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Evidence-Based Nursing Project

Rene Ames

Katherine France

Kelly Price

Jennifer Skripka

Jill Witzman

Ferris State University

Deep vein thrombosis (DVT) affects many hospitalized patients. DVT and pulmonary embolus (PE) increase mortality and morbidity in hospitalized patients and are highly preventable. It is estimated that more than 350,000 individuals in the United States are affected by DVT and PE each year (United States (U.S.) Department of Health and Human Services, 2008). There are many risk factors associated with DVTs and PEs. Some major risks that increase DVT are trauma, surgery, obesity and immobility. Other risk factors include hormone replacement therapy and smoking (U.S. Department of Health and Human Services, 2008). In order to prevent venous thromboembolism or DVT, Virchow’s triad must be minimized (Kehl-Pruett, 2006). The three components of Virchow’s triad are venous stasis, vein injury, and increased coagulation (Kehl-Pruett, 2006). A prophylaxis regimen to prevent DVTs and PEs varies according to the levels of risk factors. According to the U.S. Department of Health and Human Services (2008), “regimens may range from early, aggressive ambulation to a combination of anticoagulant therapy, intermittent pneumatic compression and/or graduated compression stockings” (p. 26). This raises the question: Is there a difference in the occurrence of thromboembolic events in inpatient post-op surgical patients between those that use sequential compression devices (SCDs) and thromboembolic deterrent (TED) hose and those that receive early ambulation and passive range of motion (ROM)?

Literature Review

The literature review served as a new learning experience for our group. Many of the first articles chosen did not address our PICO statement, thus did not provide the information to address our problem statement. After our instructor suggested different MeSH headings we were able to find more appropriate articles.

Each member of the group chose two articles and then posted them on the discussion board. After we had the list of ten articles, we each read them individually and recommended two for approval for the final four to use for our paper. There were six articles that the group first thought were pertinent to serving our problem statement, but were then discarded because we had not used the correct MeSh heading. The first article by Limpus, Chaboyer, McDonald, and Thalib (2006) was not chosen for this analysis because the sample pool was not representative of our target population. The article by Geerts et al. (2008) was eliminated from the analysis because the article discussed antithrombotic and thrombolytic therapy in several populations rather than our target population. The articles by Walker & Lamont (2008) and Le Sage, McGee, and Emed were not chosen because it did not meet our problem statement. Also the author’s aim was to prove whether thigh or knee-length TED hose are more effective in the prevention of DVTs, and did not discuss other prevention measures. The article by Caprini (2009) were not chosen because we felt the article did not address the group’s problem or PICO statement. In addition the article did not represent our target population of surgical patients. The article by Church (2000) was not used because it was written in the year 2000, and was too old for our problem statement as our article time range is 2004-2010. The article by was not chosen because it did not address our group’s problem statement (Katherine, where is the 6th article not chosen?)

The first article chosen, Deep vein thrombosis in hospitalized patients A review of evidence-based guidelines for prevention discusses known risk factors that cause deep vein thrombosis (DVT), current strategies in preventing DVT, and the current evidence-based guidelines to raise nursing awareness of early prevention methods in all hospitalized patients (Kehl-Pruett, 2006). The article discusses the prevalence of DVT in the United States general population as well as among general medical and surgical patients. According to Kehl-Pruett (2006), medical and surgical patients have a 10% to 40% risk of developing a DVT where as those who have orthopedic surgery have a 40%to 60% risk.

The article discusses the certain factors that increase the risk of DVT in hospitalized patients. These risk factors include decreased mobility, age, obesity, smoking, estrogen therapy, surgery, and central venous catheters (Kehl-Pruett, 2006). Kehl (2006) emphasizes in the article that decreased mobility is a major risk factor in developing DVT and few hospitalized patients are active due to bed rest orders. In addition Kehl (2006) explains DVT prevention techniques. Mechanical prophylactic techniques include exercises, range of motion, TED hose and pneumatic compression devices. Each of these measures improves venous return and reduces venous stasis in the leg veins. Mechanical measures to prevent DVT are appropriate for those individuals at low risk for developing DVT or those who have contraindications to anticoagulants. The article explains pharmacological ways to prevent DVT such as the use of anticoagulants. Kehl-Pruett (2006) explains anticoagulants are appropriate in patients with a moderate to high risk for DVT.

The second article, Evidence-based compression Prevention of stasis and deep vein thrombosis is a review of publications from the database Medline from 1970-2002. The purpose of this article was to summarize the currently published evidence for the venous flow effects of mechanical devices, specifically intermittent SCDs and their relation to prevention of DVT. The results of this review showed that intermittent compression is effective in preventing DVT and compares favorably with anticoagulants (Morris & Woodcock, 2004). However, there is no evidence that any specific compression is more or less effective in preventing DVT. There is no question that intermittent compression devices prevent DVT, but the mechanism of how they work is unclear.

The Third article The use of knee-length versus thigh-length compression stockings and sequential compression devices discussed whether knee-length or thigh-length SCDs or TED stockings are more comfortable, applied correctly, and worn by patients (Brady, Peterson, Denman, Resuello & De Contreaus, 2007). Also the study assessed rates of compliance among patients with SCDs and TED stockings. The study was conducted using patient surveys and six surveyors collected data from 137 randomly selected patients admitted to an acute care setting with orders for SCDs and/or TED hose (Brady et al., 2007). The survey design method was used to gather information from patients regarding if they understood why stockings or SCDs were used, whether they found them comfortable, and the duration they were worn during the day.

This article discusses the effectiveness of both length devices in SCDs and TEDs in preventing DVT. Research has exhibited that full-length devices do not provide more benefit in the prevention of DVT than knee-length devices. Also the frequency of DVT is similar with the use of both devices. Brady et al. (2007) found that many studies show below-knee products have better patient compliance rates and none of the published studies clearly show benefits of thigh-length over knee-length devices. Moreover, “if compression stockings and SCDs are used improperly, or if thigh-length stockings are rolled down, it can cause arterial thrombosis, skin necrosis, venous stasis, and reduced blood supply” (Brady et al., 2007, p. 256). The results of this study show that evidence-based practice supports the use of knee-length TEDS and SCDs for DVT prevention for those at low risk of a DVT. Furthermore, Brady et al. found that patients preferred knee-length TEDS and SCDs which resulted in greater compliance and thus prevention.

The last and final article How to detect and defend again DVT discusses ways to identify the early signs of DVT and ways to prevent it. According to Glover (2005) the “the incidence of DVT increases proportionally with the number of risk factors present” (p. 1). Glover explains that many cases of DVT are clinically silent due to collateral circulation or a partially patent vein. Unfortunately the first symptoms to manifest can be from a PE which can be fatal.

Several ways to prevent DVT include early and aggressive ambulation in low risk patients such as those who have minor surgery under the age of 40 with no additional risk factors (Glover, 2005). Mechanical methods such as SCDs and TED hose are also used to prevent DVT. This population includes patients with additional risk factors and surgical patients between the ages of 40-60. Patients with high risk factors should be started on anticoagulants and use intermittent pneumatic compression devices.

Analysis of Evidence

The first article is Deep Vein Thrombosis in Hospitalized Patients: A review of Evidence-based guidelines for prevention. What was discovered was that even though patients had known risk factors there is a declining use of DVT prevention in medical and surgical patients requiring hospitalization.

With the knowledge that there is a decline in prophylaxis this article’s goal was to review what the American College of Chest Physician (ACCP) guidelines are, and to provide nurses with the correct tools to be advocates for patients in preventing DVT. The guidelines emphasize that each patient’s history and current health status play a role in determining what the best prophylaxis should be. “Mechanical prophylactic measures are simple to use and do not increase the chance for bleeding, making them ideal for most hospitalized patients” (Kehl-Pruett, 2006, p. 56). For new surgical patients who have a higher risk of bleeding, mechanical methods are recommended (Kehl-Pruett, 2006, p. 56).

The article Evidence-Based Compression: Prevention of stasis and deep vein thrombosis is a summary of multiple scientific based research and their findings on how effective sequential compression devices (SCD) are. This article also looked at the various types of SCD’s to see if a particular style provided better results in preventing deep vein thrombosis (DVT). When comparing thigh high compression versus calf high compression there was not a lot of evidence, but one of the studies found there was “no significant difference in the calf DVT outcome, but a significant difference of the number of proximal DVT (7.2% calf-length. 2.4% thigh-length)” (Morris, 2004, p. 164). Due to the lack of research in this area and the problem with different systems, and another study that showed no difference, this is not enough evidence to dictate a change in practice.

The study also reviewed literature on whether graded sequential compression was better than uniform compression. Graded compression “inflates multiple bladders to compress the limb in a milking action” where as uniform does not produce the milking action (Morris, 2004 p. 165). The results showed that in preventing DVT uniform compression is effective and that graded compression was not seen as more beneficial. Furthermore, even if graded compression were better the benefit/cost ratio would likely not be large (Morris, 2004). Other comparisons that were done were between asymmetric and circumferential compression. Asymmetric has a bladder placed in the back of the limb that inflates and circumferential has a bladder that extends over the entire limb (Morris, 2004). As with the previous example there is little research differentiating between the two.

The use of compression stockings with SCD’s was also addressed. There can be an issue with using stockings because they may not be fitted properly, and wrinkling can occur when worn under SCD’s. There are some manufacturers that promote stocking with SCD’s, but ironically it is the same company that manufactures both products (Morris, 2004).

In the article the use of knee-length versus thigh-length compression stockings and sequential compression devices nurses on an acute care evidence based practice committee conducted research to determine which compression stocking was better (Brady, Peterson, Denman, Resuello & De Contreaus, 2007).

Most patients were in bed when the survey was conducted, however, only 29.2% had their SCDs on. In addition to this, 49% had SCDs available in their room but were not wearing them, and 19% did not have any SCDs at all. Furthermore, of the 21 patients wearing thigh-length and the 19 wearing knee-length, only 26 were applied properly and fit the patient well. For patients having TEDs ordered, 62.8% were wearing their stockings. Twenty-eight patients were wearing knee-length and 58 were wearing thigh-length and only 35 were applied and fit correctly (Brady et al., 2007). Brady et al. (2007) found that 34 of the patients had problems with thigh-length fit versus only 18 patients having knee-length fit problems. Of the 51 patients that were not wearing their TEDs, their most common reason for not being compliant was due to them being uncomfortable, an amazing 59% (Brady et al., 2007).

According to Brady et al. (2007) the evidence shows that compliance with the SCDs was a major issue. Brady et al. (2007) found that compliance with knee-length was better versus thigh-length SCDs and overall compliance with TEDs was better than SCDs. “This may reflect the fact that patients do not have to remove them when ambulating or sitting in a chair” (Brady et al., 2007, p. 260). Patients were twice as compliant if they had knee-length TEDs ordered versus thigh-length and fit was an issue twice as often with the thigh-length (Brady et al., 2007).

With this evidence the nurses were able to determine that compliance was a major barrier in getting patients to use the ordered SCDs or TEDs. This study helped change the practice in their facility to using knee-length TEDs to prevent DVT.

The article How to detect and defend against DVT focuses on educating the nurse in how to help their patient prevent DVT. Providing a thorough assessment is key. Also, knowing your patients risk factors for DVT is essential. It is common in a hospital setting to use SCDs or TEDs and often anticoagulants to prevent DVT formation. All of these options are good and can definitely be warranted with certain patients. It is important not to forget that by educating our low risk patients we can help them avoid DVT without using mechanical or pharmacological methods.

Application of evidence

Determining the type of compression devices can be difficult and time consuming. Lower limb compression devices come in at least five different varieties and cuff choice can be determined based on the type of surgery/situation or solely based on the providers’ preference (Morris & Woodcock, 2004). There has been no direct evidence to determine which cuff size is more beneficial. As another option for prevention of deep vein thrombosis, “compression stockings are cheaper and simpler than intermittent compression devices and, for that reason, remain the most popular physical method of DVT prophylaxis” (Morris & Woodcock, 2004, p. 167). Another problem that poses a risk to patient care is knowing which type of compression is desired for the patient and the length of stocking needed. “The danger is that poorly fitted stockings, or those of an incorrect shape and size, could produce tourniquets at the proximal end, causing ischemia, and an increased risk for thrombosis” (Morris & Woodcock, 2004, p.168). Assessing the patient’s compliance with the devices prior to choosing a device may be beneficial. If compression stockings are consistently removed by the patient the desired effect of preventing a DVT would be hindered.

Brady et al (2007) compared TED and SCDs, and stated “results are consistent with other studies that found that patients preferred knee-length TEDS and SCDs and resulted in greater compliance with treatment” (p. 261). The study also showed that younger patients are less compliant with DVT prophylactics, warranting the idea that alternatives should be chosen for the younger population. Patient compliance is not the only factor to consider, “13% of patients reported the devices had either never been initiated or not been put back on by the registered nurse after removal or activity or transfer from another unit” (Brady et al., p. 259). According to Brady et al. (2007), patient reinforcement and nursing education for SCD compliance to achieve optimal DVT prophylactics is needed. Kehl-Pruett (2006) identified that nurses are with the patient at the time of admission and stay with the patient throughout their hospital stay, which makes them the ideal candidate for identifying risk factors. Nurses should also be responsible for recognizing when changes in prophylactic method(s) are needed. “A worsening of patient condition warrants a re-evaluation of risk factors, just as a significant improvement in condition may signal the need to reconsider previous risk factor assessment” (Kehl-Pruett, 2006, p. 58). Nurses should be contacting the provider when a patient is identified as being at risk for developing a DVT. “Regardless of the type of prophylaxis ordered, patient education is necessary to improve compliance and acceptance of these measures” (Kehl-Pruett, p.58).

Summary Statement

Based on the research found TED hose and SCD’s are effective at preventing DVT’s as well as passive ROM and ambulation. The problems that were found with TED hose and SCDs were that they were not properly fit, correctly applied, or the patient was non compliant. “The study results reiterate the need for ongoing staff and patient reinforcement education on SCD compliance to promote optimal DVT prophylaxis” (Brady et al., 2007, p. 259). It is important that more research is done on this topic, especially in the area of improving patient compliance because that is one of the biggest barriers to these methods for DVT prevention. More research also needs to be done on early ambulation because very little research was found on the topic. There are no consequences of incorporating this into practice. The research educates and reminds nurses how important these devices are and to make sure they are applied, that it is done correctly and that patients are being compliant. This research also shows that nurses need to be reeducated on these devices so that they can explain the importance of the devices to the patients. If patients understand why they must do something they usually are more compliant because they understand the importance of the action and the negative effects that can occur if they do not. TED hose and SCDs are often thought of as hard to put on and annoying to keep on so it is up to the nurses to make sure the patient understands the benefits of these devices for preventing DVTs.

References

Brady, D., Raingruber B., Peterson J., Varnau W., Denman J., Resuello R., & De Contreaus R. (2007). The use of knee-length versus thigh-length compression stockings and sequential compression devices. Critical Care Nursing, 30(3), 255-262.

Caprini, J.A. (2009). Mechanical methods of thrombosis prophlaxis. Clinical and Applied Thrombosis/Hemostasis. doi: 10.1177/1076029609348645

Church, V. (2000). Staying on guard for dvt and pe. Nursing 30(2), 34-42. Retrieved from .

Geerts, W. H., Bergqvist, D., Pineo, G. F., Heit, J.A., Samama, C.M., Lassen, M.R., & Colwell, C.W. (2008). Prevention of venous thromboembolism. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) 133(6), 3815- 4535. doi: 10.1378/chest.08-0656

Glover, A.J. (2005). How to detect and defend against dvt. Nursing2005 35(10), 1-4. Retrieved from .

Kehl-Pruett, W. (2006). Deep vein thrombosis in hospitalized patients: A review of evidence-

based guidelines for prevention. Dimensions of Critical Care Nursing, 25(2), 53-59.

Le Sage, S., McGee, M, & Emed, J.D. (2008). Knowledge of venous thromboembolism (VTE) prevention among hospitalized patients. Journal of Vascular Nursing 26(4), 109-117

doi: 10.1016/j.jvn.2008.09.005

Limpus, A., Chaboyer, W., McDonald, E., Thalib, L. (2006). Mechanical thromboprophylaxis in critically ill patients: a stystematic review and meta-analysis. American Journal of Critical Care 15(4), 402-412. Retrieved from .

Morris, R.J. & Woodcock, J.P. (2004). Evidence-based compression prevention of stasis and deep vein thrombosis. Annals of Surgery 239(2), 162-171. Retrieved from .

United States Department of Health and Human Services. (2008). The surgeon general’s call to action to prevent deep vein thrombosis and pulmonary embolism. Retrieved from 2008.pdf.

Walker, L. & Lamont, S. (2008). Graduated compression stocking to prevent deep vein thrombosis (art & science: clinical practice review). Nursing Standard 22(40), 35-39.

Evidence Based Practice Group Project Evaluation Summary and Grade Form

Group: Ames – France – Price – Skripka - WItzman .

Project: Evidence based treatment for deep vein thrombosis .

|Item |Evaluation (below, met or exceeds expectations) |Comments |

|PICO statement and proposal |Exceeds | |

|Selection of articles for review |Exceeds | |

|Power Point Presentation |Met | |

|Peer evaluation of power point |Below x 2 | |

| |Met x 5 | |

| |Exceeds x 4 | |

|Paper (analysis) |Exceeds | |

|Introduction | | |

| | | |

|Literature Review | | |

| | | |

|Analysis of Evidence | | |

| | | |

|Application of Evidence | | |

|Summary Statements | | |

|Format | | |

| | | |

| | |Format: APA and grammatical issues. See comments on |

| | |paper. |

| |Exceeds | |

| |Exceeds | |

| |Exceeds | |

| |Exceeds | |

| |met | |

|Group Member Contribution and |Ames: met x 6, exceeds x 14 | |

|Collegiality |France: met x 10, exceeds x 10 | |

| |Price: met x 6, exceeds x 14 | |

| |Skripka: met x 6, exceeds x 14 | |

| |Witzman: below x 14, met x 6 | |

|Completion of Evaluation Forms |Done by all five group members | |

Total Score: 29 /30 Individual who was consistently evaluated as performing below expectations by all her group members will receive an alternative grade.

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