1. Hollie Shaner-McRae DNP RN FAAN
EVIDENCE BASED PRACTICE COMMITTEE MODELING EVIDENCE BASED PRACTICE: SEQUENTIAL COMPRESSION DEVICES
Ann Laramee APRN MS
Martha Jo Hebert RN
Hollie Shaner-McRae DNP RN FAAN
Linda Gruppi RN MSN

2. Venous Thromboembolism
Deep Vein Thrombosis – blood clot in the deep veins of legs that can travel to heart and lungs causing a Pulmonary Embolism
Can be fatal, cause disability
Accounts for 10% of hospital deaths
Incidence of hospital acquired is 10-40% for med and gen surg, 40-60% for major orthopedic
Post operative VTE 9.3/1000 discharges
To set the stage….The literature states…..

3. This is what we are trying to prevent!!

4. VTE The Most Common Preventable In-Hospital Death

5. Risk Factors for VTE Advancing age Family history Immobility Trauma
Obesity
Pregnancy or post partum
Central Venous catheter
Estrogen based therapy
Smoking
Family history
Trauma
Recent surgery
Medical conditions
MI, CHF, stroke
Lung disease
Cancer
Sepsis
Hospitalization
Identification and documentation of a pt’s risk for VTE is the initial step that a health care practitioner uses in minimizing and or preventing this disease.
Surgery related risk factors include immobilization, infection, dehydration, vessel injury and duration and type of surgery.
Minor surgeries have lower incidence but major surgeries such as GI, bariatric, orthopedic have greater risk.

6. Prevention of VTE Non-Pharmacological Pharmacological
Graduated Compression Stockings
Intermittent Pneumatic compression devices(SCDs)
Foot pumps
IVC filters
Pharmacological
Unfractionated Heparin
Low Molecular Weight Heparin
Fondaparinux
There are 5 different IPC devices available and vary based on the patterns of compression, length of sleeve and cycle length.
Despite the existence of VTE prevention guidelines and vast amount of evidence that prophylaxis prevents VTE, prevention strategies continue to be underused.

7. Fletcher Allen Health Care
Observation audit October 2007: 38% use of SCD (n=20/53)
SCD compression sleeves: averaged 1100 pairs/month
VTE diagnosis: July 2008 – June 2009
- 195 cases
- Incidence 8.9/1000 discharges
SCIP: VTE prophylaxis overall compliance July 2008 – July 2009
- Ordered 95% (n=201/211)
- Received 96% (n=200/209)
Issues
Variation in practice with ordering
Failure to follow policy
Knowledge deficit of appropriate use
Lack of patient education
Other institutions in the same region and similar size have between cases of VTE/year.
Fletcher Allen Health Care (FAHC) providers regularly order Sequential Compression Devices (SCD) to prevent Venous Thromboembolism (VTE). Random audits found wide variation in prescription, multiple order sets and poor compliance with SCDs use and adherence to the policy.
Consequently the policy was inactivated.

8. FAHC Nursing Evidence-Based Practice Model
State the problem
Form a team
Evaluate
outcomes
Check research
Adopt practice
change
Synthesize Evidence
As you know we have an EBP committee and this issue was brought to the committee’s attention.
We have adopted the Iowa EBP model and made our own simplified version as well.
Colleagues
Helping
Achieve
Model
Practice .
Pilot the change
Adopted from:
2001 Iowa Model

9. The Evidence Based Practice (EBP) Committee will use a structured approach and the Iowa Model of EBP to address this practice issue
Trigger was audits and compliance with use and order appropriateness. In addition, Best practice as seen in practice guidelines was in the literature and multiple articles found on DVT screening tools and nurses role as part of health care team in identifying pts at risk
Interestingly, there is a discussion on the NNE listserve regarding SCD use in CT pts and there is wide variation in this population in one region!!
Review of literature

10. Stetler’s Levels of Evidence
Level and Quality
of Evidence
Type of Evidence
Level I (strongest evidence)
Meta-analysis or systematic review of multiple controlled studies or clinical trials
Level II
Individual experimental studies with randomization
Level III
Quasi-experimental studies such as nonrandomized controlled single-group pre-post, cohort, time series, or matched case-controlled studies
Level IV
Nonexperimental studies, such as comparative and correlational descriptive research as well as qualitative studies
Level V
Program evaluation, research utilization, quality improvement projects, case reports
Level VI (weakest evidence)
Opinions of respected authorities; or the opinions of expert committees, including their interpretation of non-research based information
An additional aspect of learning and practicing nursing based on evidence is to understand the quality, validity, and applicability of evidence in research articles. The FAHC Evidence Based Practice Committee recommends the adoption of the Stetler model for a Level of Evidence hierarchy.
The Stetler hierarchy model, adapted from the 1994 Agency For Health Care Policy And Research (AHCPR[1]), hierarchy incorporates research types important to nurses and acknowledges the value of the nursing experience by placing qualitative studies in the middle of the hierarchy, and includes quality improvement and program evaluation data as well.

11. Summary of Literature Systematic Review General recommendations:
Patients at high risk of bleeding
Patients with multiple risk factors as adjunct therapy
Used properly!! Compliance!!
Lack of evidence for specifics
Initiation – when to start?
Duration
Type
The systematic review includes studies found in major electronic sources that evaluated SCDs over the last 20 years. Each research article was critically appraised and summarized by a member of the EBP committee or local expert. All studies were categorized according to the Stetler levels of evidence. 28 research studies and guidelines were reviewed and summarized. There are numerous published research articles regarding use of anticoagulation for thromboprophylaxis but there is little research on mechanical devices.
At the time of this writing, the review is in final draft form.
Despite the existence of guidelines, prevention strategies continue to be underused.
A number of studies addressing compliance which is a huge issue.
Lack of evidence about specific use of SCDs, initiation, duration, type.

12. 2nd half of the Iowa Model
2nd half of the Iowa Model. There is sufficient research so follow next steps of piloting the change in practice

13. Next Steps Multidisciplinary Team Agree on the Systematic Review
Revise and Reinstall SCD Policy
Select Outcomes to be Achieved
Pilot the change on a Surgical and Medical Unit
The EBP Committee appraised the literature and systematically reviewed the best available evidence on the effectiveness of SCDs in preventing VTE in the adult medical and surgical hospital populations.
Using this review the EBP committee will update the policy and procedures for SCD use.
Over the next year, a selected group of multidisciplinary experts (nurses, physicians, and quality consultant) will champion this change in practice. The systematic review, updated policy and recommendations from the team of experts will be used to update processes, educate caregivers and improve the quality of care we provide.
2 units have already volunteered to pilot this work.

14. Next Steps
Collect Unit Baseline Data, Evaluate Process & Outcomes, Modify the Practice
Institute the Change in Practice Hospital wide?
Monitor and Analyze: Structure, Process, and Outcome Data
Disseminate Results
On the pilot units, collect baseline data, evaluate the change process and modify practice as necessary.
Determine if new policy and process be adopted permanently and widely throughout hospital.
Ongoing Structure, process and outcome data will be monitored and analyzed to evaluate the change.
This data will determine if the change in practice will be adopted permanently or require modifications.

15. Summary The Iowa EBP Model can be effective
The EBP Committee is a resource and champion for quality changes in nursing
SCDs are an effective prophylaxis for the appropriate patients
Compliance is essential
Variation in the prescription and poor compliance in practice with SCDs triggered the need for this EBP project. The EBP committee is leading this change in practice by using a structured process and an established EBP model. Implementing best practice and assuring compliance.
This project can be a model for others who are about to incorporate a change in practice.