... (VTE) is the collective term for deep vein thrombosis ... Portsmouth Hospitals ... guideline policies guidelines guidance procedure strategy ...
The safe use of anti-embolism stockings (AES) as a mechanical method of thromboprophylaxis in adult patients
|Version |Version 1 | |Name of responsible |Thrombosis Committee | |(ratifying) committee | | |Date ratified |18/07/2012 | |Document Manager (job |Kim Carter VTE Nurse Specialist | |title) | | |Date issued |07/09/2012 | |Review date |31/08/2014 | |Electronic location |Clinical Guidelines | |Related Procedural |VTE Clinical Policy | |Documents | | |Key Words (to aid with |Stockings, compression, | |searching) |prophylaxis, VTE, DVT, PE |
QUICK REFERENCE GUIDE 3 1. INTRODUCTION 4 2. PURPOSE 4 3. SCOPE 4 4. RECOMMENDATIONS FOR PRACTICE 5 5. PROCESS 5 6. CONTRAINDICATIONS TO AES 5 7. TRAINING REQUIREMENTS 6 8. REFERENCES AND ASSOCIATED DOCUMENTATION 6 7. TRAINING REQUIREMENTS 6 8. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF PROCEDURAL DOCUMENTS 7
QUICK REFERENCE GUIDE
For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy.
1. Anti-embolism stockings (AES) must be fitted to all adult surgical patients at risk of venous thromboembolism (VTE) unless there are contraindications
2. AES must be fitted to all adult medical patients at risk of VTE who are ineligible for chemical thromboprophylaxis unless there are contraindications
3. AES must not be used in patients with acute stroke
4. AES can be used in addition to chemical thromboprophylaxis in at risk surgical and critical care patients
5. AES can be used together with calf pumps intra-operatively and in very high risk patients
6. AES can only be fitted by staff who have been trained in their use
7. AES must be prescribed on a drug chart by a doctor, registered nurse or registered midwife
8. AES must be removed daily for a maximum of 30 minutes for hygiene purposes and to monitor skin integrity
9. Patients discharged with AES, they must be provided with written and verbal information on how to apply, monitor and care for them.
Venous Thromboembolism (VTE) is the collective term for deep vein thrombosis (DVT) and pulmonary embolism (PE). Hospital associated VTE is a major cause of mortality and morbidity which is potentially preventable with appropriate risk assessment and provision of thromboprophylaxis (NICE 2010). The choice of thromboprophylaxis should be based on individual patient and admission related risk factors (NICE 2010).
Surgical and critical care patients assessed to be at risk of VTE benefit from the combined use of chemical and mechanical thromboprophylaxis. There is little evidence for the use of mechanical prophylaxis in medical patients; therefore AES should only be used in at risk medical patients where chemical thromboprophylaxis is contraindicated. AES should not be used in patients with acute stroke as there is little evidence of their effectiveness in preventing VTE and evidence of associated skin damage in this patient group (CLOTS Trial Collaboration, 1999, NICE 2010).
AES reduce the risk of VTE by producing graduated circumferential pressure which increases blood flow velocity and promotes venous return. Also, in preventing venous distension, AES reduce sub- endothelial tears and inhibit activation of clotting factors (NICE 2010).
AES are an effective intervention if used on appropriate patient groups and if fitted and monitored correctly. They are not however, a risk free intervention and can cause skin damage, pressure ulcers and necrosis if applied inappropriately and not adequately monitored. The purpose of this guideline is to ensure the safe and appropriate use of AES and to reduce the risk of harm from inappropriately fitted stockings.
This policy covers all adult patients (18 years and older) admitted to hospital as inpatients or formally admitted to a bed for day case procedures.
3.2.1 Groups that will be covered:
• Surgical inpatients (including day surgery) • Medical inpatients who are contraindicated for chemical thromboprophylaxis • Trauma inpatients • Pregnant women admitted to hospital • Critical care patients
3.2.2 Groups that will not be covered:
• People under the age of 18 years • People attending the hospital as outpatients • People presenting to emergency departments without admission
• Elderly or immobile people cared for at home, or in a residential care or rest home, unless admitted to hospital. • Patients with acute stroke • Medical patients prescribed chemical prophylaxis
3.2.3 Healthcare setting
• Secondary care
In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety
4. RECOMMENDATIONS FOR PRACTICE
Due to the potential for patient harm if stockings are inappropriately fitted, it is a requirement that AES are prescribed on a drug chart by a doctor or registered nurse who has been trained in their use. An AES care plan MUST be completed for each patient prior to fitting stockings and updated on a daily basis.
All healthcare professionals responsible for fitting AES must:
• Assess every patient individually • Identify the risks associated with AES • Identify contraindications to AES • Measure and apply the stockings correctly • Record the appropriate measurements and size of the stockings fitted in the patients medical record • Record any contraindications to AES in the patients medical record as appropriate • Remove stockings on a daily basis for a maximum of 30 minutes. This is for hygiene purposes and to monitor skin integrity (check for discoloured or cold toes, loss of sensation, swelling, skin marking, discolouration or ulceration) • Observe for pain and discomfort caused by constriction or friction on bony prominences • Check that stockings are worn correctly (wrinkling can cause skin damage and constriction, turning down the stocking can cause a tourniquet effect) • Re-measure and refit the stockings if changes occur to the limb • Remove stockings if problems occur and document on the patients medical record • Patients discharged wearing stockings should be given verbal and written information on how to remove and reapply the stockings correctly. If patients are unable to do this safely, and do not have a carer to help them, they should not be discharged wearing AES.
6. CONTRAINDICATIONS TO AES
• Gross limb oedema or oedema associated with severe congestive cardiac failure • Peripheral vascular disease • Suspected or proven arterial disease • Arterial sclerosis • Diabetic peripheral neuropathy or other causes of sensory impairment • Malformation of the lower limb preventing correct fit • Acute stroke • Medical patients prescribed full chemical thromboprophlyaxis • Local skin or soft tissue damage including o Recent skin graft (within the previous 3 months) o Gangrenous conditions o Fragile tissue paper skin o Dermatitis o Cellulitis o Ulcerated Skin
7. TRAINING REQUIREMENTS
All registered nurses, midwives and HCSWs responsible for the fitting and monitoring of AES must have received training in their use and have successfully completed the competency assessment document (see Section 10)
Registered Nurses, Midwives and Health Care Support Workers
• Training from the manufacturer or PHT approved trainer on the fitting and monitoring of AES (to be updated two yearly or whenever a new product is introduced) • Successful completion of the AES competency assessment document (see Section 10)
The Lancet, Volume 373, Issue 9679, Pages 1958 - 1965, 6 June 2009 Published Online: 27 May 2009 Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre randomized controlled trial. The CLOTS Trials Collaboration 2009
• Venous Thromboembolism: reducing the risk: Reducing the risk of venous Thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital: NICE Clinical Guideline 92, Jan 2010 http://guidance.nice.org.uk/CG92
• Venous Thromboembolism Prevention Quality Standard: NICE, June 2010 http://www.nice.org.uk/aboutnice/qualitystandards/vteprevention/vte qualitystandard.jsp
• Risk Assessment for Venous Thromboembolism: DH 2010 http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en /@ps/documents/digitalasset/dh_113355.pdf
• CLOTS Trial Collaboration, 2009 Effectiveness of thigh length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS 1 Trial): a multicentre controlled trial
9. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL DOCUMENTS
The policy will be monitored by the Thrombosis Committee through the following processes:
| | | | | | |Minimum |Lead |Evidence |Reviewed by / |Lead Responsible | |requirement to|responsible | |frequency | | |be monitored |for audit | | | | | | | | | | | | | | | | |Minimum |Ward |ESR |CSC Heads of |VTE CNS | |requirement: |managers and| |Nursing | | |80% of all |VTE Link | |Quarterly as part| | |registered |Nurses | |of the ongoing | | |nurses, | | |review of the CSC| | |midwives and | | |VTE | | |HCSWs in each | | |Implementation | | |clinical area | | |plans | | |to be trained | | | | | |to the | | | | | |appropriate | | | | | |competency | | | | | |level | | | | |
10 . COMPETENCY ASSESSMENT DOCUMENTS
1. AES competency assessment document
2. AES competency assessment document with answers
11. AES CARE PLAN