Archway Healthcare Library Critically Appraised Topic (CAT) Compression stockings and the prevention of DVT Richard Peacock
Archway Healthcare Library NHS and academic partners Whittington Hospital Key relationships, including lead research nurse CAT scheme
Archway Healthcare Library Critically Appraised Topics – applying evidence in the consideration of specific clinical questions “Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence...” (Sackett, 1996)
Archway Healthcare Library What is the evidence around the length of compression stocking and the prevention of DVT? Drivers: • Quality of patient care • Varying practice across Trust • Cost factors
Archway Healthcare Library Factors to consider: • Clinical evidence (what prevents DVT better?) • Compliance • Adverse events
Archway Healthcare Library Bottom line as of 2004: • Although there is no unequivocal evidence that knee length stockings are as effective as thigh length stockings at reducing DVT, the research indicates that this may be the case. Comfort, compliance, correct application and patient tolerance should be considered in favour of below knee stockings. • Thigh length stockings may actually cause harm due to their tendency to roll down below the knee and crease around the leg, causing a “tourniquet effect” that may lead to ischemic limbs or a dangerous increase in pressure. • Below knee stockings are cheaper, easier to apply and patients are more likely to comply.
Archway Healthcare Library Recommendations of the CAT are implemented by the Trust Saving estimated for the Trust of £90,000 pa
Archway Healthcare Library Since CAT produced in 2004, 3 key documents have appeared: • RCT - Howard, A. (2004) Randomised clinical trial of low weight molecular heparin with thigh-length or knee-length antiembolism stockings for patients undergoing surgery British Journal of Surgery • NICE Guideline CG46 on Venous Thromboembolism 2007 - thigh length stockings are preferred to knee length because there is evidence that they are more effective, but they do recognise that there may be occasions when they “are not suitable, due to fit or patient comfort. In such cases knee length stockings should be used as an alternative” • Sajid, M.S. et al (2006) Knee versus thigh length graduated compression stockings for prevention of deep venous thrombosis: a systematic review European Journal of Vascular and Endovascular surgery 32 (not included in NICE guideline)
Archway Healthcare Library Currently under discussion within the Trust, within wider context of recommendations of risk assessment and DVT. Department of Health risk assessment tool vs. Autar risk assessment tool. Clinical Guidelines Committee meets on 29 October!