RESEARCH IN BRIEF
Major difficulties and information needs recognised by nurses in applying graduated compression stocking and intermittent pneumatic compression for deep vein thrombosis prophylaxis Hwasoon Kim and Eun Sook Lee Accepted for publication: 14 March 2014
Aim The aim of this study was to investigate the practical difficulties hindering appropriate use of graduated compression stocking and intermittent pneumatic compression (IPC) for critically ill patients and to identify information that ICU nurses want to know.
Background Deep vein thrombosis (DVT) in lower extremities can extend to pulmonary vessels and cause fatal results. Critically ill patients are one of the high-risk groups for DVT, and the DVT incidence among them ranges between 3–31% (Cook et al. 2005). Some ICU patients are not eligible for prophylactic medications and should only receive mechanical intervention such as IPC. For effective mechanical prophylaxis of DVT, appropriate use of this device must be assured. Nurses might have a false sense of security in these mechanical interventions. The application of IPC and graduated compression stocking reported in previous studies was not satisfactory (Macatangay et al. 2008, Bockheim et al. 2009). Bockheim et al. (2009) evaluated compliance of IPC application in 150 surgical patients. They assessed compliance as correct placement, powering and functioning of the device. The overall compliance was 73 29%, which was suboptimal, particularly in non-ICU patients. Macatangay et al. (2008) reported 74% compliance overall, with 59% compliance in the surgical ward. Moreover, the compliance was not improved much by hospital personnel education. According to the CLOTs Trials Collaboration (2009),
Authors: Hwasoon Kim, PhD, RN, Professor, Department of Nursing, Inha University, Incheon; Eun Sook Lee, RN, Graduate Student, Inha University, Incheon, Korea
308
What does this paper contribute to the wider global clinical community?
• The results of this paper provide some information about •
the problems that nurses frequently face when caring for patients using graduated compression stocking or IPC. This paper suggests what information related to graduated compression stocking or IPC application nurses want to know in practice. This information could guide nurses in effective interventions to enhance compliance.
graduated compression stocking was associated with skin breaks, ulcers, blisters and skin necrosis. The smaller size of IPC devices and technical advances could improve compliance and might be correlated with the incidence of DVT, but such evidence is lacking (MacLellan & Fletcher 2007). IPC-related complications were reported in only a few case reports of pressure necrosis, peroneal palsy and compartment syndrome (Macatangay et al. 2008). Most patients tolerated IPC well, but some patients complained of feeling warm or restless leg syndrome due to continuous inflation/ deflation during the night (Kehl-Pruett 2006). To enhance compliance, personnel must be educated on proper use as well as the difficulties associated with using these devices and appropriate interventions for these obstacles.
Design This study was designed as a descriptive survey. This study was conducted as a part of the main study that compared prevention effects for DVT occurrence between graduated
Correspondence: Hwasoon Kim, Professor, Department of Nursing, Inha University, #253 Younghyun-dong, Nam-gu, Incheon, 402-751, Korea. Telephone: +82 32 860 8208. E-mail: [email protected]
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 308–311, doi: 10.1111/jocn.12610
Research in Brief Table 1 Major difficulty in applying intermittent pneumatic compression (IPC) or GCS and additional information needed Major problems Graduated compression stocking
n (%)
Intermittent pneumatic compression
Concern for skin breakdown around ankle and thigh due to rolling outside Difficulty in checking skin condition in oedematous state Damage due to compression of banding in thigh Difficulty putting the stocking on a patient with decreased level of consciousness Wrinkles around the ankle Difficulty using vein in lower extremities or skin damage due to the presence of IV route
13 (448)
Length and circumferences did not fit well due to limited size options Uncomfortable to eat due to the IPC pump attached to the foot side Difficult to maintain fitting when moving the leg too much Failure to sustain the Velcro part of the sleeve (easy loosening of the Velcro) Discomfort wearing lower clothes Complaints of discomfort (tightness, bothersome, pain due to pressure, disturbed sleep) Getting soggy due to sweat
3 (103) 7 (241) 14 (483) 2 (69) 3 (103)
Patient’s complaint of discomfort from tightness (get rid of it) Questionable effectiveness in thin patients, because even small size did not fit Limited variations of size supplied Difficulty in measuring the suitable size
1 (35)
Too much time in haemostasis after drawing blood from the legs
1 (35)
5 (172) 1 (35) 3 (103)
Bad appearance because it is easily soiled by blood and/or excretion Uncomfortable when moving patients Agitation induced in irritable patients by inflow and outflow of air
n (%) 1 (35) 1 (35) 2 (69) 15 (517) 1 (35) 6 (207)
5 (172) 1 (35) 2 (69) 1 (35)
Information needs of nurses Appropriate application time and effective minimum application time Efficient solution for a case in which the selected size is a little too long (Is folding the band part problematic?) Degree of effectiveness in terms of deep vein thrombosis prophylaxis in Korean patients
5 (172) 3 (103)
1 (35)
compression stocking and IPC among 147 SICU patients. Data were collected from one university hospital in Incheon, Korea, during April 2011.
Methods Subjects were 29 nurses who worked in two SICU units of the university hospital, and they answered a brief survey. They were asked to describe any problems they experienced in applying and sustaining the intervention and any additional information they would like to know. At the time the survey was administered, participating nurses had been supporting the main study that investigated the effect of graduated compression stocking and IPC for SICU patients. This study was approved by the institutional review board along with the main study. The data were analysed as percentage and frequency.
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 308–311
Safety of keeping an intravenous line in lower extremities Effectiveness of intermittent vs. continuous use Effective minimum application time Amount of applied pressures (Is it possible to control provided pressure?) Difference in effectiveness between applying stockings and IPC together and IPC alone
1 (35) 4 (138)
2 (69) 1 (35)
Results The most frequently reported problems were potential or actual skin breakdown around the ankle and thigh (448%) and difficulty putting the stocking on a patient who had decreased consciousness (483%). About 51% of nurses reported failure to sustain the Velcro on the sleeve (easy loosening of the Velcro). On the contrary, four nurses (138%) reported that some patients’ legs felt comfortable after IPC application. Nurses wanted more information about appropriate application time for graduated compression stocking (172%) and IPC (138%); in particular, nurses sought information on the effective minimum application time because of difficulty putting the stocking or applying IPC on ICU patients (Table 1).
309
Research in Brief
Conclusions
Key words
While the use of thrombus prophylaxis such as graduated compression stocking and IPC is very important, nurses’ appropriate use of mechanical prophylaxis is more important (MacLellan & Fletcher 2007). To ensure appropriate use of these devices among SICU nurses, systematic education based on their information needs such as effective minimum application time and appropriate use methods as well as efforts to improve major problems such as skin breakdown and Velcro loosening problems is needed.
deep vein thrombosis, graduated compression stocking, intermittent pneumatic compression device, critically ill patients
Acknowledgements This study was supported by the National Research Foundation of Korea (NRF-2010-0013255). This work was supported by Inha University Research Grant.
Disclosure Relevance to clinical practice These results suggest that effective application of IPC and graduated compression stocking could be assured by improving the quality of those devices, for example, by providing various sizes of stockings and IPC sleeves in practice. Appropriate usage also could be enhanced by convincing nurses of the importance of the appropriate methods and time for preventing DVT. Fulfilling their educational needs related to the application of graduated compression stocking and IPC could also enhance the compliance of SICU nurses in clinical practice.
The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_1author.html), as follows: (1) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content; and (3) final approval of the version to be published.
Conflict of interest There are no conflict of interests.
References Bockheim HM, McAllen KJ, Baker R & Barletta JF (2009) Mechanical prophylaxis to prevent venous thromboembolism in surgical patients: a prospective trial evaluating compliance. Journal of Critical Care 24, 192–196. Cook D, Crowther M, Meade M, Rabbat C, Griffith L, Schiff D, Geerts W & Guyatt G (2005) Deep venous thrombosis in medical-surgical critically ill patients: prevalence, incidence, and risk factors. Critical Care Medicine 33, 1565–1571.
310
Kehl-Pruett W (2006) Deep vein thrombosis in hospitalized patients: a review of evidence-based guidelines for prevention. Dimensions of Critical Care Nursing 25, 53–59. Macatangay C, Todd SR & Tyroch AH (2008) Thromboembolic prophylaxis with intermittent pneumatic compression device in trauma patients: a false sense of security? Journal of Trauma Nursing 15, 12–15.
MacLellan DG & Fletcher JP (2007) Mechanical compression in the prophylaxis of venous thromboembolism. Australian and New Zealand Journal of Surgery 77, 418–423. The CLOTs Trials Collaboration (2009) Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial. Lancet 373, 1958–1965.
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 308–311
Research in Brief
The Journal of Clinical Nursing (JCN) is an international, peer reviewed journal that aims to promote a high standard of clinically related scholarship which supports the practice and discipline of nursing. For further information and full author guidelines, please visit JCN on the Wiley Online Library website: http://wileyonlinelibrary.com/journal/jocn
Reasons to submit your paper to JCN: High-impact forum: one of the world’s most cited nursing journals, with an impact factor of 1316 – ranked 21/101 (Nursing (Social Science)) and 25/103 Nursing (Science) in the 2012 Journal Citation Reportsâ (Thomson Reuters, 2012). One of the most read nursing journals in the world: over 19 million full text accesses in 2011 and accessible in over 8000 libraries worldwide (including over 3500 in developing countries with free or low cost access). Early View: fully citable online publication ahead of inclusion in an issue. Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jcnur. Positive publishing experience: rapid double-blind peer review with constructive feedback. Online Open: the option to make your article freely and openly accessible to non-subscribers upon publication in Wiley Online Library, as well as the option to deposit the article in your preferred archive.
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 308–311
311
This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.
Major difficulties and information needs recognised by nurses in applying graduated compression stocking and intermittent pneumatic compression for deep vein thrombosis prophylaxis Hwasoon Kim and Eun Sook Lee Accepted for publication: 14 March 2014
Aim The aim of this study was to investigate the practical difficulties hindering appropriate use of graduated compression stocking and intermittent pneumatic compression (IPC) for critically ill patients and to identify information that ICU nurses want to know.
Background Deep vein thrombosis (DVT) in lower extremities can extend to pulmonary vessels and cause fatal results. Critically ill patients are one of the high-risk groups for DVT, and the DVT incidence among them ranges between 3–31% (Cook et al. 2005). Some ICU patients are not eligible for prophylactic medications and should only receive mechanical intervention such as IPC. For effective mechanical prophylaxis of DVT, appropriate use of this device must be assured. Nurses might have a false sense of security in these mechanical interventions. The application of IPC and graduated compression stocking reported in previous studies was not satisfactory (Macatangay et al. 2008, Bockheim et al. 2009). Bockheim et al. (2009) evaluated compliance of IPC application in 150 surgical patients. They assessed compliance as correct placement, powering and functioning of the device. The overall compliance was 73 29%, which was suboptimal, particularly in non-ICU patients. Macatangay et al. (2008) reported 74% compliance overall, with 59% compliance in the surgical ward. Moreover, the compliance was not improved much by hospital personnel education. According to the CLOTs Trials Collaboration (2009),
Authors: Hwasoon Kim, PhD, RN, Professor, Department of Nursing, Inha University, Incheon; Eun Sook Lee, RN, Graduate Student, Inha University, Incheon, Korea
308
What does this paper contribute to the wider global clinical community?
• The results of this paper provide some information about •
the problems that nurses frequently face when caring for patients using graduated compression stocking or IPC. This paper suggests what information related to graduated compression stocking or IPC application nurses want to know in practice. This information could guide nurses in effective interventions to enhance compliance.
graduated compression stocking was associated with skin breaks, ulcers, blisters and skin necrosis. The smaller size of IPC devices and technical advances could improve compliance and might be correlated with the incidence of DVT, but such evidence is lacking (MacLellan & Fletcher 2007). IPC-related complications were reported in only a few case reports of pressure necrosis, peroneal palsy and compartment syndrome (Macatangay et al. 2008). Most patients tolerated IPC well, but some patients complained of feeling warm or restless leg syndrome due to continuous inflation/ deflation during the night (Kehl-Pruett 2006). To enhance compliance, personnel must be educated on proper use as well as the difficulties associated with using these devices and appropriate interventions for these obstacles.
Design This study was designed as a descriptive survey. This study was conducted as a part of the main study that compared prevention effects for DVT occurrence between graduated
Correspondence: Hwasoon Kim, Professor, Department of Nursing, Inha University, #253 Younghyun-dong, Nam-gu, Incheon, 402-751, Korea. Telephone: +82 32 860 8208. E-mail: [email protected]
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 308–311, doi: 10.1111/jocn.12610
Research in Brief Table 1 Major difficulty in applying intermittent pneumatic compression (IPC) or GCS and additional information needed Major problems Graduated compression stocking
n (%)
Intermittent pneumatic compression
Concern for skin breakdown around ankle and thigh due to rolling outside Difficulty in checking skin condition in oedematous state Damage due to compression of banding in thigh Difficulty putting the stocking on a patient with decreased level of consciousness Wrinkles around the ankle Difficulty using vein in lower extremities or skin damage due to the presence of IV route
13 (448)
Length and circumferences did not fit well due to limited size options Uncomfortable to eat due to the IPC pump attached to the foot side Difficult to maintain fitting when moving the leg too much Failure to sustain the Velcro part of the sleeve (easy loosening of the Velcro) Discomfort wearing lower clothes Complaints of discomfort (tightness, bothersome, pain due to pressure, disturbed sleep) Getting soggy due to sweat
3 (103) 7 (241) 14 (483) 2 (69) 3 (103)
Patient’s complaint of discomfort from tightness (get rid of it) Questionable effectiveness in thin patients, because even small size did not fit Limited variations of size supplied Difficulty in measuring the suitable size
1 (35)
Too much time in haemostasis after drawing blood from the legs
1 (35)
5 (172) 1 (35) 3 (103)
Bad appearance because it is easily soiled by blood and/or excretion Uncomfortable when moving patients Agitation induced in irritable patients by inflow and outflow of air
n (%) 1 (35) 1 (35) 2 (69) 15 (517) 1 (35) 6 (207)
5 (172) 1 (35) 2 (69) 1 (35)
Information needs of nurses Appropriate application time and effective minimum application time Efficient solution for a case in which the selected size is a little too long (Is folding the band part problematic?) Degree of effectiveness in terms of deep vein thrombosis prophylaxis in Korean patients
5 (172) 3 (103)
1 (35)
compression stocking and IPC among 147 SICU patients. Data were collected from one university hospital in Incheon, Korea, during April 2011.
Methods Subjects were 29 nurses who worked in two SICU units of the university hospital, and they answered a brief survey. They were asked to describe any problems they experienced in applying and sustaining the intervention and any additional information they would like to know. At the time the survey was administered, participating nurses had been supporting the main study that investigated the effect of graduated compression stocking and IPC for SICU patients. This study was approved by the institutional review board along with the main study. The data were analysed as percentage and frequency.
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 308–311
Safety of keeping an intravenous line in lower extremities Effectiveness of intermittent vs. continuous use Effective minimum application time Amount of applied pressures (Is it possible to control provided pressure?) Difference in effectiveness between applying stockings and IPC together and IPC alone
1 (35) 4 (138)
2 (69) 1 (35)
Results The most frequently reported problems were potential or actual skin breakdown around the ankle and thigh (448%) and difficulty putting the stocking on a patient who had decreased consciousness (483%). About 51% of nurses reported failure to sustain the Velcro on the sleeve (easy loosening of the Velcro). On the contrary, four nurses (138%) reported that some patients’ legs felt comfortable after IPC application. Nurses wanted more information about appropriate application time for graduated compression stocking (172%) and IPC (138%); in particular, nurses sought information on the effective minimum application time because of difficulty putting the stocking or applying IPC on ICU patients (Table 1).
309
Research in Brief
Conclusions
Key words
While the use of thrombus prophylaxis such as graduated compression stocking and IPC is very important, nurses’ appropriate use of mechanical prophylaxis is more important (MacLellan & Fletcher 2007). To ensure appropriate use of these devices among SICU nurses, systematic education based on their information needs such as effective minimum application time and appropriate use methods as well as efforts to improve major problems such as skin breakdown and Velcro loosening problems is needed.
deep vein thrombosis, graduated compression stocking, intermittent pneumatic compression device, critically ill patients
Acknowledgements This study was supported by the National Research Foundation of Korea (NRF-2010-0013255). This work was supported by Inha University Research Grant.
Disclosure Relevance to clinical practice These results suggest that effective application of IPC and graduated compression stocking could be assured by improving the quality of those devices, for example, by providing various sizes of stockings and IPC sleeves in practice. Appropriate usage also could be enhanced by convincing nurses of the importance of the appropriate methods and time for preventing DVT. Fulfilling their educational needs related to the application of graduated compression stocking and IPC could also enhance the compliance of SICU nurses in clinical practice.
The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_1author.html), as follows: (1) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content; and (3) final approval of the version to be published.
Conflict of interest There are no conflict of interests.
References Bockheim HM, McAllen KJ, Baker R & Barletta JF (2009) Mechanical prophylaxis to prevent venous thromboembolism in surgical patients: a prospective trial evaluating compliance. Journal of Critical Care 24, 192–196. Cook D, Crowther M, Meade M, Rabbat C, Griffith L, Schiff D, Geerts W & Guyatt G (2005) Deep venous thrombosis in medical-surgical critically ill patients: prevalence, incidence, and risk factors. Critical Care Medicine 33, 1565–1571.
310
Kehl-Pruett W (2006) Deep vein thrombosis in hospitalized patients: a review of evidence-based guidelines for prevention. Dimensions of Critical Care Nursing 25, 53–59. Macatangay C, Todd SR & Tyroch AH (2008) Thromboembolic prophylaxis with intermittent pneumatic compression device in trauma patients: a false sense of security? Journal of Trauma Nursing 15, 12–15.
MacLellan DG & Fletcher JP (2007) Mechanical compression in the prophylaxis of venous thromboembolism. Australian and New Zealand Journal of Surgery 77, 418–423. The CLOTs Trials Collaboration (2009) Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial. Lancet 373, 1958–1965.
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 308–311
Research in Brief
The Journal of Clinical Nursing (JCN) is an international, peer reviewed journal that aims to promote a high standard of clinically related scholarship which supports the practice and discipline of nursing. For further information and full author guidelines, please visit JCN on the Wiley Online Library website: http://wileyonlinelibrary.com/journal/jocn
Reasons to submit your paper to JCN: High-impact forum: one of the world’s most cited nursing journals, with an impact factor of 1316 – ranked 21/101 (Nursing (Social Science)) and 25/103 Nursing (Science) in the 2012 Journal Citation Reportsâ (Thomson Reuters, 2012). One of the most read nursing journals in the world: over 19 million full text accesses in 2011 and accessible in over 8000 libraries worldwide (including over 3500 in developing countries with free or low cost access). Early View: fully citable online publication ahead of inclusion in an issue. Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jcnur. Positive publishing experience: rapid double-blind peer review with constructive feedback. Online Open: the option to make your article freely and openly accessible to non-subscribers upon publication in Wiley Online Library, as well as the option to deposit the article in your preferred archive.
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 308–311
311
This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.
