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Best Practice in the Use of VTE Prevention Methods

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Best Practice in the Use of VTE Prevention Methods Keywords: Anti-embolism stockings/ Nursing Practice Intermittent pneumatic compression/ Practice educator Thromboprophylaxis ●This article has been double-blind Patient safety peer reviewed Use of anti-embolism stockings and intermittent pneumatic compression is widespread but health professionals need assistance on aspects of these treatment options Best practice in the use of VTE prevention methods Learning points... 5 practice Ten FAQs about mechanical thromboprophylaxis points The use of Assessing patients for thromboprophylaxis suitability 1anti-embolism Recommendations for use as outlined in national guidance stockings and intermittent pneumatic Authors Emma Gee is a nurse consultant existing evidence base and the experience compression in thrombosis and anticoagulation; Cara and knowledge of specialist nurses. This devices is common Doyle is a venous thromboembolism information should be used alongside in acute hospital clinical nurse specialist, both at King’s local guidance to make clinical decisions settings College Hospital NHS Foundation Trust. about the use of mechanical thrombo- As health Abstract Gee E, Doyle C (2015) Best prophylaxis. 2professionals practice in mechanical thromboprophy- are often unclear laxis. Nursing Times; 111: 16, 12-14. Anti-embolism stockings about how best to Although anti-embolism stockings and Anti-embolism stockings are thigh- or use stockings and intermittent pneumatic compression are knee-length garments made from elastic IPC devices, their commonly used for mechanical thrombo- with a graduated compression profile that use varies widely prophylaxis, practice varies significantly. gently compresses the leg to aid venous Patients must This article reviews national guidance and return in non-ambulatory patients. NICE 3be assessed to research evidence on common questions (2010) recommends using stockings that ascertain whether relating to the use of these interventions to produce a calf pressure of 14-15mmHg, as stockings or IPC prevent venous thromboembolism. this profile has been shown to reduce the devices are suitable incidence of deep vein thrombosis (DVT). treatment options nti-embolism stockings and The procedure for applying anti-embolism Patients intermittent pneumatic com- stockings is outlined in Box 2. 4treated using pression devices are common- stockings must Aplace in the acute hospital set- For how long should stockings be worn? have their legs ting and have been used as a mode of Amaragiri and Lees (2000) reviewed clin- checked regularly thromboprophylaxis for many years. ical trials involving anti-embolism stock- for skin damage Despite this, our experience shows dis- ings and found wide variation in the length Professionals parity in their practical use. Therefore, we of time for which they should be worn; this 5must be trained put 10 frequently asked questions relating ranged from six to 14 days. and competency to mechanical thromboprophylaxis to NICE (2010) advises that clinicians assessed to ensure venous thromboembolism clinical nurse should “encourage patients to wear their they know how to specialists from across the country. Varia- anti-embolism stockings day and night use stockings tion in the answers prompted a literature until they no longer have significantly appropriately search to see what evidence is available to reduced mobility”. Patients should be inform these clinical decisions. given both verbal and written advice when The National Institute for Health and discharged from hospital and be shown Care Excellence (2010) outlines the con- how to use stockings safely. Patients dis- traindications to anti-embolism stockings charged with stockings should know how (Box 1), but it is vital that a clinical decision to access help if they experience any issues is made in conjunction with the patient, after discharge. balancing the risk of potential harm and benefit. With this in mind, we have For how long can stockings be removed? addressed the FAQs discussed with the Although no studies have looked specifi- VTE specialists using a combination of cally at how long patients can be without Anti-embolism stockings aid venous national guidelines, information from the stockings for them to remain effective at return in non-ambulatory patients 12 Nursing Times 15.04.15/ Vol 111 No 16 / www.nursingtimes.net 6 - 7 JULY 2015, BIRMINGHAM CONGRESS preventing DVT, one study found that BOX 1. venous distension starts to occur 30 min- CONTRAINDicatiONS FOR ANTI-EMBOLISM utes after stockings have been removed STOCKINGS (Coleridge Smith et al, 1991). Do not offer anti-embolism stockings to patients who have: Venous distension is thought to cause ● Suspected or proven peripheral arterial disease subendothelial tears and activate clotting ● Peripheral arterial bypass grafting factors, which may lead to thrombus for- ● Peripheral neuropathy or other causes of sensory impairment mation (NICE, 2010). ● Any local conditions in which stockings may cause damage, for example fragile “tissue-paper” skin, dermatitis, gangrene or recent skin graft Do stockings cause skin damage? ● Known allergy to the material of manufacture With any compression there is a risk of ● Cardiac failure skin damage. Ulceration and damage to ● Severe leg oedema or pulmonary oedema from congestive heart failure the heel is a recognised complication of ● Unusual leg size or shape anti-embolism stockings if applied incor- ● Major limb deformity preventing correct fit rectly, especially to patients who are vul- Use caution and clinical judgement when applying anti-embolism stockings over nerable (Merrett and Hanel, 1993). NICE venous ulcers or wounds. (2010) recommends that stockings should Source: National Institute for Health and Care Excellence (2010) be removed to check for skin damage: » Up to three times daily in those most at risk of skin damage; using thigh-length stockings compared have significant VTE risk factors, (Chal- » At least once daily for all other patients. with knee-length ones. Individual patient mers et al, 2011). Skin checks should be recorded in the factors such as leg size and shape, comfort Outcome data for the paediatric popula- patient’s clinical notes along with the leg and hygiene are considerations when tion exists for prevention of DVT (Monagle measurements and size of stocking. choosing stocking length (NICE, 2010). et al, 2008) but anti-embolism stockings Stockings should be discontinued and However, the evidence supporting thigh- have never been shown to reduce the inci- the patient’s medical team informed so length stockings should be a factor in the dence of pulmonary embolism or death in that suitable alternatives can be consid- decision-making process. children. Nurses should ensure the deci- ered if there is any: sion process for whether to apply stockings » Marking; Can stockings be used with patients in children at high risk of VTE is clearly » Evidence of skin damage; who have wounds? documented. » Pain or discomfort. NICE (2010) guidance states that: “Caution Remeasuring patients’ legs, particularly and clinical judgement should be used IPC devices in the event of swelling or oedema, to when applying stockings over venous Intermittent pneumatic compression ensure their stockings are the correct size, ulcers and wounds.” devices consist of inflatable sleeves that also contributes to risk reduction. It is important to rule out arterial insuf- wrap around the legs or feet, attached with ficiency as a cause for the wound, as com- tubing to a machine that inflates the Should qualified nurses decide which pression in this instance would inhibit sleeves intermittently. This compression patients use stockings? peripheral arterial blood flow, potentially promotes blood to return to the heart from Nurses should use a VTE risk assessment resulting in ischaemia. Although there is the limb. It is thought that IPC reduces the and local thromboprophylaxis guidelines evidence that compression can aid the risk of VTE by preventing venous stasis to establish whether stockings are indi- healing of venous ulcers, the effective pres- and stimulating the release of fibrinolytic cated for individual patients. They should sure profiles of compression bandages and factors in the blood (Kohro et al 2005). It then assess those patients for contraindi- stockings are different to that offered by is used in patients who cannot move. cations before proceeding. Merrett and anti-embolism stockings (Johnson, 2002). Hanel (1993) demonstrated the importance Patients with a wound need stockings to What is the right length of IPC sleeve? of applying stockings correctly to ensure be removed and the skin to be checked for Although there is evidence that thigh- they are in an optimum position to be any sign of damage or deterioration at least length sleeves offer superior haemody- effective in reducing DVT and to minimise three times a day. Careful documentation namic effects compared with knee-length the risk of skin damage. Nurses therefore of the wound size and characteristics versions (Patterson and Cardullo, 2013), require training and assessment to guar- is required to ensure deterioration convincing outcome data to prove superi- antee the stockings are used appropriately. can be identified on routine checks. ority does not yet exist. NICE (2010) states If deterioration occurs, stockings should that thigh- or knee-length sleeves can be When should thigh- or knee-length be removed immediately and other options used so nurses should use their clinical stockings be used? considered. judgement to assess
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