Objective To explore the current practice of venous thromboembolism (VTE) prevention in acute trusts.
Design A qualitative research design was used to explore the perceived current practice of thromboprophylaxis, and knowledge and experience of VTE prevention. Data were collected via interviews with personnel from acute trusts and other relevant organisations and charities. Constant comparison was used to generate themes grounded in the data.
Setting The UK.
Participants 17 participants, sampled due to their expertise and knowledge in the field of VTE, were interviewed for the study.
Results No one felt directly responsible for VTE risk assessment and treatment in acute trusts. There were concerns whether any action takes place based on the risk assessment. Low levels of VTE knowledge existed throughout the system.
Conclusions Our study highlights the importance of continuous training to prevent VTE risk assessment being considered a tick box exercise and for clinicians to understand the significance of the procedure to ensure that VTE preventative measures are administered. It is essential that acute trust staff acknowledge that VTE prevention is the responsibility of everyone involved in a patient's care. Concerns remain around prophylaxis treatment, administration and contraindications.
- QUALITATIVE RESEARCH
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Strengths and limitations of this study
Participants have in-depth knowledge and experience of hospital venous thromboembolism (VTE) measures and may be in positions to identify areas of excellence in the process and also those areas that may fall short.
First study to explore this issue with this group of participants.
Participants from sites that provide leadership and promote best practice in VTE prevention.
Examples of poor practice in other less prestigious sites may have gone unexplored.
Snowball sampling has been criticised for selection bias which limits the validity of the sample.
Venous thromboembolism (VTE) is a substantial healthcare problem, resulting in mortality, morbidity and economic cost.1 In 2005, VTE was estimated by the Health Select Committee to cost the National Health Service (NHS) £640 million a year to manage.2 Mortality due to VTE after hospital admission is greater than the combined total of deaths from breast cancer, AIDS, prostate cancer and road-traffic incidents each year in the UK.3 Most hospitalised patients have one or more risk factors for VTE and around 60% of people undergoing major orthopaedic surgery will suffer a deep vein thrombosis (DVT) without preventative treatment.4 Acute medical patients have a 10–20% risk of developing a DVT.5 VTE is one of the most common complications to occur in patients with cancer6 and is associated with a significant reduction in survival.7 The risk of VTE can be reduced with the use of anticoagulants.5
In 2007, the National Institute for Health and Care Excellence (NICE) published a clinical guideline offering best-practice advice for reducing the risk of VTE in inpatients undergoing surgery.8 ,9 In 2010, the NICE guidelines recommended that VTE risk assessment be undertaken at admission (and repeated after 24 h) and appropriate prophylaxis be provided where indicated.10 Commissioning for Quality and Innovation (CQUIN) agreements were introduced in June 2010 and required all acute trusts in the UK to risk assess for VTE at least 90% of patients to avoid financial penalties. Acute trusts are responsible for the management of hospitals in England.11
Alongside these initiatives, an All Parliamentary Thrombosis Group (APPTG) survey found that implementation of risk assessment was poor.12 A follow-up survey found that 58% of trusts carry out regular clinical audit of appropriate thromboprophylaxis and maintain audit data.13 The report states that risk assessment alone does not protect identified at-risk patients and failure by trusts to undertake VTE prevention duties has cost £110 million in negligence payments since 2005.13 Similarly, root-cause analyses of all confirmed cases of hospital acquired VTE are required by local commissioners and survey responses indicate that just 59% of trusts undertake this. The audit suggests that commissioners are not enforcing compliance with local contracting provisions on root-cause analysis to support the provision of appropriate resources and improve practice at the local level.13 Despite this, recent research has shown the CQUIN initiative to be associated with a significant overall reduction in mortality due to VTE in patients with hospital stays of greater than 3 days.14
However, it is clear that there is no true picture of current thromboprophylaxis practice, staff education and the budget implications within acute trusts. A study has been undertaken to try to answer these important questions15; this included interviews with experts in the field of VTE to explore the issues.
Methods and analysis
A qualitative research design was used. Data were collected via face to face and telephone interviews with an actively selected, purposive sample of personnel from acute trusts, relevant UK organisations and charities involved in the prevention of VTE. To achieve the most productive sample, key informants16 were identified (by DF, an expert in VTE thromboprophylaxis) to best represent the research focus, followed by snowball sampling,17 ,18 which involves asking key informants to recommend other appropriate people for interview and is particularly appropriate for accessing the type of participants being sought.19 Our sample was selected to reflect the diversity within a given population20 in order to obtain a rich perspective of opinion21 and comprised experts working in the field of VTE who would have knowledge and experience of VTE prevention.
Prior to the interview, participants were emailed an information pack comprising a covering letter and a participant information sheet. They were asked to complete a consent form at the time of contact or provided verbal consent for telephone interviews. Face-to-face interviews lasted between 30 and 50 min and telephone interviews 12 and 15 min. All interviews were conducted by the same researcher (LM). Interviews examined the current practice and knowledge of thromboprophylaxis, interdisciplinary communication, perceived barriers to VTE management, training provision and future requirements. The semistructured interview schedule covered the following topics: an examination of the regular and required provision of prophylaxis; concerns regarding prophylaxis treatment; an exploration of the education provided to patients and the training provision and future requirements for VTE prophylaxis management.
All interviews were digitally recorded with the permission of each participant. The contents of the recordings were transcribed verbatim and the resultant audiotapes/digital files stored in a password protected computer file. Transcripts were identified by code number only and participants were not identified in any written material resulting from the interviews. The recorded and transcribed semistructured interview data were analysed using constant comparative methods22 and managed using NVivo V.9 software. LM independently reviewed all the transcripts and developed codes in an iterative process to identify emerging patterns in the data and an initial coding framework. Similarities and differences were identified within and across the transcripts. By comparing each part of the data, analytical categories were established and key concepts selected. Final themes were reviewed and agreed between SG, EM and DF to enhance reliability.
Seventeen participants agreed to be interviewed for the study. Fifteen were face to face and two via telephone. They originated from 12 separate organisations, including a series of trusts ranging from small trusts with no VTE specialists to large trusts with specialist VTE teams. Four of these organisations were National VTE Prevention Programme Exemplar sites, consisting of hospitals that have demonstrated excellence in their work to prevent VTE.
Participants were: two physicians, a consultant haematologist, a consultant VTE lead, a VTE nurse, a critical care charge nurse, a consultant nurse for anticoagulation, a nurse tutor/VTE committee member, a VTE prevention lead nurse, a VTE trainer, a clinical medicines management pharmacist, charity directors, (one and two), from two separate VTE charities, a primary care trust commissioner, a scientific advisor for haematology, a specialist scientific lead for patient devices and a community pharmacist. Charity director 2 and the community pharmacist took part via a telephone interview.
Four main themes regarding participants’ perceptions of thromboprophylaxis practice in acute trusts emerged from the data and the results are presented under these themes:
Current attitudes to risk assessment
Staff education and training
Specific training requirements in acute care, lack of skills, critical dose clarity
Representative quotations that illustrate typical responses and a range of views have been selected to reflect these themes.
Current attitudes to risk assessment
It was suggested that some junior doctors, although recognising the need for risk assessment and the provision of preventative treatment, do not feel that it is their responsibility to carry it out. The advantages of having a champion to promote the issue in each establishment were highlighted.
There are still hospitals that are failing to do it, who don't have a champion pushing it forward. It's still quite difficult to win the hearts and mind of certain groups and the junior doctors don't seem to feel, they can see the need, but they feel it's not their responsibility. (Charity director 1)
Furthermore, it was suggested that risk assessment is regarded as little more than a tick box exercise, creating concerns that the results may not be acted on.
There is very little awareness; there is little awareness amongst secondary care staff because many see this as a chore, as a tick box exercise. (Physician 2)
There was a suggestion that the effectiveness of the process should be based on more than completion of the risk assessment form, a situation brought about by CQUIN payments. CQUIN payments are made according to the number of patients risk assessed with no regard as to whether treatment procedures have been put into place. A call for policing of the risk assessment procedure suggests that it may not always be carried out correctly.
One of the weaknesses of the current strategy is that the outcome that is being measured is the number of risk assessment forms completed. The focus needs to be on whether they have been completed correctly and clinicians have acted on that assessment. People think that it is about identifying whether a patient is at risk of thrombosis but a risk assessment tool is also there to identify whether a patient is at risk of complications of thromboprophylaxis and therefore it is essential that the information is used to guide practice. People are judged on completion of risk assessment forms, not necessarily the execution of the result of that form. (Consultant and VTE lead)
… the government has taken a role with CQUIN targets that's really pushed it to the forefront to everyone's minds but it wouldn't harm them if they actually fund some extra nursing staff to police the risk assessments that are being done and that they are being done correctly. (VTE trainer)
There were concerns that risk assessment practice might slip if the incentives of CQUIN targets are removed. There was a perception that some trusts will think it unimportant. A VTE prevention lead felt that having staff dedicated to the role would help to maintain targets.
I like the CQUIN targets because it does give incentive and if the CQUIN doesn't stay around I hope things won't slip. I wonder if some trusts, where they haven't got as big a team as we have, they haven't got a person dedicated to the role, if when they don't have to collect the data for CQUIN it's going to come off radar. I think it will affect some trusts more than others. Some trusts will just think it doesn't matter. (VTE prevention lead)
Participants considered it necessary to establish that what is in place is actually working and suggest there is evidence that it is not. This partly stemmed from the perception that no one feels directly responsible and that there exist low levels of understanding.
From the hospitals point of view they need to understand that risk assessment and treatment of the patient is not just one person's responsibility. It becomes the responsibility of everyone who is involved in treating that person. (Charity director 2)
A successful example of how to overcome the problem of a diminished sense of responsibility is in establishing knowledge of where the responsibility falls within each individual member of the clinical team, along with a backup system to make sure that risk assessment is being carried out.
All patients should be risk assessed the moment they are going to be admitted and the junior doctors know it is going to be their responsibility and in the absence of junior doctors the senior doctors know that it is someone's responsibility in the team and it might fall on them to do it. They are meant to do the risk assessment and prescribe the appropriate thromboprophylaxis. The nursing staff and the pharmacist staff remind or prompt the doctors if it is not being done and make sure that it is. It's sort of a three pronged attack. (VTE trainer)
Participants suggested that having sight of the outcome data, to confirm the belief that conducting risk assessment has reduced incidences of hospital acquired thrombosis, could incentivise staff and help to improve risk assessment for DVT.
Having outcome data that demonstrates conducting risk assessment has made a difference in reducing the incidence of hospital associated thrombosis. (Consultant Nurse for anticoagulation)
Staff education and training
A consultant nurse called for the education of clinicians and patients to improve the regular and required provision of prophylaxis.
Ensuring both clinicians and patients are educated on appropriate thromboprophylaxis and that the resources are available. (Consultant Nurse for anticoagulation)
In addition, ongoing training that will prevent the risk assessment becoming a tick box exercise and continued awareness promotion was deemed necessary to develop an understanding of why the exercise is so important.
It can just end up being another piece of paper, another tick box exercise. I think that's where the importance of the training comes in because you need people to understand why it's so important. (Nurse tutor and VTE committee member)
There were examples of low levels of knowledge of VTE risk and prevention among staff in some acute trusts, even in orthopaedic hospitals where the majority of patients will be assessed at high risk. There was clearly a requirement for improved staff understanding without which there will remain an inability to pass on vital information to patients. Participants suggested that VTE prevention education be included as a complete module during medical training.
The major deficiencies are actually among health professionals and that we need to address those first before we start educating patients anymore. (Physician 1)
When I'm doing training...it's only an awareness not -signs, symptoms, prevention, risk assessment. It is improving now because we've done a lot of work but even the knowledge amongst people who work in hospitals, in an orthopaedic hospital where it's always been higher risk, is low. If it's low for that group then the patients themselves are unlikely to have a huge amount of knowledge. Your medical training, nurse training there should be a whole module on VTE and the risks. (Nurse tutor, VTE committee member)
In the absence of specialist staff for VTE prevention, individual trusts are developing their own literature for the education of junior doctors and patients.
Bigger trusts have specific thrombosis teams or VTE nurses...we don't have that but we have just put together a document that is going through the approval process so hopefully that will help. (Nurse tutor, VTE committee member)
We have followed the NICE guidance and written our own local trust guidance and that's available on the intranet and available in a little booklet form that we give to the junior doctors. (VTE trainer)
A considerable variation in VTE teaching for a range of medical staff was identified, and a charity director suggests improvements in education are needed.
I've been looking at education and its huge variability in the amount of teaching that medical students get in haematology where most of the VTE teaching is concerned. So it varies from virtually nothing to eight weeks haematology teaching between the different medical schools and if one looks at the nursing syllabus—the midwives have nothing, there's no module at all on VTE and the nursing modules vary so there is a huge need for improvement in education. (Charity director 1)
Critical care staff who see one or two incidences of VTE a month felt they do not know enough about thromboprophylaxis.
I see 1 or 2 cases of VTE a month. I don't think I have enough knowledge or information about VTE and thromboprophylaxis. (Critical care charge nurse)
Similarly, training to cover the management of VTEs may be inadequate.
The thing we don't cover so well at the moment is the management of suspected or actual VTEs.... (Nurse tutor, VTE committee member)
A consultant nurse suggested that clinicians should devote the time necessary to complete a short training session to promote awareness that risk assessment is a continuous process should a patient's condition change.
It is a simple 2 minute process if done as part of the clerking procedure. It should also be thought about on the ward rounds and thereafter as the patient's condition changes. This requires clinicians to be VTE risk aware and that requires time to complete training on VTE prevention of about 15 to 30 minutes. (Consultant Nurse for anticoagulation)
Even when there is a clear training programme in place, a nurse tutor suggested that attention can slip and compliance rates drop off.
You almost have to police it. You think, ‘right they've got that now, they know that every patient needs to be risk assessed’ but then something else will come along that takes their attention for a while and before you know it, it's starting to drop off again. (Nurse tutor, VTE committee member)
However, that said, there were examples of excellence in staff commitment, responsibility and training. In several acute trusts, training is now mandatory.
VTE training is mandatory in our organisation and this is a very useful driver. We provide slots on all induction programmes for new doctors and nurses, regular lunchtime teaching for pharmacists and an established link nurse/midwife network with study days and monthly lunchtime meetings incorporating teaching. Teaching of new FY1's who are involved with VTE trust wide audit. (Consultant Nurse for anticoagulation)
We ask everyone that has direct patient contact to complete the e-learning VTE module, which is mandatory and we also provide, for the nurses specifically, some VTE awareness sessions. (Clinical nurse tutor)
I do a lot of teaching with the staff and I'm also trying to encourage- train the trainer. All of the adult wards have link nurses who have attended special training and we're encouraging them to teach the other nurses as well. We also do teaching with the doctors to hopefully get them to do things correctly in the first place. (VTE prevention lead nurse)
Specific training requirements in acute care
Lack of skills
It was recognised that a document outlining the appropriate treatment is required in some hospitals because they do not have specialist teams to manage VTE. This was most evident in specialist orthopaedic hospitals where staff skills are appropriate to their specialist nature with little knowledge of other medical conditions that may have relevance to surgery and VTE risk factors. Explicitly, orthopaedic surgeons are knowledgeable with regard to risk factors related to surgery and anaesthetics but do not see cases of VTE, because they are referred to a general hospital and they may be unfamiliar with risk factors associated with cancers and other comorbidities.
For some patients there are other risk factors. It would be hard to have a form that covers every eventuality. Even though we are orthopaedic specialty only, within orthopaedics there are actually spinal, oncology patients, hips and knees etc. Even within that small group there are lots of different risk factors. (Clinical nurse tutor)
The thing we don't cover so well at the moment is the management of suspected or actual VTEs. Because, we are a specialist orthopaedic Trust so we don't have the input of, I mean a lot of bigger Trusts have specific thrombosis teams or VTE nurses...In this Trust we don't have that but we have just put together a document that is going through the approval process so hopefully that will help. I'm not saying patients just don't get the appropriate treatment but I think maybe the actual process gets a bit blurred sometimes. (Orthopaedic nurse tutor)
Critical dose clarity
Participants presented some specific examples where medical knowledge appears to be lacking with regard to VTE prevention and medication. One example was the apparent confusion around giving reduced dosage appropriate to age and renal function.
The concerns that I have is that, it's the definite guidelines for when you give a reduced dose, between forty and twenty. And I think a lot of the more junior clinical staff, junior doctors, don't quite understand when to go for forty versus twenty, when you're looking at age and renal function and things like that. And it's sort of a bit, it's a bit arbitrary. I would think it would be junior doctors needing the training in their medical, somewhere. (Acute Trust Pharmacist)
A pharmacist suggested that improved documentation would provide a useful checking system when a medication dose has been reduced so that the pharmacy can see the significance of a changed dosage.
Sometimes the consultants might reduce a patient's Enoxaparin dose to twenty, we're not always sure why. So maybe some documentation somewhere in the notes to understand why the VTE medication has been reduced because normally it's reduced if their renal function's poor, but sometimes it's reduced and their renal function's fine, or it can be reduced if a wound is oozing. But sometimes neither of those are there and we're left to, there's no information as to why the patient's dose has been reduced. (Medicines Management Pharmacist)
When asked whether there were any concerns regarding the required provision of thromboprophylaxis, a critical care charge nurse enquired, ‘if patient is on warfarin do we still give it?’ When asked if training was required, the nurse asked, ‘do we need TEDs and Enoxaparin?’ There is an apparent need for further training involving: exceptions to the rules, combining treatments, reducing doses according to comorbidities and understanding the implications of a patient being on warfarin. Further, a participant inferred that a clinical barrier to the prevention of VTE may be caused by surgeons who think that prophylaxis causes bleeding on surgical wounds.
Some surgeons, particularly in orthopaedic surgery perceive that prophylaxis causes bleeds in the wound. (Charity director 2)
Immobility is a causal mechanism for VTE and there was some confusion regarding a patient's apparent mobility that requires clarification across the NHS. The NICE guidelines regarding reduced mobility are defined as; ongoing reduced mobility relative to their normal state.10 The following statement could indicate that some patients are not receiving appropriate thromboprophylaxis.
The main problem that causes confusion is with regard to the medical patients and the definition of mobility. We've done quite a lot of training on that recently and amended the risk assessment tool to add in the definition of mobility as defined by the NICE guidance. ‘Cause we've found a lot of people were thinking if the patients not bed bound then they've got normal mobility. They're missing out on thromboprophylaxis. We've done a lot of work with that definition of mobility to try and increase awareness. I still feel that it's, a little bit confusing. (VTE prevention lead)
The NICE report recognises that VTE is hidden from the radar of surgical clinicians because patients are being discharged from hospital relatively quickly and a VTE develops after the patient has left hospital.10 A consultant observes that, if a VTE event is prevented by the prescription paid for from the surgeons budget, the saving has no direct effect or benefit to the surgeon’s department.
The cost comes out of orthopaedic surgeons direct budget and the guidelines have come in and the recommendations are made to them but they are not given any additional funds to deliver it. Likewise any financial savings on preventing hospital acquired thrombosis is not fed back to them. So they are being expected to spend more for a problem they don't perceive exists because they don't see it and by doing it they don't get any additional benefit. (Consultant, VTE lead)
Similarly, a nurse tutor suggested that the use of more expensive drugs may be cost effective because they would be easier to administer (oral, rather than self-injection that many patients cannot manage on their own) and would reduce district nursing costs.
...the cost of Rivaroxaban and things like that because if they were cheaper then you could move away from Clexane which would release up nursing time, you wouldn't need district nursing at all. (Nurse tutor, VTE committee member)
Overall, the prevention of VTE is considered to be cost effective for the NHS.
There should be no financial barriers as the prevention of VTE saves money in the long term for the NHS. (Charity director 2)
Further budget implications which emerged included cost and time barriers relating to training staff to complete the risk assessment and complete it without errors and having the right facilities, in terms of sufficient numbers of staff, to carry that training out effectively. A VTE prevention lead invested considerable time in the motivation of staff to feel passionate about risk assessment so that they correctly complete the task.
Potential barriers are time, if areas are understaffed, training—if you haven't got the facilities to train people how to complete the risk assessment correctly then you might get errors and to a large extent staff awareness and motivation we put a lot of time into trying engage with the staff to get them motivated to feel passionate about VTE and if we can do that we feel they're more likely to do the risk assessment forms. If they don't really care then it gets left so we put a lot of investment in trying to get people feel passionate about it. I guess that is financial, having the staff to do that. (VTE prevention lead)
This study has highlighted a number of issues, particularly the confusion over responsibility for VTE risk assessment and treatment. Despite the belief of many participants in this study that VTE prophylaxis was well implemented in their hospital, participants from acute trusts, charities and organisations provided examples of low levels of knowledge of VTE risk and prevention and revealed examples of poor medical knowledge and understanding, including uncertainty over reduced mobility. These areas point to specific training requirements. While VTE nurses and trainers strive to motivate clinical staff to accept the task of risk assessment as a habitual part of daily clinical practice, our findings suggest that some junior doctors do not feel that it is their responsibility. Such a concern was raised in the Francis enquiry that found that assumptions were made that important functions were being carried out by others.23 Further, the report suggests that new doctors are vulnerable to being misled by poor practice and may not raise concerns (Ref. 23 (18.103 page 1225)).
Similarly, the Francis Report identified a failure to communicate the knowledge of any concerns and, in our study, it is apparent that shortcomings in VTE prevention exist at an individual level, are identified at the ward level and, currently, are not escalated. There is no guarantee that concerns regarding VTE management are raised and addressed appropriately. Our study alone has brought these issues to light.
Several participants highlight the suggestion that importance of continuous training is important to prevent risk assessment becoming ‘a tick box exercise’ and for clinicians to understand the significance of the procedure to ensure follow-on action. Despite government intervention, concerns remain around prophylaxis treatment, administration and contraindications. The ENDORSE study found that less than 40% of at-risk hospitalised medical patients receive the recommended prophylaxis. The Endorse study reinforces the necessity to improve implementation of available guidelines for evaluating VTE risk and to implement measures that ensure that at-risk patients receive appropriate prophylaxis.24 ,25
Having a dedicated VTE prophylaxis support position such as a nurse practitioner within a hospital has been demonstrated to improve prophylaxis rates by up to 48%.26 A VTE trainer calls for additional funding for extra nursing staff to police the risk assessment process.
There is evidence of reduced mortality associated with improved prophylaxis rates in the UK.14 However, studies suggest that there is an overprescribing of prophylaxis in low-risk patients.27 There remains a need for caution in terms of prescribing prophylaxis for patients at low risk of VTE.
Strengths and limitations
The strength of our study is that it examines the opinions of healthcare professionals in acute trusts and relevant organisations who have in-depth knowledge and experience of hospital VTE measures and may be in positions to identify areas of excellence in the process and also those areas that may fall short. This is the first study to explore this issue with this group of participants.
Several participants came from institutions that belong to the National VTE Prevention Programme Exemplar Centre Network. These sites provide leadership and promote best practice in VTE prevention and are selected because of their existing track record of excellent VTE prevention and care. They carry a ‘kite-mark’ for good practice in VTE care and share clinical best practice, educational and audit material, provide advice regarding VTE care and collaborate on clinical research into VTE. As such, these participants may have experienced a more proactive attitude to VTE prevention. This may be considered a strength of the study, particularly if they are able to identify a weakness within their exemplary status, but may equally be considered a limitation in that there may be cases of poor practice in other less prestigious sites that have gone unexplored. This study sought healthcare professionals’ opinions and it may be that an observational study of what actually happens in day-to-day clinical practice might highlight other issues.
Snowball sampling has been criticised for selection bias which limits the validity of the sample.28 ,29 To minimise selection bias, participants were sourced from an extensive base, ranging across acute trust personnel, commissioning bodies, individuals from the community and charities, resulting in a wide range of participants from all areas of VTE prevention. The sample size is within the range recommended to allow for data saturation to be reached.20 ,30
This study provides important insights into those aspects of VTE prevention that are perceived to continue to create concern in acute trusts. Even when dedicated VTE management support is available, some healthcare professionals appear unsure of preventative measures.
In light of the suggestion that the teaching of VTE prevention varies widely across medical schools, training in VTE prevention would benefit from being fully addressed at this stage in a medical student's education. It is essential that all healthcare professionals recognise the importance of VTE risk assessment and appropriate preventative measures and be encouraged to acknowledge that the process does not end at risk assessment but is an ongoing procedure throughout a patient's hospitalisation that becomes the responsibility of everyone involved in the patient's care.
Despite evidence of improved mortality rates associated with implementing VTE prophylaxis, this study demonstrates the need for ongoing engagement with, and education of, acute trust personnel in order to ensure continuing quality improvement and the use of cost-effective measures to reduce the burden of VTE after hospitalisation.
Contributors DF, EM, SG and AW had the original idea for the study and led the funding application. EM and AW wrote the study protocol. LM and SH contributed to the development of the protocol. LM conducted the interviews, led the qualitative analysis and drafted the paper. SG, EM and DF agreed on the analysis and reviewed the draft versions. All authors approved the final version of the paper.
Funding The research was funded by the National Institute for Health Research (NIHR; under its Programme Grants for Applied Research programme (RP-PG-0608-10073)) programme grant entitled ‘Improving the prevention and treatment of venous thromboembolism in hospital and the community’. The views expressed in this paper are those of the authors and not necessarily those of the National Health Service (NHS), the NIHR or the Department of Health.
Competing interests None.
Patient consent Obtained.
Ethics approval Ethics approval was granted by the Oxfordshire REC B Research Ethics Committee on 05/05/2011 (reference: 11/H0605/5).
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement No additional data are available.
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