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
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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
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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
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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
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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
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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
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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


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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
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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