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Cultivating Quality

Eliminating Hospital-Acquired Pressure Injuries Caused by Graduated Compression Stockings

Siby, Tessy MSN, RN, CMSRN, CNL; Smith, Uniqua PhD, MBA, RN, NE-BC; Shajimon, Alice MSN, RN, OCN, CNL

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AJN, American Journal of Nursing: July 2021 - Volume 121 - Issue 7 - p 60-65
doi: 10.1097/01.NAJ.0000758536.49559.f6
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Figure
Figure:
A patient with bilateral graduated compression stocking–associated PIs around the knees. Reprinted with permission from Hobson DB, et al. Prevalence of graduated compression stocking–associated pressure injuries in surgical intensive care units. J Crit Care 2017;40:1-6.

Graduated compression stockings are designed to prevent the development of deep vein thrombosis (DVT) in patients who have limited movement. However, there are risks associated with their use, especially when they are not used correctly. Pressure injuries (PIs) can arise when graduated compression stockings are ill fitting or there is excessive compression of the skin. In postoperative patients who have fluid overload, the use of graduated compression stockings can lead to the development of PIs at the leg opening or in any area where the stocking is tight.1 Such medical device–related PIs can occur because of a lack of staff awareness about the risk of PIs and a failure to assess the skin under the device.2 Patients who are critically ill are at higher risk for developing these injuries due to long-term device use. Additionally, confused and sedated patients cannot report their pain or discomfort, thereby increasing the risk of PIs.2 Such injuries develop more quickly than hospital-acquired PIs (HAPIs) that aren't associated with the use of a device: in one study, the former developed three days faster.3 Device-related PIs can be difficult to prevent because medical devices are often an essential part of a patient's treatment.3 HAPIs can cause an increase in morbidity and mortality, representing a significant cost to both patients and the health care system.4

BACKGROUND

The Association of periOperative Registered Nurses (AORN) and the American College of Chest Physicians recommend mechanical venous thromboembolism (VTE) prophylaxis for patients who have operative and invasive procedures.5, 6 This includes the use of intermittent pneumatic compression devices and graduated compression stockings, as well as early ambulation and foot and ankle exercises. These guidelines make no distinction between the use of graduated compression stockings and intermittent pneumatic compression devices, noting that both are recommended forms of mechanical prophylaxis. However, the AORN does caution that improper-fitting graduated compression stockings can cause harm to the patient, such as skin injury, nerve injury, compartment syndrome, and an increased risk of VTE.5 The American Society of Clinical Oncology recently published an updated guideline on VTE prophylaxis that is specific to oncology patients.7 It indicates that those who've had surgery should be offered pharmacological thromboprophylaxis, which can be combined with mechanical prophylaxis to improve efficacy in high-risk patients. The guideline doesn't specify a preferred type of mechanical prophylaxis.

The European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance guideline recommends preventing medical device–related PIs by performing routine skin assessment, regularly monitoring the tension of the device, and reducing or redistributing the pressure at the skin–device interface.8 Pressure redistribution includes rotating and repositioning the device or removing it as soon as possible. The guideline recommends reducing the risk of device-related injuries by selecting the correct size and shape for the patient and applying it according to the manufacturer's instructions.8 Additional recommendations stress the importance of assessing the skin around the device at least twice a day or more frequently if there is a risk of fluid shifting or edema.9, 10

At our academic cancer center, the standard of care for preventing DVT among postoperative patients had been to apply two forms of mechanical prophylaxis (intermittent pneumatic compression devices and graduated compression stockings) and administer one form of pharmacological prophylaxis. Postoperative orders have historically called for using graduated compression stockings in all surgical oncology patients because of the high risk of DVT among these patients. In the preoperative assessment area, an RN or patient care technician would measure the patient's leg circumference and apply the appropriately sized graduated compression stockings before the patient went into the operating room (OR). Graduated compression stockings were worn during the patient's stay in the OR, postanesthesia care unit, and surgical units. Many surgical patients are given high volumes of fluid in the OR, which can cause swelling in the lower extremities. Because of the lengthy surgery, many wore graduated compression stockings continuously for more than 24 to 36 hours, depending on the type of surgery performed.

Education has been a key factor in PI prevention at our institution. An education initiative started in January 2017 and completed that March involved all of our institution's RNs and patient care technicians, some of whom voluntarily became skin care champions, obtaining additional education on PI identification, early intervention, and management. These skin care champions completed mandatory training using the National Database of Nursing Quality Indicators PI prevention module and demonstrated their competency by managing the skin integrity of our oncology patients. PIs have been documented in the electronic health record since our institution initiated its use in March 2016 and are also included in the institution's safety intelligence reports.

DESCRIPTION OF THE PROBLEM

In March 2017, our hospital initiated weekly and monthly initiatives to better determine PI prevalence. In the division of nursing, the weekly initiative was a collaboration between wound ostomy continence nurses (WOCNs) and clinical nurse leaders (CNLs) to assess suspected PIs. The latter would take a photo of a potential PI, uploading it to the patient's chart. The WOCN then looked at the uploaded photo and participated in rounds to reassess and verify the PI. This weekly assessment revealed a higher number of PIs related to the use of graduated compression stockings on the GI sarcoma surgery unit than had been reported in our institution's safety intelligence reports. The latter require nurses to document PIs, but they often forget to do so; moreover, nurses weren't reporting device-related PIs. In addition, nursing practice on the unit wasn't standardized in terms of daily skin assessment and the application and removal of graduated compression stockings. Nursing staff members also didn't consistently measure the patient's leg circumference for accurate sizing prior to the application of graduated compression stockings, increasing the risk of PIs at the opening of the stocking.

From March 1 to May 31, 2017, six PIs were documented on this unit. The monthly incidence rate per 1,000 patient-days was 3.88 in March, 0.00 in April, and 2.25 in May. Of the documented PIs, five were related to the use of graduated compression stockings, a rate of 1.99 per 1,000 patient-days. The fluctuating PI rate was attributed to the new educational initiative, which led to nurses consistently assessing for medical device–related PIs. In April 2017, the two CNLs on the unit formed a team with the associate director, nurse manager, nurse educator, quality officer (a surgeon), and WOCN with the intention of conducting a literature review to seek ways to address the unit's PI rate.

Literature review. We searched PubMed, the Cochrane Library, and CINAHL using the terms DVT prophylaxis and DVT prevention. The purpose was to identify research that might support altering the practice of using both graduated compression stockings and intermittent pneumatic compression devices. The search produced more than 90 articles. Of these, five from 2010 to 2018 specifically discussed the use of mechanical prophylaxis. Most research compared the use of pharmacological and mechanical prophylaxis rather than intermittent pneumatic compression devices and graduated compression stockings. Of the studies, four were systematic reviews and one was a prospective cohort study on VTE prevention. The authors of the systematic reviews noted that the use of two forms of mechanical prophylaxis was not necessary to prevent VTE. Morris and Woodcock suggested using graduated compression stockings when intermittent pneumatic compression devices were not used for a significant period of time, specifically during ambulation.11 Based on trials indicating an increased risk of lower extremity skin damage in patients whose treatment included the use of graduated compression stockings, the American College of Physicians recommended against using this type of mechanical prophylaxis for the prevention of VTE.12 For patients who had a higher risk of VTE, researchers recommended adding pharmacological prophylaxis if mechanical prophylaxis was insufficient alone.13 Pai and Douketis recommended the provision of prophylaxis interventions throughout a patient's hospital stay.14 We found no recommendations regarding the number of hours per day a patient should receive mechanical prophylaxis. The authors of the prospective cohort study of 798 ICU patients concluded that using intermittent pneumatic compression devices—but not graduated compression stockings—was associated with a significantly lower risk of VTE.15

The key finding from our literature search was that a combination of only one form of mechanical prophylaxis and one form of pharmacological prophylaxis is needed to prevent the occurrence of DVT.11-15 Additionally, findings from the prospective cohort study suggest intermittent pneumatic compression devices are more effective than graduated compression stockings and don't pose a risk of skin complications.15

Specific aims. The purpose of this evidence-based practice project was to reduce the incidence of PIs related to graduated compression stocking use in surgical patients on the GI sarcoma surgery unit. The project specifically aimed to evaluate the impact on PI and DVT risk of using only anticoagulation therapy and intermittent pneumatic compression devices during one nursing shift each day.

METHODS

In June 2017, the team decided to conduct a pilot project in which graduated compression stockings were removed from patients' legs at 7 AM each day and reapplied nightly at 9 PM. The majority of patients were ambulatory and transitioned out of bed to a chair during the day.

During the pilot, which lasted from June to August 2017, nurses on the unit assessed their patients for DVTs by monitoring swelling and calf pain during every shift. If DVT was suspected, the nurse reported this to the provider, who ordered an ultrasound to rule it out.

To ensure active participation in the pilot project, the team engaged with staff members during morning huddles and staff meetings. The latter included a monthly meeting in which the unit's quality metric data, including the number of falls and rates of central line–associated bloodstream infections, catheter-associated urinary tract infections, and PIs, were presented to all staff. All staff members, including RNs, patient care technicians, and the patient service coordinator, participated in huddles. The nurses provided patient updates, and the CNLs gave updates on unit initiatives, hospital initiatives, and new education modules. When we discussed the number of PIs that had occurred in March 2017 during one of these huddles, some of the nurses responded by providing insight into their experiences with the use of graduated compression stockings, which they found to be ill-fitting and bunched at patients' ankles.

RESULTS

Figure 1 describes our project's timeline. Data from the pilot show that the incidence of PIs related to the use of graduated compression stockings among 497 study patients was zero. No DVTs occurred among these patients. This improvement in PI rates was presented at our unit quality meeting on September 20, 2017, which was attended by the unit surgical quality officer, advanced practice nurses, and physician assistants. The unit surgical quality officer requested that the nursing staff present the initiative at our institution's morbidity and mortality meeting, a monthly conference attended mostly by surgeons, who review cases that have unexpected outcomes and discuss innovative techniques.

Figure 1.
Figure 1.:
Timeline of the Evidence-Based Practice PI Project

At the morbidity and mortality meeting in November 2017, the team presented the most recent data from the project, which showed that the unit had cared for 856 patients from June to October 2017 and that PI and DVT rates had remained at zero (after the pilot project concluded in August 2017, the GI sarcoma surgery unit staff continued the practice of taking off graduated compression stockings during the day). A senior surgeon mentioned during the meeting that 14 years earlier he had discontinued the use of two forms of mechanical prophylaxis—graduated compression stockings and a sequential compression device—and only used the latter plus one type of pharmacological prophylaxis. He did so after noticing that his patients had necrotic tissue damage in the calf area due to the use of graduated compression stockings. Since discontinuing the use of these stockings, he reported that he hadn't seen an increase in the rate of DVT among his patients. His observations supported our pilot project findings, which suggested that discontinuing the use of graduated compression stockings would be beneficial to postsurgical patients at our institution.

On May 10, 2018, the surgical team unanimously voted to discontinue the use of graduated compression stockings in the preoperative area, OR, postanesthesia care unit, and inpatient unit for all surgical patients, both during the day and night. An institution-wide huddle was sent via e-mail to all staff regarding this new policy, which would begin June 1, 2018.

From June 2017 to October 2018, the GI sarcoma surgery unit cared for 3,141 patients—an average of 174 patients per month and a total of 15,530 patient-days—with a zero rate of DVT. Figure 2 shows the PI incidence rate over the course of this project and for several months afterward.

Figure 2.
Figure 2.:
The Project's HAPI Incidence Rate Over Time

DISCUSSION

At the start of the pilot, the CNLs and unit leadership observed the bedside shift report daily and noticed that some of the staff RNs weren't willing to take off the graduated compression stockings during the morning shift change. Surgical nurses had applied graduated compression stockings for many years, and some were hesitant to accept the practice change. The team estimated that approximately 5% of the nursing staff was resistant to the change. To overcome this challenge, the CNLs provided unit staff with evidence from the literature and reviewed DVT outcomes data from the senior surgeon who hadn't used graduated compression stockings for the past 14 years. The CNLs were instrumental during the pilot project, checking on each patient after the morning shift change to ensure graduated compression stockings were removed. If they weren't, the CNL provided individual counseling to the nurse on the importance of the practice change. The team achieved compliance by providing continuous leadership presence, education on the project's progress, and the transparency of patient outcomes. Patient safety metrics, for instance, were discussed during the unit's monthly quality and staff meetings and posted on the unit's quality board.

The project's results support the evidence in the literature that two forms of mechanical prophylaxis are not needed to prevent DVT in postsurgical patients. This practice change aided in the elimination of PIs from the use of graduated compression stockings and led to cost savings for the organization. The approximate cost of a pair of knee-high graduated compression stockings is $9, and thigh-high stockings are $17. The GI sarcoma surgery unit averages 170 patients per month; therefore, the potential cost savings has been $1,530 to $2,890 per month. The organization has a cohort of seven surgical units, each with a similar monthly census. Therefore, the surgical cohort cost savings would potentially be $10,710 to $20,230 per month, yielding $128,520 to $242,760 in cost savings each year.

Limitations of the project included that it was conducted at a single site on a single unit of oncology patients having GI surgery. Therefore, the generalizability of results is limited. It's recommended that future projects examine the effects of similar interventions in a variety of patient populations and settings.

CONCLUSIONS

This evidence-based practice project contributes to the literature by highlighting the PI risk and limited benefit of using graduated compression stockings when other DVT prophylaxis measures, either mechanical or pharmacological, are available. Our goal as health care professionals is to not cause additional harm to patients when they seek medical care. It's important that we review trends in patient outcomes and identify opportunities for quality improvement. This practice change demonstrates that the discontinuation of graduated compression stockings use eliminates the risk of associated PIs without putting patients at a greater risk for DVT.

As we strive to prevent PIs, we must not overlook skin integrity issues related to the use of medical devices. This project demonstrates the value of seeking evidence from the literature and questioning the rationale for long-held practices that have been unchanged for many years. Translating evidence into practice can transform the way we assess patients' risk of harm and empower us to intervene to prevent adverse events. What began with a small test of change on one unit grew to widespread changes in physician and nursing practice that resulted in reduced patient harm, improved outcomes, and institution-wide cost savings.

REFERENCES

1. Hobson DB, et al. Prevalence of graduated compression stocking-associated pressure injuries in surgical intensive care units. J Crit Care 2017;40:1–6.
2. Barakat-Johnson M, et al. Medical device-related pressure injuries: an exploratory descriptive study in an acute tertiary hospital in Australia. J Tissue Viability 2017;26(4):246–53.
3. Kayser SA, et al. Prevalence and analysis of medical device-related pressure injuries: results from the International Pressure Ulcer Prevalence survey. Adv Skin Wound Care 2018;31(6):276–85.
4. Bauer K, et al. Pressure ulcers in the United States' inpatient population from 2008 to 2012: results of a retrospective nationwide study. Ostomy Wound Manage 2016;62(11):30–8.
5. AORN. Guideline for prevention of venous thromboembolism. In: Guidelines for perioperative practice. 5th ed. Denver: Association of periOperative Registered Nurses; 2019. p. 773–98.
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11. Morris RJ, Woodcock JP. Intermittent pneumatic compression or graduated compression stockings for deep vein thrombosis prophylaxis? A systematic review of direct clinical comparisons. Ann Surg 2010;251(3):393–6.
12. Qaseem A, et al. Venous thromboembolism prophylaxis in hospitalized patients: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2011;155(9):625–32.
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15. Arabi YM, et al. Use of intermittent pneumatic compression and not graduated compression stockings is associated with lower incident VTE in critically ill patients: a multiple propensity scores adjusted analysis. Chest 2013;144(1):152–9.
Keywords:

deep vein thrombosis; graduated compression stockings; hospital-acquired pressure injury; postoperative care; pressure injury

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