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Tap and Twist Preventing Deep Vein Thrombosis.5 PDF
Tap and Twist Preventing Deep Vein Thrombosis.5 PDF
ABSTRACT
Neurosurgical patients tend to have the highest rate of deep vein thrombosis (DVT) rate among other
postsurgical patients. The methods and timing of DVT prevention and treatment continue to be debated
among neurointensivists. The greatest opportunity to intervene is early during the stay in the intensive
care unit. There are many factors, however, that can make this the most neglected time for aggressive
prevention measures. For large university teaching hospitals, the target of the University Health System
Consortium is to achieve an average DVT rate at or below half that of previous reported rates. The current
recommendations are effective only if there is compliance with these measures during the majority of the
patients’ hospitalization. Our hypothesis states that without changing any of the current measures to
prevent DVT, a structured program of foot and ankle range-of-motion (ROM) exercises will decrease the
incidence of DVT in the neuroscience intensive care patient population. This quasi-experimental study
was a quality improvement project examining 315 individuals over the age of 18 years, who were
admitted to the neurospine intensive care unit and who received a new program of foot exercises as a
method of DVT prevention. Data for the outcome measures were derived from bedside measurement
of lower extremity doppler, the percentage of time the exercises were performed, patient history, and
standard DVT prevention measures. Overall, there was no difference in DVT rates for those receiving the
foot ROM intervention during the study period in 2008Y2009 compared with the usual nursing practice
for the previous year. However, during the study period, those who developed DVT had a significantly
lower compliance rate with the ROM exercises (38.7%) than did those who did not develop DVT (58.4%;
p G .001). Therefore, foot and ankle ROM exercises may have a promising role in reducing the incidence
of DVT in neuroscience intensive care patients when there is diligent performance of the exercises.
O
ne of the most common complications afflict- disposing comorbidities prior to admission, significant
ing patients undergoing surgery is the pre- prolonged immobility during the acute stage of ill-
ventable condition of deep vein thrombosis ness, neurosurgical or procedural interventions that
(DVT), which results from venous stasis, vein injury, tend to be complex and require prolonged length of
and increased coagulation also know as Virchow’s triad stay, and increased inflammatory and infectious
(Burke, 2007). This triad is more prominent in the conditions. The use of higher risk pharmacological
neuroscience intensive care population because of pre- prophylactic interventions in the neurosurgical pa-
tient population may not always be appropriate.
Questions or comments about this article may be directed to Janet
Palamone, MSN APN CCRN CNRN, at jpalamon@nmh.org. She
is a practice manager at the NeuroSpine ICU at Northwestern Significance
Memorial Hospital, Chicago, IL. According to the Center for Disease Control and Pre-
Susan Brunovsky, BSN CNRN CCRN, is a staff nurse at the vention, DVT and pulmonary embolism (PE) are a
NeuroSpine Intensive Care Unit, Northwestern Memorial Hos- growing public health issue. Currently in the United
pital, Chicago, IL. States, 200,000Y400,000 people have DVT (Depart-
Matt Groth, BSN CCRN, is a staff nurse at the NeuroSpine Inten- ment of Health and Human Services, 2010). One third
sive Care Unit, Northwestern Memorial Hospital, Chicago, IL. of patients with DVT develop a chronic disabling con-
Linda Morris, PhD APN CCNS FCCM, is an advance practice dition known as post-thrombotic syndrome with symp-
nurse for the Respiratory Care Department, Northwestern Memorial toms of swelling, pain, discoloration, and scaling in the
Hospital, and assistant professor of clinical anesthesiology with
Feinberg School of Medicine, Northwestern University, Chicago, IL.
affected limb. Neurosurgical intensive care patients
are vulnerable to the development of DVT because
Mary Kwasny, ScN, is a statistician at the Department of Preven-
tative Medicine, Northwestern University, Chicago, IL.
they tend to have a higher degree of immobility due
to their neurological deficits, which can be com-
The authors declare no conflict of interest.
pounded by lengthy stays in the intensive care unit
Copyright B 2011 American Association of Neuroscience Nurses (ICU). In addition, the ICU milieu predisposed pa-
DOI: 10.1097/JNN.0b013e318234e9f2 tients to restricted mobility from such things as cables,
Copyright @ 2011 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
Volume 43 & Number 6 & December 2011 309
Copyright @ 2011 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
310 Journal of Neuroscience Nursing
Copyright @ 2011 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
Volume 43 & Number 6 & December 2011 311
Copyright @ 2011 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
312 Journal of Neuroscience Nursing
Copyright @ 2011 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
Volume 43 & Number 6 & December 2011 313
wellness and to enable them to gain some control in everyone, as compliance rates could have been nurse
the ICU environment. The role of physical therapy dependent. High compliance with the exercises by
in the NSICU is variable and can be delayed when one nurse could have been offset by low compliance
patient stability is in question. Foot and ankle ROM of another.
exercises were meant to be an adjunct to current DVT An additional limitation was that we were unable
prophylaxis and a further bonus to early mobility to determine whether failure to document poten-
measures. These ROM exercises have been adver- tially contributed to the low compliance rates. We
tised in the media to prevent the Economy Class followed the premise that if the exercises were not
Syndrome and are now embraced by airline trav- documented, they were not being done. The reasons
elers (Vavra-Hadzahmetovi, 2006). We feel that in- for failure to document included the following: not
corporating these simple exercises should become initiating the form at time of admission, stopping
a part of daily practice and nursing education through- documentation when one form was completed for
out a patient’s hospital stay. the week rather than initiating a new form for ad-
ditional weeks, and missing documentation for an
entire shift by the nurse caring for the patient. Again,
Limitations the program depended on the accountability of each
This study had several limitations. First, exercises nurse to document performance of the exercises for
occurred only while the patient was in the ICU. Due success of the ROM program.
to the nature of care, critically ill neurology and Because we did not change the standard practice
neurosurgery patients often required frequent trips for screening patients for DVT, we were unable to
off the unit to the interventional radiology suite, ensure that all patients had LED done as part of their
computed tomography, or magnetic resonance im- ICU plan of care. We included only those patients
aging scans. These frequent trips resulted in many who had the LED done to make a direct conclusion
missed opportunities to provide exercises and were about the results. If all our subjects had LEDs, our
a contributing factor to the overall low compliance n would have been higher, contributing to more ro-
rates. In addition, we were unable to control for read- bust conclusions. Another limitation was not includ-
missions to the unit. These included patients who were ing length of stay in our study population as a risk
stable enough to be transferred out of the ICU but factor for developing DVT. Length of stay ranged
returned at some point later, with or without DVT. from 2 to 60 days, and this variability could have
Unless the patients were diagnosed with DVT while explained the overall failure to reduce DVT rates
they were in the ICU, we were unable to determine between the control and study groups.
at what point readmitted patients developed DVT.
We may have strengthened the results of our study Recommendations for Practice
if we had branched out to all the neurological areas
Because our study showed statistical significance in
beyond the ICU, so as to eliminate the need to con-
the patients who were more compliant with the foot
trol for readmissions to the ICU.
and ankle exercises, the following recommenda-
Another limitation was the low compliance rate
tions should be considered for nurses to incorporate
of the ROM exercises. Numerous factors contrib-
into their daily plan of care. The patient or nurse
uted to compliance with the exercises. The culture
should perform the minimum goal of 13 sets of ‘‘tap
of the ICU seems to place less value on ‘‘low-tech’’
and twist’’ exercises each day. In patients who require
interventions; therefore, ROM exercises may have
passive ROM, more frequent repetitions may be re-
been a lower priority. Many nurses feel that the ICU
quired. In addition, involving family members in the
is not the setting to begin early mobility initiatives
tap and twist exercises can increase compliance with
without patients first being evaluated by physical
performing the exercises with the added benefit of
therapy, providing a reason for deferring the exer-
helping families become more engaged with the pa-
cises. In addition, less experienced staff had some
tient’s care.
apprehension about the safety of moving patients with
more technical equipment, such as arterial line place-
ment in the foot. Time constraints became another lim- Summary
itation, as newer staff with less organizational skills Nurses play an important role in reducing the oc-
placed ROM exercises as a low priority in their busy currence of DVT, which has been supported in the
day. More experienced staff appeared to have a greater literature. Early mobilization has been shown to im-
understanding of the value of mobility and may have prove outcomes, and ROM exercises improve blood
made it more of a priority. The success of the program flow to the lower extremities. Although our study re-
depended on the commitment and accountability of vealed no difference in overall DVT rates, it did show
Copyright @ 2011 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
314 Journal of Neuroscience Nursing
that those who did not develop DVT were more Geerts, W., Heit, J. A., Clagett, G. P., Pineo, G. F., Colwell, C.,
compliant with the foot and ankle exercises. Active Anderson, F. A., & Wheeler, H. B. (2008). Prevention of
venous thromboembolism: American College of Chest Phy-
ROM proved to be the best method to decrease sicians’ evidence-based clinical practice guidelines (8th ed.).
one’s risk of DVT. Nurses are the key to incorpo- Chest, 133(6), 380SY453S.
rating these exercises into the daily plan of care for Graziano, J., & Charpie, J. (2001). Thrombosis in the intensive
their patients. Efforts to improve nursing compli- care unit: Etiology, diagnosis, management, and prevention
ance with this ROM exercise program should be the in adults and children. Cardiology in Review, 9(3), 173Y182.
focus of future studies to reach a more robust con- Hitos, K., Cannon, M., Canon, S., Garth, S., & Feltcher, J. P.
(2007). Effect of leg exercises on popliteal venous blood flow
clusion. With further study, foot and ankle ROM during prolonged immobility of seated subjects: Implications
exercises have a promising role in reducing DVT oc- for prevention of travel-related deep vein thrombosis. Journal
currences with diligent performance of the exercises of Thrombosis and Haemostasis, 5(9), 1890Y1895.
in critically ill patients. Hopkins, R., & Spuhler, V. (2009). Strategies for promoting early
activity in critically ill mechanically ventilated patients. AACN
Advances in Critical Care, 20(3), 277Y289.
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