Adult medical inpatient
Acute medical admission. Assess VTE and bleeding risk within 24 h of admission.
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Internal MedicineManagement
VTE Prophylaxis in Hospitalized Medical Patients
VTE Prophylaxis in Hospitalized Medical Patients: Adult medical inpatient → Check first: already anticoagulated, pregnant or under 18? → High VTE risk? ...
Pathway Overview
14 steps
Algorithm Steps
14 total
01Start 02Warning Check first: already anticoagulated, pregnant or under 18?
This pathway is for non-pregnant adults who are not on an anticoagulant.
- Already on full-dose anticoagulant: do not add prophylaxis. If it is paused, reassess VTE risk.
- Pregnant or within 6 weeks after birth: use an obstetric VTE risk tool, not this pathway.
- Under 18 years: this pathway does not apply.
03Decision High VTE risk? (Padua score 4 or more, or ICU)
Use the Padua score or your hospital's endorsed tool. Critically ill ICU patients count as high risk.
- 3 points each: reduced mobility, active cancer, previous VTE, known thrombophilia
- 2 points: trauma or surgery in the past month
- 1 point each: age over 70, heart or respiratory failure, acute MI or ischaemic stroke, hormone therapy, BMI over 30, acute infection or rheumatic disorder
- If Yes
04Action High VTE risk: plan prophylaxis
Padua 4 or more, or critically ill. Weigh VTE risk against bleeding risk.
- Drug prophylaxis is preferred to mechanical prophylaxis
- Do not combine drug and mechanical prophylaxis routinely
- Start drug prophylaxis within 14 h of the decision to admit, unless bleeding risk is high
05Action Specific groups: adjust the plan
Check these before you choose a method.
- Acute ischaemic stroke: IPC if immobile; no compression stockings. Drug prophylaxis only after stroke team review of bleeding risk.
- ICU: LMWH preferred, or heparin, unless contraindicated. Reassess VTE and bleeding risk daily.
- Active cancer: drug prophylaxis; LMWH preferred
- COVID-19 on a ward with low bleeding risk: consider therapeutic-dose heparin or LMWH (dose per local protocol). COVID-19 in ICU: prophylactic dose.
- Palliative care: decide with the patient and family; review daily
06Decision Bleeding risk low enough for drug prophylaxis?
No if active bleeding, platelets under 50 x 10^9/L, IMPROVE bleeding score 7 or more, or any item below. Antiplatelet drugs and uncontrolled hypertension also raise bleeding risk.
- Active bleeding, or bleeding in the 3 months before admission
- Active gastroduodenal ulcer
- Liver failure (INR above 1.5) or a bleeding disorder
- Haemorrhagic stroke or acute bacterial endocarditis
- If Yes
07Warning Low bleeding risk. Before heparin or LMWH: prior HIT, spinal, acute stroke?
- Prior heparin-induced thrombocytopenia (HIT): no heparin or LMWH. Use a non-heparin anticoagulant such as fondaparinux; ask haematology.
- Spinal or epidural needle or catheter, or lumbar puncture: at least 12 h after a prophylactic enoxaparin dose (24 h if CrCl under 30 mL/min). Next dose at least 4 h after catheter removal. SC heparin: agree timing with the anaesthetist.
- Acute ischaemic stroke, including thrombolysis in the past 24 h: ask the stroke team before any heparin. Allergy to heparin or LMWH: do not use.
08Warning Low bleeding risk. Before dosing: CrCl under 30 mL/min or low body weight?
These change the drug or the dose.
- CrCl under 30 mL/min: enoxaparin 20 mg SC once daily, or heparin. Do not use fondaparinux.
- Weight under 45 kg (women) or 57 kg (men): higher enoxaparin exposure; watch for bleeding. Fondaparinux: caution under 50 kg.
- BMI over 30: no agreed dose change; follow local protocol.
09Action Low bleeding risk: start drug prophylaxis
Adults. LMWH is the first choice. Not if active bleeding or platelets under 50 x 10^9/L. Extra care with antiplatelet drugs or uncontrolled hypertension.
- Enoxaparin 40 mg SC once daily (CrCl under 30 mL/min: 20 mg once daily)
- Or heparin 5000 units SC every 8 to 12 hours (5000 units/0.2 mL ampoule)
- Heparin or LMWH not possible (for example prior HIT): fondaparinux 2.5 mg SC once daily; not if CrCl under 30 mL/min; off-label for medical patients in Australia
- Do not use a DOAC for inpatient prophylaxis
10Warning On heparin or LMWH: watch for HIT
Check the platelet count before the first dose.
- Heparin (UFH): platelets every 2 to 3 days from day 4 to day 14 (from day 0 if heparin in the past 30 days)
- LMWH or fondaparinux: HIT risk is low. ASH advises no routine checks; the Australian PI advises regular counts. Follow local policy.
- Platelets fall by more than 30%, or new clot, usually 5 to 10 days after start (within 1 day if heparin in the past 30 days): 4Ts score. Intermediate or high: stop all heparin, start a non-heparin anticoagulant, ask haematology.
11Action Duration: continue while in hospital
Continue while acutely ill with reduced mobility (usually 6 to 14 days).
- Reassess VTE and bleeding risk if the condition changes, and at least every 7 days
- Stop when fully mobile or at discharge
12Outcome At discharge: stop prophylaxis in most patients
Reassess VTE and bleeding risk before discharge.
- No routine extended prophylaxis after discharge, including DOACs
- Give a written VTE prevention plan; send it to the GP within 48 h
If No13Action High bleeding risk: mechanical prophylaxis
IPC or compression stockings. No stockings with acute stroke, arterial disease, neuropathy or severe leg oedema.
- Intermittent pneumatic compression (IPC) or graduated compression stockings
- No stockings with acute stroke, arterial disease, neuropathy, fragile skin or severe leg oedema
- Reassess bleeding risk regularly; start drug prophylaxis when it falls
- Path rejoins step 11Shared downstream outcome
If No14Outcome Low VTE risk (Padua under 4): no prophylaxis
Encourage early mobilisation.
- No drug or mechanical prophylaxis
- Reassess VTE and bleeding risk if the condition changes, and at least every 7 days
Guideline Source
ASH 2018 guidelines for management of VTE: prophylaxis for hospitalized and nonhospitalized medical patients (Schünemann et al., Blood Adv 2018)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults only; not for pregnancy, postpartum or surgical patients
- Local VTE policy and product information take precedence for doses in renal impairment, low body weight and obesity
- Padua and IMPROVE scores support, but do not replace, clinical judgement
- Fondaparinux is off-label for medical patients in Australia
- Does not cover VTE treatment or HIT management
Contraindicated Populations
pediatricpregnancypostpartum
Applicable Regions
AUUSEUGlobal
AU: ACSQHC VTE Prevention Clinical Care Standard (2020) applies. Enoxaparin 20 mg daily if CrCl under 30 mL/min (Clexane PI). Fondaparinux is TGA-registered for surgical prophylaxis only. Follow local VTE policy.
EU: NICE NG89: LMWH first line; fondaparinux if LMWH is contraindicated; no anti-embolism stockings in acute stroke.
US: CHEST 2012 (AT9) is older; ASH 2018 is the current US society guideline for medical inpatients.
Global: Based on ASH 2018 (medical patients), ASH 2018 (HIT), ASH 2021 (cancer) and ASH COVID-19 guidelines, with NICE NG89 (2018, updated 2019).
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the VTE Prophylaxis in Hospitalized Medical Patients?
The VTE Prophylaxis in Hospitalized Medical Patients is a management clinical algorithm for Internal Medicine. It provides a structured decision tree to guide clinical decision-making, based on ASH 2018 guidelines for management of VTE: prophylaxis for hospitalized and nonhospitalized medical patients (Schünemann et al., Blood Adv 2018).
What guideline is the VTE Prophylaxis in Hospitalized Medical Patients based on?
This algorithm is based on ASH 2018 guidelines for management of VTE: prophylaxis for hospitalized and nonhospitalized medical patients (Schünemann et al., Blood Adv 2018) (DOI: 10.1182/bloodadvances.2018022954).
What are the limitations of the VTE Prophylaxis in Hospitalized Medical Patients?
Known limitations include: Adults only; not for pregnancy, postpartum or surgical patients; Local VTE policy and product information take precedence for doses in renal impairment, low body weight and obesity; Padua and IMPROVE scores support, but do not replace, clinical judgement; Fondaparinux is off-label for medical patients in Australia; Does not cover VTE treatment or HIT management. Individual patient factors may require deviation from these recommendations.
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