patients. The data were examined using IBM SPSS Statistics 23 (IBM Corporation). Normality was assessed with the Kolmogorov-Smirnov test. Because none of the continuous variables were normally distributed, they were presented as medians with IQRs and compared across the 3 periods using the Kruskal-Wallis test. The χ² test was used for categorical variables.

In the retrospective analysis, patients were assigned anonymous identification numbers, and data were retrieved from the hospital information management system as encrypted files. Informed consent was not required for retrospective data but was obtained for prospective data collection and analysis. Prospective clinical data were also encrypted and deidentified after the analysis period. This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Hacettepe University Non-Interventional Clinical Research Ethics Committee(No. GO 2022/735).

Post hoc pairwise comparisons were performed when overall comparisons were statistically significant across the 3 study periods. The Dunn test with Bonferroni correction was applied to continuous variables, and pairwise χ² tests with Bonferroni correction were used for categorical variables. Only the overall P values are presented in the tables; the results of the post hoc pairwise comparisons are described in the text and table footnotes. Statistical significance was defined as P < .05.

RESULTS

The study included 653 hospitalized patients across 3 periods: 300 in the retrospective cohort, 193 in the first prospective cycle, and 160 in the second prospective cycle (Figure 1).

Among all patients, 47.9% were female, and no significant differences were found between the groups in patient demographics (Table 1). The most common comorbidities were hypertension (41.5%), diabetes (29.7%), chronic kidney disease (17.3%), and malignancy (particularly, acute myeloid leukemia and acute lymphocytic leukemia) (16.8%); no patients were diagnosed with COVID-19. The number of patients assessed at high risk of VTE (n = 247) was similar across the 3 periods (n = 124, n = 67, and n = 56, respectively), whereas the total number of patients assessed at high risk of bleeding was higher in the first cycle (n = 31; 16.1%) than in the second cycle (n = 11; 6.9%) and retrospective baseline (n = 36; 12%). The number of patients assessed as high risk for VTE and low risk of bleeding was similar in the retrospective and prospective periods.

At baseline assessment, 62.1% of patients at high risk of VTE received thromboprophylaxis, which increased to 79.1% in the first prospective cycle and to 82.1% in the second (Table 2). Appropriateness criteria are detailed in eAppendix Table 1. The main reason for inappropriate prophylaxis was failure to initiate thromboprophylaxis during hospitalization (53%); however, no patients received inadequate doses for thromboprophylaxis during any study period (Table 2).

Figure 2 stratifies prophylaxis appropriateness by both VTE and bleeding risk categories. Although patient numbers varied across study periods, the proportional analysis demonstrates that the intervention most effectively targeted the highest-priority group: The proportion of patients assessed with a high risk of VTE and a low risk of bleeding was 71 (82.6%) in the retrospective period compared with 86 (81.1%) in the prospective period (Figure 2[B]).

Regarding thromboprophylaxis management, drug therapy (98.8%), primarily enoxaparin (82.7%), was the preferred method for all patients without contraindications. A small proportion of patients received nonpharmacological prophylaxis (3 of 192 were given mechanical thromboprophylaxis). The incidence of VTE was recorded in 1 patient during the retrospective period and in no patients during the prospective periods. Heparin-induced thrombocytopenia was not observed at any point during the study; clinically significant bleeding occurred in only 1 patient during the first cycle of the prospective period, with no bleeding in the retrospective period.

The distribution of individual Padua Prediction Score components showed that reduced mobility/immobility (37.3% at baseline vs 26.9%-29.4% in prospective cycles), acute infection and/or rheumatological disorder (55.7% vs 48.7%-53.9%), and obesity (21.0% vs 15.0%-19.2%) were the most common risk factors across all study periods (eAppendix Table 2). Similarly, the distribution of IMPROVE Bleeding Risk Score components remained relatively stable, with the most prevalent factors being aged 40 to 84 years (61.0%-69.4%), male sex (50.6%-54.9%), and mild to severe kidney failure (28.7%-29.6% combined) (eAppendix Table 3).

During the prospective phases of the study, the clinical pharmacist actively engaged with admitting medical residents, securing numerous ward-based discussions to optimize VTE prophylaxis, but those interactions were not recorded. Discrepancies that arose were escalated to consultant rounds for final decision and recorded in the weekly report to the QI team. A total of 27 recommendations were made by the pharmacist, addressing various aspects of VTE management: initiating new pharmacological prophylaxis (n = 14), starting mechanical prophylaxis (n = 2), changing the current anticoagulant drug (n = 4), discontinuing anticoagulation (n = 3), and increasing the anticoagulant dose (n = 4). Among these, 70.4% were accepted and implemented by the attending physicians, reflecting a high level of collaboration and adaptation to the QI initiative.

DISCUSSION

This study evaluated the impact of a comprehensive QI intervention on VTE prophylaxis in hospitalized patients. Our multifaceted approach combined physician education with clinical decision support tools and an audit-feedback mechanism, implemented through a multidisciplinary team that included a clinical pharmacist. The results were significant: The proportion of high-risk patients receiving guideline-recommended VTE prophylaxis increased from 62.1% at baseline to 79.1% in the first cycle and to 82.1% in the second cycle. Notably, clinical pharmacists’ recommendations achieved a 70.4% acceptance rate, demonstrating successful integration of the QI initiative in our setting. This emphasizes the value of interdisciplinary communication and coordination in maintaining evidence-based treatment.¹⁸ Although it is challenging to determine whether provider education or clinical pharmacist feedback had the greater impact on clinical practice, it is clear that integrating multiple QI strategies resulted in substantial and sustained improvements. The development of clinical decision support systems that use artificial intelligence to calculate Padua Prediction, Caprini risk, or Khorana risk scores for assessing the risk of VTE in medical, surgical, or oncology patients may offer numerous advantages in clinical practice.

The multinational ENDORSE study, which evaluated 15,487 inpatients, found that 41.5% (24% in the Turkish population arm were at high risk, whereas 38.5% received appropriate prophylaxis) of patients are at high risk of VTE.^10,22 More concerning, the DissolVE-2 study showed that only 9.3% of patients at high risk of VTE received guideline-concordant thromboprophylaxis.²³ These findings highlight a critical gap in care: A significant proportion of vulnerable patients are not receiving guideline-recommended VTE prophylaxis.

Although the prevalence of patients at high risk for VTE appears relatively consistent across countries,^10,22 there are marked variations in prophylaxis implementation. The ENDORSE study reported that VTE prophylaxis rates in high-risk patients ranged from 3% to 70% across different regions.¹⁰ We hypothesize that these disparities stem from a combination of physician-related factors (varying experience or opinions, concerns about bleeding complications, unfamiliarity with current guidelines), health system issues (absence of local protocols, insufficient training, reimbursement limitations, or unavailability of mechanical prophylaxis), and pharmacist-related factors (differences in the roles and responsibilities of pharmacists across countries). The complex nature of VTE management underscores that effective prophylaxis requires a multifaceted approach and interdisciplinary collaboration.

Previous research has consistently shown that multidisciplinary interventions—including education, clinical decision support, audits, and feedback—can significantly improve VTE prophylaxis rates.^19-21,24-27 One of those studies reported that appropriate prophylaxis rates increased from 43% to 86% after implementing a multifaceted intervention that included regular supervision, feedback to medical residents, periodic education, and the distribution of decision support tools.¹⁹ Another evaluation of clinical pharmacist services over 12 months showed that the proportion of high-risk patients receiving VTE prophylaxis increased from 36% at baseline to 68% at 3 months and 72% at 12 months.²¹ A Turkish study focusing on surgical patients found that optimal VTE prophylaxis rates rose from 40% before intervention to 45% after educating physicians and posting reminders in clinics, and to 59% when multidisciplinary care included clinical pharmacist recommendations.²⁴ Notably, a VTE stewardship team that combined education, daily medication chart audits, weekly clinician performance evaluations, and regular audits demonstrated significant improvements in appropriate prophylaxis prescribing.²⁰ Even simpler interventions, such as educational posters highlighting the importance of VTE prophylaxis, have shown positive effects, with one study reporting a dramatic increase in the proportion of eligible patients receiving prophylaxis.²⁸ In this study, the combined multifaceted intervention was implemented through the following: 1) a clinical pharmacist actively participating in ward rounds by providing recommendations regarding anticoagulant dose monitoring and adjustment; 2) regular feedback to physicians regarding VTE prophylaxis practice in accordance with the guidelines and institutional policy; 3) periodic physician education regarding drug use and guideline recommendations; 4) development and implementation of an alert system that can be integrated into hospital EHRs; 5) routine risk assessment and stratification for thrombosis and bleeding; 6) assessment and management of adverse drug reactions by monitoring patients’ medical records; and 7) development and implementation of decision support tools. However, attributing improvements to specific components of these interventions remains challenging, and maintaining these gains often depends on the continued involvement of dedicated health care professionals within the clinical setting.

The persistence of unnecessary VTE prophylaxis in low-risk patients, although it decreased from 5% to 3% in our study (P = .68), suggests that additional efforts are needed to eliminate inappropriate anticoagulant use, given the potential for adverse events and the burden of additional monitoring. However, these cases might also represent situations in which clinical judgment identified substantial VTE risk despite a low score. The overarching objective of guidelines is to strike a balance between the overuse of thromboprophylaxis (excessive risk of bleeding) and underuse (risk of avoidable VTE). In a modeled analysis using IMPROVE risk-assessment scores, patients at low bleeding risk (score < 7) had a 0.5% probability of major or clinically significant bleeding compared with 3.4% among those at high bleeding risk (score ≥ 7; P = .001), whereas VTE probability did not differ significantly by VTE-risk category.²⁹ These findings demonstrated that 44% of VTE prophylaxis decisions were inappropriate (13% due to underuse and 31% due to overuse).²⁹ Findings from a cohort study by Glise Sandblad et al indicated that the risk of excessive bleeding from anticoagulant treatment was high during the initial treatment period (incidence rate difference: 2.19 per 100 person-years), particularly among female patients and older patients, but lower during extended treatment (incidence rate difference: 0.70 per 100 person-years).³⁰ Although clinical guidelines enhance decision quality, rigid adherence to scoring tools and inflexible recommendations may limit clinicians’ ability to personalize care. As noted, these scoring systems have inherent limitations, and effective assessment still requires clinical expertise to account for individual patient circumstances.³¹

A study conducted by Kahn et al investigated the efficacy of various interventions (eg, alerts, educational courses, preprinted orders, or multifaceted) in enhancing the rate of prophylaxis or appropriate prophylaxis. Alerts were associated with an increase in the rate of prophylaxis and of appropriate prophylaxis; multifaceted interventions were associated with a small increase in the rate of prophylaxis. A similar trend was observed in this study: The implementation of multifaceted interventions (eg, electronic and human alerts, education, and continuous feedback) in the second cycle increased the rate of guideline-recommended prophylaxis.³²

Strengths and Limitations

One of this study’s strengths is its substantial sample size and its demonstration of the impact of a QI initiative. Beyond the immediate research findings, this project has contributed to sustainable improvements in VTE prophylaxis practices, with provider education now incorporated into the internal medicine residency curriculum and quality indicators integrated into regular hospital audits. Existing literature demonstrates that multidisciplinary approaches improve prophylaxis rates,^18-21,24-28 but questions about how to implement these interventions in resource-limited settings remain incompletely addressed. Our study bridges this gap by providing granular implementation details: the iterative refinements between PDSA cycles, quantified pharmacist-integration metrics showing a 70.4% recommendation acceptance rate, and strategies for managing workflow concerns among medical residents. These operational insights offer a replicable framework for institutions where baseline adherence is low and QI infrastructure is developing.

Study limitations include the single-center design, which may limit generalizability, and a sample size insufficient to demonstrate significant improvements in clinical end points such as VTE incidence or bleeding complications. Although there was a higher proportion of high-risk patients in the baseline period than in the interventional periods, the variation in this proportion across study periods appeared random and did not affect our primary outcomes. Additionally, we did not formally assess changes in providers’ knowledge or conduct a pharmacoeconomic evaluation of adverse event prevention or of cost or time benefits of the pharmacist’s role in the risk assessment process—outcomes that, although valuable, were beyond our primary objectives. Although we had initially planned to extend this project to other clinical areas, time and resource constraints prevented this broader implementation. However, our findings suggest that the study design could be extended to different patient populations or hospital wards in future implementation efforts to sustain QI in patient care.

CONCLUSIONS

Assessing the need for VTE prophylaxis in hospitalized patients is a multifaceted process that requires a comprehensive assessment of patient-specific factors, the selection of guideline-recommended prophylaxis modalities, timely initiation and adherence to prophylactic measures, monitoring for adverse events, and patient education. With appropriate implementation of guideline-recommended VTE prophylaxis, health care professionals can reduce the incidence of thromboembolic events and improve overall patient safety and clinical outcomes among hospitalized patients. Multidisciplinary collaborative care helps bridge the gap between clinical practice and guideline recommendations, thereby improving the quality of care.

Author Affiliations: Faculty of Pharmacy, Department of Clinical Pharmacy (TES, ABE), Hacettepe University, Ankara, Turkiye; Faculty of Medicine, Department of Internal Medicine (MÖ, MDT), Hacettepe University, Ankara, Turkiye; Faculty of Life Sciences and Medicine, King’s College London (MÖ), London, UK.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (TES, MDT, ABE); acquisition of data (TES); analysis and interpretation of data (TES, MÖ, MDT, ABE); drafting of the manuscript (MÖ, ABE); critical revision of the manuscript for important intellectual content (MÖ, MDT, ABE); statistical analysis (MÖ); and supervision (MÖ, MDT, ABE).

Address Correspondence to: Aygin Bayraktar-Ekinciog˘lu, Hacettepe University, Faculty of Pharmacy, Department of Clinical Pharmacy, 06100 Sıhhiye-Ankara, Turkiye. Email: aygin@hacettepe.edu.tr

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