Running head: IMPLEMENTATION OF A PRACTICE CHANGE 1
Implementation of a Practice Change:
Utilization of Intermittent Pneumatic Compression Devices to Prevent Deep Vein Thrombosis in Immobile Stroke Patients Alyssa Blumenthal University of South Florida
Running head: IMPLEMENTATION OF A PRACTICE CHANGE 2 Implementation of a Practice Change: Utilization of Intermittent Pneumatic Compression Devices to Prevent Deep Vein Thrombosis in Immobile Stroke Patients Deep vein thrombosis (DVT) is a blood clot that forms a deep vein, usually in the legs. These clots are dangerous because they can break loose and travel to the lungs, block blood flow and ultimately cause a life threatening pulmonary embolism (CDC, 2012). The annual incidence of deep vein thrombosis is approximately 1-2 people per one thousand and one hundred per one thousand in patients over the age of eighty (CDC, 2012). Every year, approximately 60,000 to 100,000 Americans will die of deep vein thrombosis (CDC, 2012). The annual total healthcare costs associated with deep vein thrombosis ranges from ten to fifty-two billion dollars (Mahan, Holdsworth, Welch, Borrego & Spyropoulos, 2011). One of the most high risk patient populations for deep vein thrombosis remain neurosurgical patients who have suffered a stroke and are immobile. For this reason, preventative measures need to be utilized. Unlike other patients, neurosurgical patients who have suffered a stroke are often contraindicated for the use of anticoagulants as a preventative measure. Therefore other preventative measures must be utilized such as intermittent pneumatic compression devices or gradual compression stockings. The following randomized controlled trials examine the effectiveness of both intermittent pneumatic compression devices and gradual compression stockings and answer the question of which is more effective in this patient population. The current standard of care is for all patients to utilize intermittent pneumatic compression devices during their hospitalization however many patients choose not to use them due to a lack of understanding, finding them uncomfortable, or a variety of personal reasons. Studies show that in patients at risk for DVT, between the Running head: IMPLEMENTATION OF A PRACTICE CHANGE 3 ages of sixty and one hundred, have a history of stroke and are immobile, gradual compression stockings are not as effective as intermittent pneumatic compression devices when used during the course of their hospitalization and ten days following discharge. It should also be noted that gradual compression stockings were shown to have increased instances of skin breakdown, ulcers and necrosis (Dennis, Sandercock, Reid, Graham, Murray, Venables, Bowler, 2009). PICOT Question: The initial step in this review process was the development of the following PICOT question: In immobile stroke patients, does the use of intermittent pneumatic compression devices compared to the use of gradual compression stockings or nothing at all decrease the rate of deep vein thrombosis when used during the patients hospital stay and up to ten days following discharge? Infrastructure to Support Practice Change St. Josephs Hospital (SJH) is committed to providing excellent patient care. This commitment is reflected in their values as found on the St. Josephs Hospital website, We believe in: Respect and compassion for ourselves and others, excellence in service, the dignity of human life and commitment to the community (http://saintjosephs.org). The values and culture of SJH encourages an environment where health care providers strive towards quality patient care. After the Nurse Manager approves the use intermittent pneumatic compression devices and mandates that they be used in immobile stroke patients, all health care providers including doctors, nurses, patient care techs and physical therapy will be responsible for complying. Meetings will be held by the Nurse Running head: IMPLEMENTATION OF A PRACTICE CHANGE 4 Manager in order discuss this change with health-care providers, educate on its importance and determine the best way to implement it based on evidence based practice. Summary of Synthesized Literature Review of Best Practice Literature Search Google scholar, PubMed and the USF online database were searched using the terms deep vein thrombosis, prevention, immobile, stroke patients, intermittent pneumatic compression devices and gradual compression stockings. Only articles published after 2008 were utilized. Three peer-reviewed studies were selected for evaluation and synthesis. Synthesis Exploration of the use of intermittent pneumatic compression devices in immobile stroke patients revealed positive evidence of reduced incidence of deep vein thrombosis. In patients sixty to one hundred year of age who have had a stroke and are immobile, intermittent pneumatic compression devices are shown to reduce the risk of deep vein thrombosis when compared to graduated compression stockings (Dennis et al., 2013). According to the CLOTS 3 trial, intermittent pneumatic compression devices could save about 1,500 lives each year (Dennis et al., 2013). Compared to the routine care group only, the intermittent pneumatic compression group showed a 14% mortality risk reduction (p = 0.042) during the first six months after hospital admission for stroke (Dennis et al., 2013). The CLOTS 3 trial also discovered that gradual compression stockings were not nearly as effective in preventing deep vein thrombosis and they may even accelerate skin breakdown ultimately causing ulcers, blisters and skin necrosis in this patient population (Dennis et al., 2013). CLOTS 1 and CLOTS 3 provide a basis for Running head: IMPLEMENTATION OF A PRACTICE CHANGE 5 implementing evidenced based practice while the last study justifies the need for evidenced based practice implementation by addressing the healthcare costs associated with DVT as well as the statistics and evidence related to DVT prevention. Proposed Practice Change Using intermittent pneumatic compressions devices for immobile stroke patients appears to be a relatively low risk intervention for decreasing the incidence of deep vein thrombosis in said patient population. Gradual compression stockings should be evaluated for risks associated with skin breakdown and possibly replaced with the use of intermittent pneumatic compression devices. Intermittent pneumatic compression devices should be utilized in patients who have experienced a stroke and are immobile. Nurses should educate, implement and document the use of IPCS. Change Strategy Promote Engagement All health care providers and hospital staff are encouraged to participate in the process and have open communication regarding the implementation. If anyone has a concern with the new implementation, designated staff will be available to answer questions. At first monthly meetings will be held to discuss the progress of the implementation and after a year, meetings will be held less frequently. The Model for Evidence-Based Practice Change Once employees of the hospital have accepted the mandated use of pneumatic compression devices for the indicated patients, guidelines and regulations should be put in place to ensure superior care. Saint Josephs Hospital currently uses The Johns Hopkins Model for Evidence-Based Practice Change when implementing EBP into the Running head: IMPLEMENTATION OF A PRACTICE CHANGE 6 clinical setting. This model has been selected because it is the model utilized by the hospital where the EBP change is intended on being implemented. Roll Out Plan Steps Definition Timeframe For Rollout Step 1 Assess the need for change in practice Include stakeholders (i.e. Nurse Manager, Doctors, Nurses, patient care techs, nurse educator, Physical Therapy) Collect data about current practice (Talk to Nurse Manager about what is currently in place) Compare external and internal data. Compare researched data with St. Josephs data. Identify problem- DVT prevalence in immobile stroke patients Link problem, interventions and outcome. DVT Prevention by using intermittent pneumatic compression devices will decrease DVT prevalence in immobile stroke patients.
Completed September, 2013 Running head: IMPLEMENTATION OF A PRACTICE CHANGE 7
Step 2 Locate the best evidence- Randomized control trials, peer reviewed. Talk to librarian & Nurse Manager. Identify types and sources- RCT, peer reviewed. Review research concepts- Compare research. CLOTS 1 and 3 and prevalence of DVT study. Conduct the search
Completed October, 2013 Step 3 Critically analyze the evidence Appraise and weigh the evidence Synthesize the evidence Assess feasibility by discussing with Nurse Manager, review benefits and risks of new practice.
Completed November, 2013 Step 4 Design practice change Define proposed change Identify needed resources Design the Ongoing December 2013 Running head: IMPLEMENTATION OF A PRACTICE CHANGE 8
Project Evaluation From the time the change will be implemented in February, all immobile stroke patients will receive intermittent pneumatic compression stockings following a specific guideline as defined in the roll out plan above. Thorough data will be collected and each evaluation of the pilot Design the implementation plan Step 5 Implement and evaluate change in practice Implement pilot study Evaluate processes, outcomes, and costs Develop conclusions and recommendations
Step 6 Integrate and maintain change in practice Communicate recommended change to stakeholders Integrate into standards of practice Monitor process and outcomes periodically Celebrate and disseminate results of project
Running head: IMPLEMENTATION OF A PRACTICE CHANGE 9 year an evaluation will be made based on comparing the incidence of deep vein thrombosis in immobile stroke patients before the implementation of intermittent pneumatic compression devices was mandated versus obligatory IPCS. Success will be determined by a decline in DVT in this patient population by at least an additional twenty percent. Dissemination of EBP Encouraging adoption of this practice change can be done in several ways. By using posters, power-points, holding meetings and sending emails messages can be received and staff members are reminded of the importance of IPCS for immobile stroke patients. Additionally, when one hospital implements this practice change and emerging data is obtained, statistics can be published in medical and nursing journals, therefore spreading the credibility of this practice change. Other hospitals should be notified of this practice change and when success is achieved many hospitals will want to implement this practice change as well.
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References Centers for Disease Control and Prevention (CDC) (2012). Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)-Blood Clot Forming in a Vein. Retrieved from http://www.cdc.gov/ncbddd/dvt/data.html Dennis, M., Sandercock, P., Reid, J., Graham, C., Forbes, J., & Murray, G. (2013). Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who have had a stroke (CLOTS 3): A multicentre randomised controlled trial. Lancet, 382(9891), 516-524. doi:10.1016/S0140- 6736(13)61050-8 Dennis, M., Sandercock, P., Reid, J., Graham, C., Murray, G., Venables, G., ... Bowler, G. (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(9679), 1958-1965. doi:10.1016/S0140-6736(09)60941-7 Mahan , C., Holdsworth, M., Welch, S., Borrego, M., & Spyropoulos, A. (2011). Deep-Vein thrombosis: A United States cost model for preventable and costly adverse event. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21833446 Running head: IMPLEMENTATION OF A PRACTICE CHANGE 11 Saint Josephs Hospital (n.d) Saint Josephs Hospital Webside: Mission Statement. Retrieved from: http://saintjosephs.org on November 16 th , 2013. Taniguchi, S., Fukuda, I., Daitoku, K., Minakawa, M., Odagiri, S., Suzuki, Y., ... Ohkuma, H. (2009). Prevalence of venous thromboembolism in neurosurgical patients. Heart & Vessels, 24(6), 425. doi:10.1007/s00380-008-1135-9 Retrieved from http://www.guideline.gov/content.aspx?id=35208