SCDs vs. Compression Stockings in DVT Prevention

1. SCDs vs. Compression Stockings in DVT Prevention By: Sophia Britton , Megan Riedy, Karen Raber, Tina Van Kan, & Ashton Vottero

2. Research Question What is the most effective method for prevention of DVTs in adult post-surgical patients SCDs or TED hose?

3. Background According to the Agency for Healthcare Research and Quality (AHRQ), a property of the United States Department of Health and Human Services, greater than 2 million Americans suffer from venous thromboembolism (VTE) each year Nosocomial Origins: >50% of these occur during hospitalization or within 30 days of discharge from the hospital. High-Risk Patients: Surgical patients are among the highest risk subjects for the development of a type of VTE called proximal deep vein thrombosis (DVTs) The AHRQ states that every year, 23 million people undergo surgery within the United States. Post-surgical patients, many whom already suffering from comorbidities contributing to their risks of VTE, incur additional risks with surgical intervention Without VTE prophylaxis, the incidence of proximal deep vein thrombosis (DVT) and subsequent cardio-pulmonary embolisms would be critically high. An estimated 20% of all high-risk surgical patients (those with a history of disabling diseases and/or those undergoing hip or knee arthroplasties or hip fracture surgery) would develop VTE We are responsible for providing good discharge information to clients. If VTEs or DVTs are occurring within 30 days of our client�s returning home, we may not be giving adequate discharge instructions to prevent complications related to immobility. (AHRQ, 2011)We are responsible for providing good discharge information to clients. If VTEs or DVTs are occurring within 30 days of our client�s returning home, we may not be giving adequate discharge instructions to prevent complications related to immobility. (AHRQ, 2011)

4. Risk Factors for DVT Development Adult incidence is about 1 in 1,000 Obesity Surgery or Trauma Immobility Genetics Previous diagnosis of any circulatory system problem Adult incidence is about 1 in 1,000 - The incidence increases significantly around 45 years of age, but slightly less of an increase is seen for females compared to males Obesity- further research is needed to determine the pathophysiological mechanism. However, research speculated the correlation of DVT development and obesity is linked to increased body mass and decreased venues return. Also, there is belief that increased coagulation and inflammation are contributing factors to DVT development in obese patients Surgery or Trauma � The damage t veins endured during surgery or from trauma will slow blood flow, thus increasing the risk for a clot forming. Also, general anesthetics which are used during surgery tend to cause vasodilation. This increases the pooling of blood and thus increases clotting formation. Immobility � Stasis of blood flow results from immobility. This blood stasis increases clotting and therefor increases DVT development risk Genetics � several gene variants have been identified to be linked to cause hypercoagulability. The genes are more prevalently found in the Caucasian population. Previous diagnosis of any circulatory system problem � such as heart failure, coronary heart disease, or a previous DVT. Any factor which decreases the body�s ability to circulate blood increases the risk of DVT formation. Even dehydration may increase risks. (Cushman, 2007) Adult incidence is about 1 in 1,000 - The incidence increases significantly around 45 years of age, but slightly less of an increase is seen for females compared to males Obesity- further research is needed to determine the pathophysiological mechanism. However, research speculated the correlation of DVT development and obesity is linked to increased body mass and decreased venues return. Also, there is belief that increased coagulation and inflammation are contributing factors to DVT development in obese patients Surgery or Trauma � The damage t veins endured during surgery or from trauma will slow blood flow, thus increasing the risk for a clot forming. Also, general anesthetics which are used during surgery tend to cause vasodilation. This increases the pooling of blood and thus increases clotting formation. Immobility � Stasis of blood flow results from immobility. This blood stasis increases clotting and therefor increases DVT development risk Genetics � several gene variants have been identified to be linked to cause hypercoagulability. The genes are more prevalently found in the Caucasian population. Previous diagnosis of any circulatory system problem � such as heart failure, coronary heart disease, or a previous DVT. Any factor which decreases the body�s ability to circulate blood increases the risk of DVT formation. Even dehydration may increase risks. (Cushman, 2007)

5. Venous Thromboembolism (VTE) According to Virchow�s Triad, a combination of several, uninhibited factors must be present within one patient the formation of a DVT: vessel wall damage, increased coagulability of blood, and blood stasis Vessel wall damage is endemic to the surgery itself, something unpreventable. To counter the increased coagulability of blood and blood stasis, both mechanical and pharmacological prophylactic practices have been employed. But for some, the risks of receiving medications such as heparin or warfarin outweigh the benefits. The least invasive and safest method of prevention is mechanical prophylaxis. Mechanical DVT prophylaxis consists of: 1. Intermediate pneumatic compression devices (IPCs) or sequential compression devices (SCDs) 2. Graduated compression stockings (GCS) or thrombo-embolic deterrent (TED) hose. If the Virchow�s Triad can be interrupted or have just one factor missing, it is possible to prevent a DVT. (Black & Hawks, 2009)If the Virchow�s Triad can be interrupted or have just one factor missing, it is possible to prevent a DVT. (Black & Hawks, 2009)

6. Nonpharmacologic Treatment As inactivity and dehydration are associated with increased blood viscosity, early ambulation after surgery and hydration are recommended to prevent clots and improve/maintain venous return. Graded Compress Stockings work by compressing superficial veins, thereby increasing blood flow velocity in the deep veins, reducing venous endothelial injury caused by venous congestion and dilation in the lower limbs. � Compression stockings are useful in preventing a complication of a leg blood clot called postthrombotic syndrome or postphlebitis syndrome, in which the affected leg swells and becomes chronically painful. � Sequential Compression Devices are used to simulate blood flow through the legs and stimulate fibrinolytic activity. The leg is compressed in an ascending fashion so as to provide for venous return and prevent stagnation. SCDs may be used until the patient is able to ambulate for more than 30 minutes per day. The goals of treatment for Deep Vein Thrombosis include: Preventing a clot from growing Preventing a clot from breaking off and traveling to the lung or other organ Avoiding long-lasting complications (i.e. leg pain and swelling) Preventing blood clots from recurring (Manabu & Munenori, 2011) The goals of treatment for Deep Vein Thrombosis include: Preventing a clot from growing Preventing a clot from breaking off and traveling to the lung or other organ Avoiding long-lasting complications (i.e. leg pain and swelling) Preventing blood clots from recurring (Manabu & Munenori, 2011)

7. DVT Identification Clinical presentations of DVT Symptoms include: Calf or thigh pain Unilateral extremity edema or enlargement Calf tenderness (Homan�s sign) Pain can vary from dull ache to tightness or frank pain. Low grade fever, increased tissue turgor, tachycardia and distension of the superficial venous collaterals may occur from increased venous pressure Skin may become pale or cool with massive swelling and restriction Occlusion of the femoral and iliac veins causes the skin to appear cyanotic Deep Vein Thrombosis (DVT) is defined as the development of a single or multiple blood clots within the deep veins of the extremities or pelvis. DVT is considered to be a result of Virchow�s Triad: a condition associated with venous stasis, hypercoagulability and injury to the inner epithelial layer of the vessel. (Kehl-Pruett, 2006)Deep Vein Thrombosis (DVT) is defined as the development of a single or multiple blood clots within the deep veins of the extremities or pelvis. DVT is considered to be a result of Virchow�s Triad: a condition associated with venous stasis, hypercoagulability and injury to the inner epithelial layer of the vessel. (Kehl-Pruett, 2006)

8. Importance to Nurses Nurses must use the best EBP to care for their patient�s best interests. DVT incidences decreased in a particular hospital by switching from the use of anti embolic stockings, to the use of Sequential Compression Devices. Nurses must work to promote patient�s basic care needs such as comfort. 1. 600,000 patients develop a deep vein thrombosis (DVT) every year in U.S. hospitals. Complications arising from DVTs are serious and cost thousands of dollars including prolonged length of stay, increased cost of hospitalization and emotional stress. Nurses must work for their patient�s best interests by using the best proven therapies to reduce long term complications resulting from the development of DVT�s (Esche, C. 2011). 2. Evidence was shown within one hospital that by eliminating anti embolic stockings completely, and using only mechanical prophylaxis, such as SCDs (along with pharmacologic therapy), that the incidence of DVT�s decreased among patients (Esche, C. 2011). 3. By promoting comfort, patients recover quicker and are more likely to proceed with their treatments when their comfort is considered. Thigh length antiembolic stockings have an elastic band that is itchy and tighter on patient�s legs than SCD�s; SCD�s are proven to be more comfortable for patients, so patients are more likely to comply with treatment (Brady, D., et al. 2007). 1. 600,000 patients develop a deep vein thrombosis (DVT) every year in U.S. hospitals. Complications arising from DVTs are serious and cost thousands of dollars including prolonged length of stay, increased cost of hospitalization and emotional stress. Nurses must work for their patient�s best interests by using the best proven therapies to reduce long term complications resulting from the development of DVT�s (Esche, C. 2011). 2. Evidence was shown within one hospital that by eliminating anti embolic stockings completely, and using only mechanical prophylaxis, such as SCDs (along with pharmacologic therapy), that the incidence of DVT�s decreased among patients (Esche, C. 2011). 3. By promoting comfort, patients recover quicker and are more likely to proceed with their treatments when their comfort is considered. Thigh length antiembolic stockings have an elastic band that is itchy and tighter on patient�s legs than SCD�s; SCD�s are proven to be more comfortable for patients, so patients are more likely to comply with treatment (Brady, D., et al. 2007).

9. How Nursing Can Impact This Topic Nurses must work as patient advocates and implement the best practices into their units or hospitals. By remaining up to date with current research, nurses can save tons of lives. Nurses are educators for patients and the hospital staff. If nurses work at a hospital or nursing home that is still using anti embolic stockings over SCD�s, nurses can review the best evidence and try to implement these practices into their places of employment so that their patients are receiving the best possible care (Kehl-Pruett, W. 2006). Nurses must review the most current and best literature when providing care for patients. By becoming knowledgeable about a particular topic, nurses can educate their patients and promote patient compliance. They can educate the hospital staff as well, so that the hospital is aware of the best practices and can begin to implement the better practices for patient safety and better outcomes (Esche, C. 2011). If nurses work at a hospital or nursing home that is still using anti embolic stockings over SCD�s, nurses can review the best evidence and try to implement these practices into their places of employment so that their patients are receiving the best possible care (Kehl-Pruett, W. 2006). Nurses must review the most current and best literature when providing care for patients. By becoming knowledgeable about a particular topic, nurses can educate their patients and promote patient compliance. They can educate the hospital staff as well, so that the hospital is aware of the best practices and can begin to implement the better practices for patient safety and better outcomes (Esche, C. 2011).

10. �Intermittent pneumatic compression and deep vein thrombosis prevention in postoperative patients� Purpose: to determine the effectiveness of intermittent pneumatic compression (IPCs) devices in the prevention of DVTs Study design: meta-analysis Method: Half of the sample population wore the IPC devices while half received no prophylactic treatment at all ICP therapy was started preoperatively and continued after surgery until the patient was fully ambulatory Sample population: This study involved over 2,000 patients who were orthopedic, general surgical, oncological, neurosurgical, and urological patients Statistics: IPC devices reduced the risk of DVT by 60% when compared to patients with no mechanical or pharmacologic prophylaxis Outcome: IPC significantly reduced the risk of DVTs among surgical patients Compliance rate may have been an issue as it ranged from 53%-78% This study recommends the use of mechanical prophylaxis when the patient is at risk for bleeding or in addition to pharmacologic prophylaxis Topic support: Provides an excellent description of how these devices work Focuses on our same sample population (postsurgical) and studied a large number of patients (over 2,000) Supported that SCDs are necessary for the prevention of DVTs (Urbankova, Quirzo, & Goldhaber, 2006)Topic support: Provides an excellent description of how these devices work Focuses on our same sample population (postsurgical) and studied a large number of patients (over 2,000) Supported that SCDs are necessary for the prevention of DVTs (Urbankova, Quirzo, & Goldhaber, 2006)

11. �Graduated Compression Stocking to Prevent Deep Vein Thrombosis� Purpose: Describe the correct use and length of graduated elastic compression stockings to prevent deep vein thrombosis in general surgical patients. Method: 38 randomized controlled trials divided into high, moderate and low risk Study design: randomized controlled trials Sample Population: 3,339 general surgical patients Statistics: general surgical patient showed no statistical significance between the outcome of acquiring a DVT whether receiving below knee stockings Outcome: The use of compression stockings are an effective intervention in prevention of DVT provided patients are asses and correct application is adhered to. The study does not provide any comparison of SCD�s which is the basis of our topic. Topic support: This study made in interesting point that the different length of stockings has not been shown to provide for better stasis but simply it is a matter or preference. (Walker & Lamont, 2008)Topic support: This study made in interesting point that the different length of stockings has not been shown to provide for better stasis but simply it is a matter or preference. (Walker & Lamont, 2008)

12. �Verification of the Effect of Techniques Used to Prevent Deep Vein Thrombosis� Purpose: verification of the effectiveness of elastic stockings and intermittent pneumatic compression in the prevention of DVTs. Study Design: a one group experimental design with multiple variables. Methods: The blood flow velocity of the femoral vein was measured under three different conditions: at rest wearing elastic intermittent pneumatic compression device Sample Population: 16 healthy males with no past history of vascular lesions. Statistics: The blood flow velocities in the femoral vein were 30.7 � 5.2 cm/sec at rest, 29.1 � 6.6 cm/sec with SCD and 50.4 � 19.3 cm/sec with the application of intermittent pneumatic compression respectively. This difference was not of statistical significance with a P value of >0.05 Conclusion: The difference in observed blood-flow velocity between wearing the elastic stockings and the application of intermittent pneumatic compression is minimal. Topic support: Provides good information on the effects of SCD and GCD, how they work and what they do to prevent thrombosis. Compression stockings compress the exterior layer of capillaries. This study hypothesized that in doing so, the lumen of the inner veins would have to expand in order to maintain blood flow. In doing so, the blood flow would slow. They felt this explained the reason the compression stockings had the same or less blood flow velocity than those without the stockings. The study felt that the use of ankle pumping, deep breathing and early ambulation were more effective in prevention that these devices. (Manabu & Munenori, 2011)Topic support: Provides good information on the effects of SCD and GCD, how they work and what they do to prevent thrombosis. Compression stockings compress the exterior layer of capillaries. This study hypothesized that in doing so, the lumen of the inner veins would have to expand in order to maintain blood flow. In doing so, the blood flow would slow. They felt this explained the reason the compression stockings had the same or less blood flow velocity than those without the stockings. The study felt that the use of ankle pumping, deep breathing and early ambulation were more effective in prevention that these devices. (Manabu & Munenori, 2011)

13. �Deep Vein Thrombosis in Hospitalized Patients� Purpose: review risk factors and current methods for prevention of a DVT in hospitalized patient in order to raise clinician awareness of the preventable complication Study design: Aggregate Study Sample Population: 5451 patients over 6 months, 17 months of patients Meta-analysis of 14 studies Statistics: 2726 developed a DVT while hospitalizes 66% of surgical patients received prophylaxis, where at 23%o nonsurgical patients were given prophylaxis 69% received a DVT Prophylaxis Outcome: Data suggests that compliance and proper administration of both SCDs and Compression Stockings is important Both SCD�s and Compression Stockings are useful prophylactic treatment of DVTs Topic support: Provides good background information on the importance of SCDs, compression stockings and DVT prevention measures. Does not give a clear indication that one is better than the other (Kehl-Pruett, 2006)Topic support: Provides good background information on the importance of SCDs, compression stockings and DVT prevention measures. Does not give a clear indication that one is better than the other (Kehl-Pruett, 2006)

14. �An interdisciplinary evidence based practice approach to effective mechanical thrombolytic therapy� Purpose: To review whether anti embolic stockings, or SCD�s are most effective at preventing DVT�s at Franklin Square Hospital Center. Study Design: Review of Literature Method: The Chief of Surgery, a medical surgical nurse educator and a clinical nurse specialist reviewed the literature regarding sequential compression devices (SCDs) and anti-embolic stockings for preventing DVT�s in hospital patients. Sample Population: All patients at Franklin Square Hospital Center Statistics: 600,000 patients develop a deep vein thrombosis (DVT) every year in U.S. hospitals. Complications arising from DVTs are serious and cost thousands of dollars including prolonged length of stay, increased cost of hospitalization and emotional stress. Outcome: For the quarter following implementation of sequential compression devices, two patients developed an acute venous embolism while in the hospital. This represents a decrease in the number of patients developing DVT within the Franklin hospital on a quarterly basis Topic Support: Education and discussion with both doctors and nurses helped the hospital achieve their goal of one consistent approach to mechanical thrombolytic therapy. This study shows evidence within one hospital that by eliminating anti embolic stockings completely, and using only mechanical prophylaxis, such as SCDs (along with pharmacologic therapy), that the incidence of DVT�s decreased among patients. SCD�s are the prophylactic treatment of choice for preventing DVT�s over anti embolic stockings. (Esche, 2011)Topic Support: Education and discussion with both doctors and nurses helped the hospital achieve their goal of one consistent approach to mechanical thrombolytic therapy. This study shows evidence within one hospital that by eliminating anti embolic stockings completely, and using only mechanical prophylaxis, such as SCDs (along with pharmacologic therapy), that the incidence of DVT�s decreased among patients. SCD�s are the prophylactic treatment of choice for preventing DVT�s over anti embolic stockings. (Esche, 2011)

15. �Intermittent Pneumatic Compression or Graduated Compression Stockings for Deep Vein Thrombosis Prophylaxis? A Systematic Review of Direct Clinical Comparisons�  Purpose: to review the relative efficacy of intermittent pneumatic compression (IPC) and graduated compression stockings (GCS) stated in direct clinical comparisons. Study Design: A systematic review. Sample Type: post-surgical clients. Methodology: The MEDLINE, EMBASE, AMED , and CINAHL databases were searched from 1970 to August 2008 for papers relating to the use of IPC and GCS in DVT prophylaxis. The relevance of references was determined by the abstract, or when there was no abstract available by obtaining the full article, if indicated by the title. Further still, all references given by included articles were also investigated for pertinent information. Statistical Research Findings: IPC devices produced lower DVT rates in 7 of the 10 trials utilized. However, only 3 cases of those 7 determined that the difference in DVT prophylaxis reached statistical significance (IPC still had a lower rate in each of these). If the results are accumulated, the crude DVT incidence rate (P) for all the trials is 5.9% for GCS and 2.5% for IPC. In the end, IPC devices (read: SCDs) are marginally better in DVT prophylaxis. Conclusion: The direct comparisons analyzed in this systematic review provide weak evidence to show that one device (IPS) is better than the other (GCS). However, weak evidence does not imply strong evidence for equivalency. The best practice should be evaluated in larger-scale, longer-term trials. Topic Support: Reviewed many different studies in the effectiveness of both IPCs and compression stockings which were the same variables we were looking at Did not give specific information on the population samples in these studies (Morris & Woodcock, 2010)Topic Support: Reviewed many different studies in the effectiveness of both IPCs and compression stockings which were the same variables we were looking at Did not give specific information on the population samples in these studies (Morris & Woodcock, 2010)

16. �A Prospective Study of Nurse and Patient Education on Compliance with Sequential Compression Devices� Purpose: Assess the affect of patient and nurse education by surgeons on SCD compliance Method: None of the nurses or patients were aware of the study Residents made an initial observation of patient compliance and then held an informational meeting will all nurses on the floor on the purpose and benefits of SCDs. Each patient was also given a 1 page informational flier on SCDs Resident surgeons made rounds every morning and afternoon and checked patient compliance with SDCs Study design: Perspective observational study Sample Population: All surgical patients within one teaching hospital Statistics: Before education, surgical units had a compliance rate of 61.5%. After nursing and patient education, compliance rate increased to 65%. This difference was not of statistical significance with a P value of 0.515 Outcome: Data suggests that compliance rates have more to do with nursing experience than with structured lectures. Patient education did not significantly increase compliance rates This study brings up an important point that it doesn�t matter which is better SCDs or Ted hose in preventing blood clots if the patient is not compliant with them. This study also made an interesting point that nurses must document patient medications very specifically but there is no such thing that exists for SCD compliance. This study brings up an important point that it doesn�t matter which is better SCDs or Ted hose in preventing blood clots if the patient is not compliant with them. This study also made an interesting point that nurses must document patient medications very specifically but there is no such thing that exists for SCD compliance.

17. Conclusions All of our analyzed research studies found that there was not a significant difference between the effectiveness of SCDs and Compression Stockings in DVT prevention They did however conclude that some type of prophylaxis is necessary in the prevention of DVTs in post-surgical patients Mechanical prophylaxis is very effective especially when anti-embolics are contraindicated

18. Future research regarding SCDs Vs. Compression Stockings It seems no perfect side by side comparison has been made to determine efficacy of one over the other. Research results indicate that the most important determining factor is whether or not the Compression stockings or SCDs were applied correctly. Another important point in some of our research studies was that compliance can be a huge factor�it doesn�t matter which device works better if the patient isn�t wearing it. Patient compliance could be added in as a factor in further research of this topic Future research will need to directly compare both prophylactic treatments and better minimize unintended variables. Perhaps use one post op. unit with a consistent nursing staff.

19. References Agency for Healthcare Research and Quality (AHRQ). (2011). Preventing Hospital-Acquired Venous Thromboembolism. United States Department of Health and Human Services. Retrieved from, http://www.ahrq.gov/qual/vtguide/vtguideapa.htm. Black, J.M., & Hawks, J.H. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed.) St. Louis, MO: Saunders of Elsevier. Cushman, M. (2007). Epidemiology and risk factors for venous thrombosis.�Semin Hematol,�44(2), 62-69. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2020806/pdf/nihms21418.pdf Esche, C. (2011). An interdisciplinary evidence based practice approach to effective mechanical thrombolytic therapy. The Annual Maryland Patient Safety Center�s Call for Solution.RetrievedFrom:http://www.google.com/url?sa=t&rct=j&q= evidence%20based%20practice 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), 53-61.

20. References Continued Manabu Uchida, Munenori Katoh (2011). Verification of the effect of techniques used to prevent deep-vein thrombosis. Journal of Physical Therapy. Vol.�23:243-245. Morris, J. & Woodcock, J.P. (2010). �Intermittent Pneumatic Compression or Graduated Compression Stockings for Deep Vein Thrombosis Prophylaxis? A Systematic Review of Direct Clinical Comparisons. Annual Surgeon. 251(3):397-8. Stewart, D. et al. (2006). A prospective study of nurse and patient education on compliance with sequential compression devices. American Surgeon. 72(10). 921-923. Retrieved from Ebscohost. Urbankova, J., Quirzo, R., & Goldhaber, S. (2006). Intermittent pneumatic compression and deep vein thrombosis prevention in postoperative patients. Phlebology. 21. 19-22. Retrieved from Ebscohost Walker, L., & Lamont, S. (2008). Graduated compression stockings to prevent deep vein thrombosis. Nursing Standard, 22(40), 35-38. Retrieved from EBSCOhost.