Venous Thromboembolisms (VTE)

Publication ID: 6233824595
Published on: August 2023
Major Revision: August 1, 2024


Our actionable evidence-based practices were designed by world-renowned patient safety experts to serve as proven step-by-step guidelines on eliminating the top causes of preventable harm. This blueprint has a proven track record of ensuring the best patient care. Please note that our guidelines are continually updated and incorporate the latest safety practices recognized as the gold standard of care.
Frontline staff

This blueprint outlines the steps that frontline staff can follow to prevent venous thromboembolisms (VTE):


  1. Utilize risk-assessment models, such as Caprini and Padua, to evaluate all patients admitted for a risk of developing VTE.
  2. Record risk-assessment determination in the EHR.
  3. Prescribe risk-appropriate VTE

Routine Care:

  1. Administer all doses of prescribed risk-appropriate VTE prophylaxis throughout hospital admission.
  2. Reassess VTE risk frequently throughout hospitalization and adjust VTE prophylaxis for the patient’s current VTE risk profile, as needed.
  3. Utilize guideline-appropriate VTE prophylaxis, recommending type, dose, timing, and duration of anticoagulants.
  4. Monitor the anticoagulant response.
  5. Monitor signs and symptoms of bleeding, such as GI bleeding in stool, oozing at wound and/or incision sites, nosebleeds, and/or coughing up blood.
  6. Explain to the patient and family members what VTE is and why the patient in particular is at risk for VTE, and elaborate on the method of VTE prophylaxis.
  7. For patients receiving anticoagulation after a major bleeding episode, resume oral anticoagulants within 90 days rather than completely discontinuing them.
  8. Monitor for signs and symptoms of bleeding.


  1. Consider extended prophylaxis for patients who may be at high risk for developing VTE after discharge and coordinate close follow-up appointments to carefully manage risks and benefits associated with extended anticoagulation.
  2. Assess the risk of patient bleeding or falling post-discharge and discuss with patients and family members.
  3. Evaluate possible drug interactions patient may experience post-discharge, such as with direct oral anticoagulants.
  4. Educate patients and family members on symptoms of deep vein thrombosis, pulmonary embolism, and bleeding.
  5. Consider low molecular weight heparin and direct oral anticoagulants 7–14 days post-discharge.
  6. Use read-back methods to ensure the patient knows what to do if symptoms are present.
  7. Describe the organization’s VTE standards to patient and family members. If any of the protocols changed due to this specific patient’s circumstance, articulate these changes to the patient and family members.
  8. Help the patient and family members integrate this VTE prophylaxis into their daily lives post-discharge, if applicable.
  9. Be sure to thoroughly explain necessary post-discharge appointments, therapies, medications, and potential complications.
    1. Assess for patient preference in time and location of follow-up appointments, if possible.
  10. Provide patients and family members resources, including direct contact phone numbers to the hospital, for post-discharge questions.
    1. Make sure the resources are in their own language.
  11. Help the patient set realistic expectations for recovery.
Unit Managers

This guide outlines the steps that managers can follow to prevent venous thromboembolisms (VTE):

To support your staff in maintaining safe practices associated with preventing Venous Thromboembolisms:

  1. Develop protocols for the appropriate use of mechanical and pharmacological prophylactic measures.
  2. Ensure adequate training of frontline staff.
    1. Ensure adequate VTE prevention competencies and skills for frontline staff.
  3. Ensure that DVT and VTE prevention protocols are embedded into clinical workflows.
  4. Take steps to ensure that patients, regardless of low or high risk, do not develop VTE.
  5. Report VTE prevention measures and compliance monthly.
  6. Determine and report number of instances where guidelines were missed and reinforce the necessity of reporting this data with staff.
  7. Measure and report the proportion of patients who are prescribed risk-appropriate VTE prophylaxis.
  8. Measure and report the proportion of non-administered doses of prescribed VTE prophylaxis.
  9. Determine and report the number of patients who received no VTE prophylaxis prior to the day before the date of the first positive VTE diagnostic test.
  10. Measure and report the proportion of hospitalized patients with a documented VTE risk assessment completed.
  11. Note trends in areas with low compliance and high VTE incidence.
    1. Routinely reassess outcomes.
  12. Reassess VTE/DVT risk daily.
  13. Organize patient education resources to ensure ease of access for frontline staff.
  14. Ensure proper documentation of VTE prophylaxis measures in patient record.
  15. Ensure there are enough staff to effectively manage necessary preventive care.
  16. Eliminate barriers to making rapid changes to documentation templates and order sets.
  17. Debrief team on a regular basis to solicit feedback about barriers to sustained compliance. Adjust the plan quickly and nimbly as needed.
  18. Reduce all prophylaxis options to preferred options to simplify processes and reduce confusion.
  19. Fully investigate any instances of a patient developing DVT/VTE to assess potential failures in prevention.
  20. If VTE rates indicate room for improvement, initiate a performance improvement project.
  21. Ensure frontline involvement in VTE improvement activities. Maintain their engagement and remove barriers to progress.
    1. Gather the right project team.
      1. Be sure to involve the right people on the team. You’ll want two teams: an oversight team that is broad in scope, has 10-15 members, and includes the executive sponsor to validate outcomes, remove barriers, and facilitate spread. The actual multidisciplinary project team consists of 5-7 representatives who are most impacted by the process. Whether a discipline should be on the advisory team or the project team depends upon the needs of the organization. Patients and family members should be involved in all improvement projects, as there are many ways they can contribute to safer care.
      2. Recommended VTE improvement team:
        • Physicians
        • Nurses
        • Physical and occupational therapists
        • Residents
        • Pharmacists
        • Information technology (program/build within EHR)
        • Data analyst (pull/analyze data from EHR)
      3. Understand what is currently happening and why.
        1. Reviewing objective data and trends is a good place to start to understand the current state, and teams should spend a good amount of time analyzing data (and validating the sources), but the most important action here is to go to the point of care and observe. Even if team members work in the area daily, examining existing processes from every angle is generally an eye-opening experience. The team should ask questions of the frontline during the observations that allow them to understand each step in the process and identify the people, supplies, or other resources needed to improve patient outcomes.
      4. Prioritize the gaps to be addressed and develop an action plan.
        1. Consider the cost effectiveness, time required, potential outcomes, and realistic possibilities of addressing each gap identified. Determine which are a priority for the organization to focus on. Be sure that the advisory team supports moving forward with the project plan so they can continue to remove barriers. Design an experiment to be trialed in one small area for a short period of time and create an action plan for implementation.
      5. Evaluate outcomes, celebrate wins, and adjust the plan when necessary.
    2. Ensure that an after-discharge plan exists in your department.
    3. Report number of DVTs and VTEs monthly with staff.
      1. Share successes of zero events with staff.
      2. Hold staff accountable for providing standardized care and reward success.
    4. The action plan should include the following:
      1. Assess the ability of the culture to change and adopt appropriate strategies.
      2. Revise policies and procedures.
      3. Redesign forms and electronic record pages.
      4. Clarify patient and family education sources and content.
      5. Create a plan for changing documentation forms and systems.
      6. Develop the communication plan.
      7. Design the education plan.
      8. Clarify how and when people will be held accountable.

Metrics to consider assessing in VTE prevention:

  1. Total numbers of VTEs
  2. Risk score use
  3. Pharmacological prophylaxis ordered
  4. Pharmacological prophylaxis missed doses
  5. Patient refusal of pharmacological prophylaxis
  6. Mechanical prophylaxis ordered
  7. Patient refusal of mechanical prophylaxis
  8. VTE prophylaxis continuation post-discharge
  9. Mechanical prophylaxis in pre-op areas
  10. Percent of patients who have a documented VTE risk assessment within 24 hours of admission
  11. Percent of patients with mechanical prophylaxis ordered versus those who actually have compression devices in place
  12. VTE patients receiving unfractionated heparin with dosages/platelet count monitoring by protocol
  13. Surgical patients who received appropriate VTE prophylaxis within 24 hours post-surgery
  14. Patients readmitted due to VTE
  15. Number of patients diagnosed with confirmed VTE during hospitalization (not present at admission) who did not receive VTE prophylaxis between hospital admission and the day before date of the first positive VTE diagnostic test
Hospital Executives

This protocol outlines the steps that hospital executives can follow to prevent venous thromboembolisms (VTE):

Venous thromboembolism is estimated to be the second most common medical complication, the second most common cause of excess length of hospital stay, and the third most common cause of excess mortality. More than half of VTE cases are caused by hospitalization—24% specifically attributable to the surgical setting. Though the actual number is uncertain, an estimated 100,000 to 300,000 Americans die in the US every year from VTE, according to the CDC, with 10%–30% dying within one month of diagnosis. However, sudden death is the first and only symptom in 25% of individuals with pulmonary embolism specifically. In many cases, only a minority of hospitalized patients of those found to have deep vein thrombosis (DVT) have classical clinical findings to suggest the diagnosis. Even in post-recovery, one third will have a recurrence within 10 years.

The clinical impact of VTE extends beyond the initial event and can include recurrent VTE, post-thrombotic syndrome, chronic thromboembolic pulmonary hypertension, and anticoagulation-related adverse drug events. The implementation of a standardized VTE prophylaxis protocol is inexpensive, readily available and effective, and can significantly decrease VTE-related readmissions, harm, and death.

VTE costs approximately $18,000–$23,000 per incident. With 375,000–425,000 newly diagnosed, medically treated VTE cases, medical costs associated with VTE in the US are estimated to total $5–$10 billion annually. These figures are consistent when compared with other countries’ VTE figures. For example, the total cost for patients who survived one year beyond initial diagnosis in Germany was between €20,275 and €21,351. While costs differ by country, it is consistently found that the majority of the total pulmonary embolism hospitalization cost is due to room and board (53%). Globally, recurrent VTE requiring readmission is estimated to be almost 50% more expensive than the initial event. 

Leadership Checklist:

On a monthly basis, or more frequently if a problem exists, the executive team should review VTE prevention practices and outcomes across their systems:

  1. Ensure that VTE prevention protocols are embedded into clinical workflow.
  2. Ensure that there is VTE education for patients and families throughout the organization.
  3. Ensure that an after-discharge plan exists in your organization.
  4. Review objective data and trends of VTE in your organization on a monthly basis.
  5. Remove barriers to implementing best practices for VTE prevention.
  6. Ensure an adequate staffing level to carry out best practices in your organization.
  7. Hold your management team accountable for implementing best practices.
  8. Create a learning environment so that your team can learn from failures and celebrate successes.
  9. Ensure that your management team has a simple process to oversee VTE improvements.
  10. Align your VTE improvement plans with other performance improvement initiatives across the organization.
  11. Encourage your staff to engage patients in VTE prevention improvement plans.
  12. Be an active participant in performance improvement projects and oversee the trends as the organization progresses toward better patient outcomes.
Patient & Families

This guide outlines the steps that patients can follow to help them prevent venous thromboembolisms (VTE):

Patients placed in a hospital bed are at risk for blood clots forming in the veins of the legs and pelvis. These clots, if formed, may break loose, particularly when the patient is mobilized, and travel to the heart and lungs. This is called a venous thromboembolism, or VTE.

Ask a member of your care team to explain what VTE is, why you in particular are at risk, and what method of VTE prevention is being used. Your care team should also explain if you are at distinct risk of VTE due to comorbid conditions or history.

Who is at risk of VTE?

  1. Older individuals
  2. Pregnant women
  3. Individuals with COVID-19
  4. Individuals who are obese or overweight
  5. Individuals with cancer or other conditions (including autoimmune disorders, such as lupus)
  6. Individuals whose blood is thicker than normal
  7. Individuals with a family history of heart disease
  8. Individuals undergoing surgery
  9. Individuals with respiratory failure
  10. Individuals who are immobile
  11. Individuals hospitalized with injuries to veins

Signs of VTE?

  1. Pain in the calves and redness
  2. Swelling
  3. Shortness of breath
  4. Any kind of bleeding, such as GI bleeding, wound bleeding, nose bleeds, and coughing up blood, especially for those taking blood thinners

How to prevent VTE?

  1. Keep bed rest to a minimum time necessary.
  2. Use sequential compression devices and/or graduated compression stockings as recommended by care team.
  3. Take any prescribed blood thinners as instructed by care team.
  4. Ask for clarification of VTE standards from medical staff.
  5. Make sure legs are moisturized at least once daily if using compression stockings.
  6. Check legs for sores or pressure wounds.
  7. Speak up if there are any abnormalities, such as pain or redness in the leg.
  8. Monitor all healthcare providers and visitors for proper hand hygiene practices.
  9. Monitor for anticoagulant side effects, including indigestion, dizziness, headaches, and/or vomiting of blood.
    1. If any of these are detected, patients and family members should alert staff immediately.
  10. Stop smoking if you are a smoker.
  11. Ask the care team about when to ask for help, how to call for help, where to go for help, and whom to speak to.

Potential considerations:

  1. Just getting up and moving around is not sufficient for preventing VTE and is not a substitute for or a reason to discontinue pharmacologic and/or mechanical prevention methods.
  2. If you have an acute VTE, you may require a secondary prevention program (ongoing treatment).
    1. This could mean extended use of anticoagulation and follow-up visits with a doctor to carefully manage the risks and benefits of the secondary prevention methods.

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