Graduated compression stockings: Support for your practice

1. Graduated compression stockings: Support for your practice Sue Sendelbach, PhD, RN, CCNS Director of Nursing Research Clinical Nurse Specialist Abbott Northwestern Hospital Minneapolis, MN

2. Graduated compression stockings: Support for your practice Objective: Describe the care of hospitalized patients wearing graduated compression stockings

3. Graduated compression stockings: Support for your practice Graduated compression stockings reduce the risk of venous thrombosis by: Increase blood flow velocity Reduce the risk of venous wall dilation and intimal tear Improve venous value function May reduce coagulability 1. Also called anti-embolism stockings or by their company name1. Also called anti-embolism stockings or by their company name

4. This patient was wearing GCS, thought they were too tight and rolled them down

5. Graduated compression stockings: Support for your practice Graduated compression stockings Used incorrectly can actually increase complications including skin breakdown Winslow & Brosz had planned to study 300 patients but, because of the problems uncovered, stopped at 200 Found incorrect usage in 29% of patients, more often the patients wearing thigh-high GCS than knee-high GCS 26% had incorrect size � most were larger than they should have been Size redness was found in 19% of those wearing thigh high GCS and in 3% wearing knee high GCS 85% of patients said the GCS were uncomfortableWinslow & Brosz had planned to study 300 patients but, because of the problems uncovered, stopped at 200 Found incorrect usage in 29% of patients, more often the patients wearing thigh-high GCS than knee-high GCS 26% had incorrect size � most were larger than they should have been Size redness was found in 19% of those wearing thigh high GCS and in 3% wearing knee high GCS 85% of patients said the GCS were uncomfortable

6. Graduated compression stockings: Support for your practice Medical device related pressure ulcers Hospital-acquired pressure ulcers 5.4% (113/2079) Of those patients with a HAPU, 34.5% (39/113) were device related GCS were identified as one source of MDR pressure ulcer Thigh 3 (5%) Knee 3 (5%) Lower leg 7 (11%) Ankle 3 (5%) Feet 3 (5%) Hell 5 (8%) Toes 4 (6%) Total of 45% of MRD were on the thigh, knees, lower leg, ankle, feet, heel or toes Thigh 3 (5%) Knee 3 (5%) Lower leg 7 (11%) Ankle 3 (5%) Feet 3 (5%) Hell 5 (8%) Toes 4 (6%) Total of 45% of MRD were on the thigh, knees, lower leg, ankle, feet, heel or toes

7. Case StudyRathore et al., 2009 20 year old male Car accident Surgery for a T5 fracture dislocation within 24 hours Post operative � knee-length GCS applied One week post-operatively transferred to the spinal rehabilitation units GCS removed � Stage II pressure ulcers on the lateral aspect of both little toes and medial aspect of left big toe Pressure ulcers healed over 4 weeks without infection or other complications

8. Case StudyRathore et al., 2009 75 year old male Traumatic C5 fracture after a bus accident Thigh high GCS � three days after GCS applied discoloration of his skin was noted and the GCS were discontinued Stage II pressure ulcers on the lateral aspects of both small toes and medial aspect of the right big toe Pressure ulcers were managed conservatively without incident

9. Case StudyHayes et al. 2002 Female patient post-operatively GCS Two �severe� pressure ulcers developed after ill-fitting stockings were applied during a surgical procedure Research: To investigate the use of GCS in the institution

10. Graduated compression stockings: Support for your practice Patient report Charts on all patients on 12 medical-surgical units assessed N=151 with 34 having orders for GCS 8 patients never had GCS applied or they had been removed because they were no longer necessary n=26 with interview of 23 16/23 had thigh high GCS 8 complained of a problem with fit 8 complained of discomfort (hot, itchy, or painful) Seven with thigh-high and one with knee-high GCS had a �tourniquet� effect at the knee Skin assessment revealed 14 pressure ulcers (most were stage I): several patients had more than one pressure ulcer Four pressure ulcers were on heels, three on tops of the feet, and seven at an area of tourniquet effect

11. Graduated compression stockings: Support for your practice Nursing practices N= 15 No consistency related to removal, skin inspection, and assessments of GCS use 33% removed GCS to inspect skin 2/15 (13%) measured to determine patient�s size

13. Graduated compression stockings: Support for your practice Graduated compression stockings should be properly sized and used. www.medscape.com/viewarticle/579923_1#question

14. Graduated compression stockings: Support for your practice Barriers to measuring: Finding tape measures Sizing for GCS are inside the bag

15. Graduated compression stockings: Support for your practice Review of the literature on GCS

16. Levels of evidence (University of Iowa. The University of Iowa Gerontological Nursing Interventions)

17. ALLINA PROFESSIONAL NURSINGEvidence-based Practice Protocol: Graduated Compressions Stockings and Compression StockingsGraduated Compression Stockings (GCS) and Compression StockingsTarget Patient Population: Any patient for whom graduated compression stockings are orderedPersonnel: Nursing

18. ALLINA PROFESSIONAL NURSINGEvidence-based Practice Protocol: Graduated Compressions Stockings and Compression StockingsGraduated Compression Stockings (GCS) and Compression StockingsTarget Patient Population: Any patient for whom graduated compression stockings are orderedPersonnel: Nursing

19. ALLINA PROFESSIONAL NURSINGEvidence-based Practice Protocol: Graduated Compressions Stockings and Compression StockingsGraduated Compression Stockings (GCS) and Compression StockingsTarget Patient Population: Any patient for whom graduated compression stockings are orderedPersonnel: Nursing References 1Hameed MF et al. 2002. Should knee-length replace thigh-length graduated compressions stockings in prevention of deep-vein thrombosis? SAJS. 40(1):15-16. 2Amaragiri SV & Lees TA. 2007. Elastic compression stockings for prevention of deep vein thrombosis. The Cochrane Collaborative. Issue 4. 3Cohen AT et al. 2007. The use of graduated compression stockings in association with fondaparinux in surgery of the hip. Journal of Bone and Joint Surgery. 89-B:887-892. 4Sajid MS et al. 2006. Knee versus thigh length graduated compression stockings for prevention of deep venous thrombosis: A systematic review. Eur J Vasc Endovasc Surg. 32:730-736. 5Byrne B. 2001. Deep vein thrombosis prophylaxis: The effectiveness and implications os using below-knee or thigh-length graduated compression stockings. Heart & Lung. 30(4):277-284. 6Best AJ et al. 2000. Graded compression stockings in elective orthopaedic surgery. An assessment of the in vivo performance of commercially avaialbe stockings in patients having hip and knee arthroplasty. J Bone Joint Surg Br. 82(1):116-118. 7Chan DLH, Meyer JF, Rod JH & Burnand KG. 2001. Toe ulceration associated with compression bandaging: observational study. BMJ. 323:1099. 8Williams NM et al. 1996. Knee-length versus thigh-length graduated compression stockings in the prevention of deep veing thrombosis. British Journal of Surgery. 83:1553. 9Horner J , Lowth LC & Nicolaides AN. A pressure profile for elastic stockings. BMJ.280:818-20. 10National Collaborating Centre for Acute Care.at the Royal College of Surgeons at England. 2007. Venous Thromboembolis: Reducing the Risk in Surgical Patients.

20. ALLINA PROFESSIONAL NURSINGEvidence-based Practice Protocol: Graduated Compressions Stockings and Compression StockingsGraduated Compression Stockings (GCS) and Compression StockingsTarget Patient Population: Any patient for whom graduated compression stockings are orderedPersonnel: Nursing Contraindications include (Evidence Grade = A1): Critical limb ischemia Severe peripheral neuropathy Massive leg or pulmonary edema Local skin/soft tissue diseases such as recent skin graft or dermatitis Gangrenous limb Gross limb cellulitis 1. Dorothy Doughtery reviewed the policy for her expertise1. Dorothy Doughtery reviewed the policy for her expertise

22. Road Map to a Comprehensive Skin Safety Program Anti-embolism stockings (AES) The facility has an anti-embolism stocking practice in place which addresses: 2m) Indication and contraindications to use 2n) Alternatives to AES 2o) When to discontinue AES 2p) Correct fitting 2q) Skin inspection care 2s) Patient/family education 2t) Minimize use of thigh high AES 3a) The facility has assessed access to pressure ulcer prevention and treatment products 3b) Pressure ulcer products are organized in a common location that is readily accessible to staff 3c) A process is in place to inventory products and ensure appropriate supplies are available to staff Weight gain and/or loss � when to remeasure for GCSWeight gain and/or loss � when to remeasure for GCS

23. Graduated compression stockings: Support for your practice ��we recommend that mechanical methods of thromboprophylaxis be used primarily for patients at high bleed risk (Grade IA) or possibly as an adjunct to anticoagulant thromboprophylaxis (Grade 2A).� Geerts et al. 2008. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. 133:381S-453S �Analysis of these RCTs confirm that GCS are effective in diminishing the risk of DVT in hospitalized patients.� Amargiri SV & Lees TA. 2007. Elastic compression stockings for prevention of deep vein thrombosis. The Cochrane Collaborative.

24. Graduated compression stockings: Support for your practice

25. Graduated compression stockings: Support for your practice Key Points: Measurement is critical and we need to make systems to support this Skin inspection remains an important component in patients wearing pressure ulcers Graduated compression stockings should be used on appropriate patients as identified in evidence based guidelines