Running head: PREVENTION OF DEEP VEIN THROMBOSIS
A Comparison of the Combination of Heparin Based Anticoagulants and Ambulation to
Ambulation Alone, in the Prevention of Deep Vein Thrombosis in
Adult Medical-Surgical Patients
Rebecca Enright, Jiali Luc, Jenny Parish, Ashley Weststrate
Ferris State University
1
PREVENTION OF DEEP VEIN THROMBOSIS
2
A Comparison of the Combination of Heparin Based Anticoagulants and Ambulation to
Ambulation Alone, in the Prevention of Deep Vein Thrombosis in
Adult Medical-Surgical Patients
The purpose of this paper is to review and analyze the current literature related to the
prevention of deep vein thrombosis (DVT). Specifically, how heparin injections combined with
ambulation compare to ambulation alone, in the prevention of a DVT. Current evidence-based
practice (EBP) suggests that patients who receive heparin injections and participate in early
ambulation exercises during hospitalization, demonstrate improved outcomes in the development
of DVT (Pashikanti & Von Ah, 2012, p. 88). In contrast, early ambulation alone is suggested
only for low-risk medical and surgical patients (Brophy et al., 2005, p. 1321).
Venous thromboemolism (VTE), characterized by deep vein thrombosis and pulmonary
embolism (PE), are both familiar complications for hospitalized patients in the United
States. Many patients are affected by these morbidities and it is estimated that between 60,000 to
100,000 patients die each year based on these diagnoses (Van Wicklin, 2011, p. 444). As a
result, DVT prophylaxis is extremely important in the hospital setting. Nurses play an important
role in educating patients regarding interventions for prevention. To do so it is crucial for nurses
to assess the patients’ knowledge of DVT prevention and educate the patient with cognitive
appropriate material. By providing adequate education, the nurse can promote patient
participation in recommended interventions such as early ambulation and compliance with
anticoagulant injections (LeSage, McGee, & Emed, 2008, p. 109).
PREVENTION OF DEEP VEIN THROMBOSIS
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Due to the fact DVT is such a serious complication for medical and surgical patients,
many hospitals are using assessment tools to identify patient risk factors. If DVT risk factors are
identified, appropriate prevention measures can then be implemented. In order to achieve the
best outcomes related to DVT prevention, many hospitals evaluate protocols to ensure that
guidelines are being adequately implemented and to monitor the incidence of DVT development
(LeSage et al., 2008, p. 110).
Literature Review
To discover the existing knowledge of our proposed research topic, the authors of this
paper conducted an online search for articles in Pubmed, CINAHL, and MEDLINE databases
through the Ferris Online Library. A total of eleven articles were reviewed and critiqued based
on the Ferris State University NURS 350 Research Article Critique Matrix in order to find the
best and most relevant information for this evidence-based nursing project (Ford, 2012). By
utilizing this matrix, articles were selected on the foundations of research purpose, significance,
clarity in identification of variables, review of supporting or conflicting prior work, relevance of
methodology, identification of threats to validity, appropriate sampling and data collection,
report of objective findings, author credibility, and publication date (2012).
The eleven articles initially selected were “Venous Thromboembolism Prevention in
Acutely Ill Nonsurgical Patients” (Brophy et al., 2005); “Improving the use of Anticoagulant
therapies in Acutely Ill Medical Patient” (Dobesh, Phillips & Haines, 2008); “Knowledge of
Venous Thromboembolism Prevention Among Hospitalized Patients” (LeSage, McGee & Emed,
2008); “Impact of Early Mobilization Protocol on the Medical-Surgical Inpatient Population: An
Integrated Review of Literature” (Pashikanti & Von Ah, 2012); “Early Mobilization After
Conventional Knee Replacement May Reduce the Risk of Post-operative Venous
PREVENTION OF DEEP VEIN THROMBOSIS
4
Thromboembolism” (Pearse, Caldwell, Lockwood & Hollard, 2007); “Physician Alerts to
Prevent Symptomatic Venous Thromboembolism in Hospitalized Patients” (Piazza et al., 2009);
“Venous Thromboembolism Prophylaxis in Medical Inpatients: A retrospective Chart Review”
(Rahim, Panju, Pai & Ginsberg, 2003); “Attitudes Toward Practice of Venous
Thromboembolism Prevention in General Internal Medicine Wards: A Multicultural Survey from
Member Countries of the European Federation of Internal Medicine” (Vardi, Dagna, Haran &
Duckit, 2012); “Implementing a Research Utilization Plan for Prevention of Deep Vein
Thrombosis” (Van Wicklin, Ward & Cantrell, 2006); and “Implementing AORN Recommended
Practices for Prevention of Deep Vein Thrombosis” (Van Wicklin, 2011).
After review of these articles, group consensus chose the four best articles to answer the
question: what does the literature reveal about the combination of heparin based anticoagulants
and ambulation compared to ambulation alone, in the prevention of deep vein thrombosis (DVT).
These four articles include “Venous Thromboembolism Prevention in Acutely Ill Nonsurgical
Patients” by Brophy et al., 2005; “Knowledge of Venous Thromboembloism (VTE) Prevention
Among Hospitalized Patients” by LeSage et al., 2008; “Impact of Early Mobilization Protocol on
the Medical-Surgical Inpatient Population” by Pashikanti and Von Ah, 2011; and “Implementing
AORN Recommended Practices for Prevention of Deep Vein Thrombosis” by Sharon A. Van
Wicklin, 2011.
In the Brophy et al. (2005) article “Venous Thromboembolism Prevention in Acutely Ill
Nonsurgical Patients,” the authors’ conducted a MEDLINE data search to find and review
research relating to recent advances in the prevention of DVT. The article includes a discussion
of the most current prevention strategies, risk factors, and assessment tools utilized in the
medical field. The findings of this article suggest that although specific anticoagulant regimens
PREVENTION OF DEEP VEIN THROMBOSIS
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have been found to effectively prevent DVT, these prophylactic measures are being underused
(Brophy et al., 2005 p. 1319).
The study “Knowledge of Venous Thromboembolism (VTE) Prevention among
Hospitalized Patients by” LeSage et al. (2008) published in the Journal of Vascular Nursing used
a qualitative, cross-sectional survey design to gather evidence about the patients’ awareness and
knowledge of DVT. The study also examined patient perspectives on pharmacologic agents,
while seeking to address the nurses’ role in patient education and advocacy (2008 p. 110). This
article suggests that although hospitals are adopting evidence-based protocols on the prevention
of DVT, gaps in the knowledge exist on how to strengthen the nurse’s role in educating the
patient on risk factors and prophylaxis (2008 p. 115).
In the article “Impact of Early Mobilization Protocol on the Medical-Surgical Inpatient
Population,” Pashikanti and Von Ah (2012) conduct an integrative review and synthesis of nine
empirical studies in an effort to examine what the current and best evidence reveals about the
nursing intervention of early ambulation in the medical-surgical inpatient population. A
comprehensive analysis of these studies revealed an improvement in patient outcomes pertaining
to an early ambulation protocol. However, this review and analysis of the literature found that
no evidence-based guidelines for the nursing intervention of early ambulation currently exist
(Pashikanti & Von Ah, 2012 p. 87). Although this article supports the incorporation of early
ambulation into DVT prophylaxis, the article does not include a comparison of ambulation in
regards to other methods of DVT prophylaxis such as anticoagulant therapy.
The article “Implementing AORN Recommended Practices for Prevention of Deep Vein
Thrombosis” by Sharon A. Van Wicklin (2011), delves further into the literature to reveal nine
current practice recommendations related to DVT prophylaxis. This article serves to guide the
PREVENTION OF DEEP VEIN THROMBOSIS
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perioperative RN to identify and minimize the patients’ risk through a multidisciplinary approach
in establishing protocols for mechanical and pharmacological DVT prevention (2011, p. 443).
This article supports further research and makes suggestion to the development of DVT
protocols based on assessment of risk factors and appropriate implementation of interventions
such as early ambulation and anticoagulant administration (2011, p. 446). This article however
fails to directly address the effectiveness of early ambulation and anticoagulant therapy in
comparison to early ambulation alone.
With the exception of the Brophy et al. (2005) article, the four preceding articles were
written by Registered Nurses seeking to address what can be done to prevent or improve
outcomes in the hospitalized patient in relation to DVT (e.g., LeSage et al., 2008; Pashikanti &
Von Ah, 2012; Van Wicklin, 2011). Although the findings of these articles indicate further
research is needed, current evidence does demonstrate improved outcomes with the
implementation of the nursing intervention of early ambulation with or without the addition of an
anticoagulant (if indicated) based on assessment of risk factors and the patients knowledge of
preventative measures (e.g., Brophy et al., 2005; LeSage et al., 2008; Pashikanti & Von Ah,
2012; Van Wicklin, 2011).
Analysis of Evidence
As a whole, the medical field of professionals recognizes that DVTs are an all too
familiar complication during hospitalization. Therefore, the authors of this paper realized a need
for further review and analyze of the literature to determine what evidence-based practice reveals
in regards to the use of heparin based anticoagulants and ambulation versus ambulation alone in
prevention of DVT.
PREVENTION OF DEEP VEIN THROMBOSIS
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Brophy et al. indicates, “A recent survey showed that 28% of hospitalized medical
patients with risk factors for VTE (venous thromboembolism) received appropriate prophylaxis,”
(Brophy et al., 2005, p. 1321). The above authors compared three separate studies involving
anticoagulants in the prevention of DVT. These studies were primarily double-blind,
randomized trials from which a meta-analysis was then compared to previous studies (Brophy et
al., 2005, p. 1323). Overall, the meta-analysis determined that “acutely ill medical inpatients
should be risk-stratified in their early hospitalization,” (Brophy et al., 2005, p. 1321). Having
clinicians assess for risks on or shortly after admission enables early implementation of
anticoagulant prophylaxis. Brophy further states, “Recent randomized trials indicate that the use
of anticoagulant prophylaxis reduces the incidence of VTE. Effective prevention requires prior
identification of the at-risk population,” (Brophy et al., 2005, p. 1324).
The Brophy et al. article is less aggressive when it comes to ambulation. It is stated,
“Early ambulation is recommended only for low-risk surgical or medical patients,” (Brophy et
al., 2005, p. 1324). Furthermore, mechanical methods such as ambulation should only be
initiated as a single preventive measure if the use of anticoagulants is contraindicated (Brophy et
al., 2005, p. 1324). In conclusion this article suggests that clinicians are responsible for
screening the patient’s risks to determine what prophylactic measures should be implemented to
prevent a DVT. Anticoagulants should be initiated along with mechanical methods such as early
ambulation unless contraindicated. However, if use of anticoagulants is contraindicated, then
mechanical methods alone should be initiated.
In the article titled “Knowledge of Venous Thromboembolism Prevention among
Hospitalized Patients,” authors explore patient knowledge in relation to DVT prophylaxis. This
study was a quantitative, cross-sectional survey design in which forty-eight patients participated
PREVENTION OF DEEP VEIN THROMBOSIS
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(LeSage et al., 2008, p. 110). Candidates who met criteria were recruited over a three month
period and had to give informed consent in order to participate. Using a VTE protocol
implemented in 2005, researchers focused on staff and public awareness of DVT prophylaxis. It
was found that, “participants were satisfied with pharmacological thromoprophylaxis but were
less satisfied with the information received on VTE,” (LeSage et al., 2008, p. 109). In addition,
“Participants reported hearing VTE more frequently from friends, family, or the media than from
healthcare providers, including nurses,” (LeSage et al., 2008, p. 109). By combating the
knowledge deficit regarding prevention of DVTs, patient compliance with interventions is
increased. “Increased patient knowledge also promotes adherence to pharmacological
thromboprophylaxis and early mobilization,” (LeSage et al., 2008, p. 109). In conclusion, this
article did not take a strong stand for either pharmacological or nonphamacological approaches
rather than advocated for patient education to increase compliance of both.
Early mobilization is important in improving inpatient outcomes according to the article
by Pashikanti and Von Ah (2012) titled, “Impact of Early Mobilization Protocol on the MedicalSurgical Inpatient Population.” This article reviewed nine empirical studies, one that included
“A randomized control trial with forty-five patients diagnosed with DVT,” (Pashikanti & Von
Ah, 2012, p. 88). Though these patients received anticoagulants, “researchers found that
participants who performed early ambulation exercises had lower overall pain scores and
significant reduction in leg swelling,” (Pashikanti & Von Ah, 2012, p. 89). In addition, “these
two medical studies revealed that implementing the basic tenets of an early mobilization protocol
for DVT patients assisted in symptom control, in turn maintaining functional well-being,”
(Pashikanti & Von Ah, 2012, p. 93). Though not all research in this study was conclusive it was
PREVENTION OF DEEP VEIN THROMBOSIS
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found that facilities in which processes were implemented to increase mobility did promote
positive patient outcomes.
“Implementing AORN Recommended Practices for Prevention of Deep Vein
Thrombosis” is an article composed of nine recommendations for clinicians to decrease
occurrence of DVT. Primarily targeted at perioperative nurses, a multidisciplinary approach is
encouraged and states “an organization-wide protocol that includes care of the perioperative
patient” should be initiated (Van Wicklin, 2011, p. 445). Focusing on risk factor screening and
assessments, nurses are responsible for educating patients in regards to recommendations
(Wicklin, 2011). “The perioperataive RN should provide the patient and his or her designated
caregiver(s) instructions regarding prevention of DVT and the prescribed prophylactic
measures,” (Wicklin, 2011, p. 447). This article does not focus on pharmacologic measures
rather on nursing interventions and education to promote well-being. It is inconclusive if this
article would recommend the use of anticoagulants in addition to nursing interventions and
education.
Application of Evidence
After review of the four articles analyzed above the authors of this paper have formulated
a plan to incorporate findings into their clinical practice. In the following paragraphs are
discussions regarding barriers and recommendations based on the above research reviews.
Barriers
Barriers to using evidence based practice (EBP) related to DVT prophylaxis are personal
barriers per patient. Vision, hearing, and educational background can create barriers when
implementing EBP interventions. These barriers have the potential to play key roles in
communication barriers. LeSage et al. (2008), suggests that patients will benefit from further
PREVENTION OF DEEP VEIN THROMBOSIS
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education about blood clots, including signs and symptoms and potentially severe complications.
Additionally, another barrier that poses a threat to EBP is nurse and doctor decisions. The doctor
and nurse may have conflicting ideas for DVT prevention and to be effective, a team approach
must be encouraged among professionals to promote improved patient outcomes. It is also
important to find a physician that encourages EBP and is willing to teach fellow cohorts
regarding best practices for DVT prevention (Van Wicklin, 2011, p 445).
Preference
Patient preference is another factor to consider. If a patient were to have the choice
between an injection or early ambulation and activity, more often than not, patients would
choose the less invasive. Therefore, nurses must stress the importance of a dual therapy approach
consisting of ambulation and anticoagulant use (if indicated) in the prevention of DVT.
Research proves there is a decreased risk of complications when using prophylaxis measures
such as heparin based anticoagulants. Thus, it is imperative that patients make an educated
decision.
Implementation
To implement the EBP from this review of research the authors of this paper recommend
the nursing intervention of early ambulation with an additional DVT prophylaxis such as heparin
based anticoagulants, based on patient risk screening tools and assessment data. EBP has proven
that this method is most effective. “Nurses working with physicians, pharmacists, and physical
therapists can develop the best combination of preventative measures based on evidence, to help
prevent DVT” (Van Wicklin, 2011, p 445). Nurses should use a standardized definition of early
ambulation. If early ambulation is not contraindicated each nurse should know how often the
PREVENTION OF DEEP VEIN THROMBOSIS
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patient will ambulate and how far. This will help prevent discrepancies in documenting
(Pashikanti & Von Ah, 2012, p 83).
Summary Statement
It is important for nurses to understand the significance of patients who are at moderate
and high risk of developing DVT. After in-depth review of current literature, the authors of this
paper support the use of heparin injection combine with early ambulation as EBP. This
combination therapy will promote the best method of DVT prophylaxis. The bedside nurse
needs to systematically assess the patient’s risk factors in developing DVT, initiate appropriate
prophylactic measures, and follow the protocols for their department to ensure all guideline are
met.
Review indicates that further research needs to be developed to set standard nursing
protocols and risk factor assessment tools which will be consistent in lowering the risk of
developing a DVT. Standard nursing protocols for prevention are imperative as they document
step by step interventions which ensure that all necessary regimens are followed. Furthermore,
the use of standard protocol will allow the nurse to do things systematically. In order to
effectively incorporate EBP in relation to DVT prevention all of the above steps should be
implemented into daily clinical.
PREVENTION OF DEEP VEIN THROMBOSIS
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References
Brophy, D. F., Dougherty, J. A., Garrelts, J. C., Parish, R. C., Rivey, M. P., Stumpf, J. L., … &
Mathis, A. S. (2005). Venous thromboembolism prevention in acutely ill nonsurgical
patients. The Annals of Pharmacotherapy, 39(7), 1318-1324. doi:10.1345/aph.1G127
Dobesh, P., Phillips, K., & Haines, S. (2008). Improving the use of anticoagulant therapies in
acutely ill medical patients. American Journal of Health-System Pharmacy, 65(15), S512. doi:10.2146/ajhp080240
Ford, L. (2012). Research Article Critique Matrix and Analysis. NURS 350 Research in Nursing.
Ferris State University.
Le Sage, S., McGee, M., & Emed, J. (2008). Knowledge of venous thromboembolism (VTE)
prevention among hospitalized patients. Journal of Vascular Nursing, 26(4), 109-117.
Nutescu, E. (2007). Assessing, preventing, and treating venous thromboembolism: evidencebased approaches. American Journal Of Health-System Pharmacy, 64S5-13.
doi:10.2146/ajhp070108
Pashikanti, L., & Von Ah, D. (2012). Impact of early mobilization protocol on the medicalsurgical inpatient population: an integrated review of literature. Clinical Nurse Specialist:
The Journal for Advanced Nursing Practice, 26(2), 87-94.
Pearse, E., Caldwell, B., Lockwood, R., & Hollard, J. (2007). Early mobilization after
conventional knee replacement may reduce the risk of post-operative venous
thromboembolism. Journal of Bone & Joint Surgery, British Volume, 89B(3), 316-322.
Piazza, G., Rosenbaum, E. J., Pendergast, W., Jacobson, J. O., Pendleton, R.C., McLaren, G. D.,
… Goldhaber, S. Z. (2009). Physician alerts to prevent symptomatic venous
PREVENTION OF DEEP VEIN THROMBOSIS
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thromboembolism in hospitalized patients. Journal of the American Heart Association,
119, 2196-2201. doi:10.1161/CIRCULATIONAHA.108.841197
Rahim, S. A., Panju, A., Pai, M., &Ginsberg, J. (2003). Venous thromboembolism prophylaxis in
medical inpatients: a retrospective chart review. Thrombosis Research, 111(4-5).
doi:10.1016/j.thromres.2003.09.010
Vardi, M., Dagna, L., Haran, M., & Duckit, R., (2012). Attitudes towards and practice of venous
thromboembolism prevention in general internal medicine wards; a multinational survey
from member countries of the European Federation of Internal Medicine. Thrombosis
Research, 129, 573-576.
Van Wicklin, S. A., Ward, K. S., & Cantrell, S. W. (2006). Implementing a research utilization
plan for prevention of deep vein thrombosis. Association of Preoperative Registered
Nurses, 83(6). doi:10.1016/S0001-2092(06)60149-X
Van Wicklin, S., (2011) Implementing AORN recommended practices for prevention of deep
vein thrombosis, Association of Preoperative registered nurses journal, 94(5), p 443-454.
doi:10.1016/j.aorn.2011.07.018
Component
Introduction: Includes
a statement of the
problem or question, a
summary of the support
for relevance to the
question, a description
of the aim of the
literature review project
and paper. This serves
as your abstract.
YOUR GRADE
Below Expectations
(<80%)
Inappropriate grammar
or misspelled words.
Plagiarism.
Statements are not
clear.
Meets Expectations
(80 – 95%)
Presents a cogent
statement of the
problem or question,
and a succinct
description of the aim(s)
of the review of the
literature.
PICO statement clear
and appropriate to the
assignment.
Exceeds Expectations
(>95%)
Stellar and scholarly
response to need for a
cogent and clear
presentation.
X
PREVENTION OF DEEP VEIN THROMBOSIS
Literature Review:
A descriptive summary
of the published items
found to answer the
PICO question.
Objective statements of
findings.
Inappropriate grammar
or misspelled words.
Plagiarism.
Statements are not
clear.
Less than 4 articles
reviewed/ inappropriate
literature sources.
Subjective/ interjection
of personal opinion.
A discussion regarding
what initial 10 articles
were selected and how
they were evaluated for
appropriate use.
All four articles are
presented, appropriately
cited, and summarized.
Objective statements.
YOUR GRADE
Analysis of the
evidence: is a critical
appraisal of the
evidence and what the
group consensus is
regarding the level of
evidence to support the
practice
recommendations.
Review demonstrates
that an evaluation
matrix was used to find
best and most relevant
information for this EBN
project.
Articles selected are
current, relevant, and
from best resource site,
with recognized experts
in area of interest.
Excellence in summary
statements.
X
Inappropriate grammar
or misspelled words.
Plagiarism.
Statements are not
clear.
Subjective interjections
to analysis.
Does not apply evidence
based practice critique
rubric.
Each critique
demonstrates an
understanding of
research analysis and
application of levels of
evidence theory.
Stellar and scholarly
response. Response
demonstrates that the
students have
incorporated not only
what has occurred over
the semester, but have
gone beyond to
alternative and
additional references.
Excellent use of EBN
critique principles from
course modules and
text.
X
Inappropriate grammar
or misspelled words.
Plagiarism.
Statements are not
clear.
Subjective opinions not
supported by evidence.
Use of colloquialisms.
Discussion presents
identification of barriers
and bridges to
application of the
evidence in the practice
setting.
Presentation of
application of evidence
may include:
assessment of
incorporation into
practice, barriers and
bridges for other
providers of health care,
identified plan to
approach integration of
EBN into practice, or
discovery and critique of
publications that discuss
application of the EBN
practice into their
setting.
YOUR GRADE
Application of
evidence: an analysis
of potential barriers and
bridges to application of
these findings.
14
PREVENTION OF DEEP VEIN THROMBOSIS
YOUR GRADE
Summary
statements: a
recommendation as to
whether or not the
evidence found will be
incorporated into your
practice with rationale.
X
Inappropriate grammar
or misspelled words.
Plagiarism.
Statements are not
clear.
Recommendation is a
cogent statement that is
a natural consequence
of the former discussion
of the EBN practice.
Stellar and scholarly
response to identify
objectively why/ why
not this will alter
practice. Discussion of
‘next steps’ include an
understanding of the
importance of continued
research into nursing
outcomes and
interventions data and
the dissemination of
findings.
Clear consequential
statements from former
portions of paper that
demonstrate a critical
analysis of the
consequences of
incorporation of the EBN
practice
recommendations.
X
Body of paper less than
7 pages, or more than
10 pages. Missing
reference list in item or
total. Member of group
does not participate or
dominates work load.
APA format of paper
structure and citations.
Page limit: 10 pages
within body of paper.
APA reference list.
All members contribute.
Minimal errors with APA
format, according to 6th
edition, second printing
of manual.
YOUR GRADE
Format:
APA format of paper
structure and citations.
Page limit: 10 pages
within body of paper.
APA reference list.
All members contribute.
YOUR GRADE
15
X
COMMENTS: Excellent – you might consider submitting this for publication.