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 3 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 5 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 6 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 7 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 8 (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 9 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 10 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 11 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 12 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 13 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.