”DVT Prevention What Works BestSHINE BELL, .docx

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DVT Prevention:
What Works Best?
SHINE BELL, RN, LACEY KEITH, LPN, AMBER MCGRAW,
RN, REGAN WENTZ, RN.
FACULTY CONSULT: JAMIE MORRIS, MS RN
OU College of Nursing: Degree Completion
Evidence-Based Practice Symposium
Friday, April 26. 2019
Objective
regarding the most effective means of
DVT prophylaxis.
PICO Question

For Deep Vein Thrombosis (DVT) prophylaxis, which
intervention,
mechanical, pharmacological or combination, best decreases
DVT occurrence in the acute care setting?
What is the Problem?
current standardized practice guideline for DVT
prevention.
for whom it is ordered.
pharmacological therapeutic agent.
Why is this a Problem?
-associated blood clots are
preventable, yet

fewer than half of hospitalized patients receive appropriate
preventive
treatment (CDC, 2018).
for
developing a DVT
(Sachdeva, 2018).
morbidity and
mortality in many surgical specialties (Chibbaro, 2018).
–60 percent of
postoperative cases in
the 7–14 days following surgery (AHRQ, 2012).
Literature Review
Briggs
mechanical, pharmacological, DVT best practice, DVT
acute care setting.
-2018

Literature Review & Conclusions
A large database analysis asking (1) What are the differences in
VTE incidence in primary
TKA after administration of aspirin, warfarin, enoxaparin, or
factor Xa inhibitors? (2) What
are the differences in bleeding risk among these four agents? (3)
How has use of these
agents changed with time? Concluded that utilization trends for
these agents are not
well-studied.
A systematic review with meta-analysis and trial sequential
analysis of randomized
controlled trials (RCTs) comparing pharmacological
thromboprophylaxis with low
molecular weight heparin (LMWH) versus unfractionated
heparin (UFH) in ICU patients.
Concluded a need for future trials.
A prospective comparative study analyzing results from two
separate prophylaxis
protocols implemented in a European neurosurgical center to
assess the safety and
efficacy of prevention. Concluded that mechanical devices are
non-negligible support
in the prophylaxis of clinically symptomatic DVT.

A two-stage sequential multi method design study aimed at
developing a clinical
tool to guide nurses’ assessment of postoperative patients at
risk for DVT. Concluded
that due to multiple limitations, there is no identified gold
standard in clinical
assessment for the detection of early DVT. Further research
needs to be conducted
for both screening and assessment of DVT.
Comprehensive Meta-Analysis comparing the efficacies and
safety profiles of UFH,
LMWH, mechanical prophylaxis and no prophylaxis. Study did
observe a significant
reduction of DVT risk with pharmacologic prophylaxis
compared to the control
group. Concluded that the choice of best thromboprophylaxis
technique still needs
further investigation.

A Cochrane Database Systemic Review to evaluate the
effectiveness and
safety of graduated compression stockings in preventing DVT in
various groups
of hospitalized patients. Concluded that the occurrence of
problems with
wearing GCS was poorly reported in the included studies.
A prospective, randomized control trial examining whether
there is a difference
in DVT occurrence using aspirin-based prophylaxis with or
without extended
use of mechanical compression device (MCD) therapy.
Conclusion: This study
did not establish the best prevention protocol.
risk of DVT by 52
percent when compared with pharmacological prophylaxis alone
(AHRQ,
2012).
Types of Prophylaxis
Pharmacological
-molecular-weight
heparins (Lovenox)

inhibitors
Mechanical
hose)
(SCD machine)
Pros and Cons
Mechanical Interventions:
and intermittent pneumatic
compression.
interactions
nosocomial infections, dislodge pre-
formed DVT that can result in fatal PE.
little evidence is available to guide

clinicians in the efficacy of mechanical
thromboprophylaxis.
Pharmaceutical Interventions
s: aspirin, unfractionated heparin,
low molecular weight heparins, vitamin k
antagonists and fondaparinux
thromboprophylaxis could be a more
effective, equally safe, and less
expensive measure for the prevention of
VTE.
n: The choice of best
thromboprophylaxis technique still needs
further investigations.
STOPDVTs
(O'Brien, 2018)
Kotter’s Model of Change
(Kotter, 2018.)
Recommendations for Change
n

postoperative patients
as they conduct frequent patient assessments, follow patients
through their
inpatient journey and have the ability to prompt initial
investigation of potential
cases and escalation of care (O'Brien, 2018).
ditional education for the nurses staff.
Increase knowledge to
incorporate the DVT assessment as a daily standard. Implement
a rounding tool to
assist with early detection.
prevention upon admission
and discharge.
developing
complications which can be avoided.
Evaluation of Effectiveness
implications
for practice can be made regarding the greater effectiveness of

pharmacological, mechanical, or combination prophylaxis.
complexity of DVT,
its risk factors and the constant change in medication and health
status of
an individual in the acute care setting.
Suggestions for Further Study & New
Research Question
pharmacological prophylactic agent and in the combination of
pharmacological and mechanical prophylaxis.
prophylaxis
in the acute care setting are needed.
America to
contribute to the development of a standardized DVT protocol
in the
acute care setting.

of
interdisciplinary staff regarding implementation of mechanical
prophylaxis.
Questions?
References
hods Guide for Effectiveness and
Comparative Effectiveness Reviews. Retrieved from
www.effectivehealthcare.ahrq.gov/ehc/
products/60/318/MethodsGuide_Prepublication-
Draft_20120409.pdf.
Amanatullah, D.F. (2017). Venous thromboembolism
prophylaxis after tka: Aspirin, warfarin, enoxaparin, or factor
xa
inhibitors? Clinical Orthopaedics and Related Research., 475
(9), 2205-2213. https://doi.org/doi:10.1007/s11999-017-5394-6
I., Kjaervik, L., Sandset, P. M., Sunde,
K., & Eken, T. (2015). Thromboprophylaxis with low molecular
weight heparin versus unfractionated heparin in
intensive care patients: a systematic review with meta-analysis
and trial sequential analysis. Intensive Care Medicine., 41(7),
1209-19. https://doi.org/doi: 10.1007/s00134-015-
3840-z

August 29). Fact sheets about blood clots | CDC. Retrieved
March 8, 2019, from
https://www.cdc.gov/ncbddd/dvt/materials/factsheets.html
D., Abid, H., ... Pop, R. (2018). Evolution of prophylaxis
protocols for venous thromboembolism in neurosurgery:
Results from a prospective comparative study on low-
molecular-weight heparin, elastic stockings, and intermittent
pneumatic compression devices. World Neurosurgery,
109, E510-e516. https://doi.org/doi:10.1016/j.wneu.2017.10.012
A. F. (2018). STOPDVTs: Development and testing of a clinical
assessment tool to guide nursing assessment of
postoperative patients for deep vein thrombosis. Journal of
Clinical Nursing, 27(9-10), 1803-
1811.https://doi.org/https://doi.org/10.1111/jocn.14329
, J.M., J.S., &Cho, Y. (2016). Pharmacological
and mechanical thromboprophylaxis in critically ill patients: A
network meta-analysis of 12 trials. Journal of Korean
Medical Science, 31(11), 1828-1837. https://doi.org/doi:
10.3346/jkms.2016.31.11.1828
achdeva, A., Dalton, M., & Lees, T. (2018). Graduated
compression stockings for prevention of deep vein thrombosis.
Cochrane Database of Systemic Reviews, 12,
CD001484.
https://doi.org/doi:10.1002/14651858.CD001484.pub3
cheuerman, C. M., Gregg,
J. L., & Hussain, L. R. (2017). Efficacy in deep vein thrombosis
prevention with extended mechanical compression
device therapy and prophylactic aspirin following total knee
arthroplasty: A randomized control trial. The Journal of

Arthroplasty, 32(5), 1478-
1482. https://doi.org/10.1016/j.arth.2016.12.027
https://webmail.ouhsc.edu/owa/redir.aspx?C=q5hRt7FOYTjkBV
JPiUQOmowgfSL0AgoAWJMFBf4D7JQ8_haVuMXWCA..&UR
L=https://doi.org/doi:
https://www.cdc.gov/ncbddd/dvt/materials/factsheets.html
https://webmail.ouhsc.edu/owa/redir.aspx?C=MK338lpk99ipMk
XkI5oI46iFhMPXvUnF2awZ4OHCAT08_haVuMXWCA..&URL
=https://doi.org/https://doi.org/10.1111/jocn.14329
https://webmail.ouhsc.edu/owa/redir.aspx?C=WI1SSd9HdfKy8C
TrZKJ0HrtofJ95B_B3AiJHItRHH3Y8_haVuMXWCA..&URL=h
ttps://doi.org/10.1016/j.arth.2016.12.027
EBP Literature Review
Do nurses who work 12 hour shifts make more medication
errors compared to nurses who work 8 hour shifts?
· P: Nurses
· I: 8 hour shifts for all nurses
· C: 12 hour shifts compared to 8 hour shifts
· O: Less medication errors
· T: 30 days

Literature search: Hardin-Simmons University Database
· When searching for peer reviewed academic journals within
the last five years...
· ‘Nurse’ → 664,538 articles
· ‘Nurse’ AND ‘Shift’ → 118,413 articles
· ‘Nurse’ AND ‘Shift’ AND ‘Medication errors’ → 11,812
articles
Article #1 (Jordan Boles)
Abdelbaset M. Saleh, Nabil J. Awadalla, Yosr M. El-masri, &
Wafaa F. Sleem. (2014). Impacts
of nurses’ circadian rhythm sleep disorders, fatigue, and
depression on medication
administration errors. Retrieved from
http://search.ebscohost.com.ezproxy.hsutx.edu:2048/login.aspx?
direct=true&db=edsbas
&AN=edsbas.F8CC962F&site=eds-live&scope=site
Main Ideas and Recommendations
This article looks into the effects of fatigue, shift length,
depression, and circadian rhythm on nurses and the impact these
factors make on medication errors. The researchers used a
cross-sectional study design with a sample population of 52 full
time nurses. Each nurse filled out demographic data,
questionnaires on depression and fatigue, a sleep diary, and was
directly observed for medication errors during a full shift. The
results of the study concluded that medication errors were
increased during long shifts and when sleep was decreased.
Other studies presented in the article supported these findings.
Recommendations for this study would include taking a larger

sample size that is more inclusive. The current population does
not account for the older generation of nurses and only accounts
for 1 male out of 52 nurses. Another improvement that could be
made concerning this study is the need to include more
specialties. This article only utilized medical/surgical nurses at
an oncology center. A hospital-wide study that included all
specialties such as labor and delivery, intensive care, and
pediatrics would provide a complete picture of effects of shift
length and fatigue on full time nurses.
Article #2 (Tamara Rossi)
Perry, L., Lamont, S., Brunero, S., Gallagher, R., & Duffield, C.
(2015). The mental health of
nurses in acute teaching hospital settings: a cross sectional
survey. BMC nursing, 14(1),
15.
The article presents a cross-sectional study that aims to reach an
understanding on how the continuous challenging nature of the
nursing profession can impact the mental wellbeing of nurses in
the long-term. The instrument used is the survey and a total of
382 nurses participated. Each participant was asked to fill in a
questionnaire that included closed-ended questions regarding
demographics (age, gender, ethnicity, type of contract), general
health and comorbidities, sleeping patterns, eating habits and
alcohol and tobacco use. The results of the study showed that
more than half of the sample population experienced symptoms
that could potentially indicate a mental health issue.
Furthermore, nurses had better mental health if male, physically
healthy, and living with a significant other or family rather than
alone. Researchers emphasized the importance of both mental
and physical wellbeing of nurses in order to provide high
quality, safe, patient-centered nursing care. Finally, the study

supported the creation of workplaces where working practices
promoted nurses’ wellbeing. Participants were kept anonymous
and the selection was very broad, since all nurses working in
the hospitals were invited to participate. This fact ruled out any
bias that could have possibly affect the entire study.
Article #3 (Danna Gonzales)
Thompson, B. J. (2019). Does work-induced fatigue accumulate
across three compressed 12 hour shifts in hospital nurses and
aides? PLoS ONE, (2). Retrieved from
direct=true&db=edsgov&AN=edsgcl.573035248&site=eds-
live&scope=site
Main ideas and Recommendations
This article discusses the mental capabilities in the differences
between nurses that work a single 12-hour shift to three
consecutive 12-hour shifts. This nonexperimental design tests
one group of nurses and aids at two different points of time,
once at the end of a 12-hour shift and again at the end of the
third 12-hour shift. A total of twenty-six nurses and aids
participated in this study; 16 RNs, 8 CNAs and 2 LPNs. These
tests included a psychomotor vigilance test, vertical jumps and
muscle assessment in order to evaluate reaction time, lapses of
attention and muscle function. The overall outcome of this
cohort study concluded that there was a significant decline in
each test that was given at the end of the third day. These
results indicate the need for fatigue management strategies that
will lower the risk for fatigue-related mishaps in the workplace.
Recommendations to improve this study is to provide more
fatigue assessment tests and fatigue assessment time points in
order to determine when fatigue accumulation becomes most
severe and when do certain strategies need to be implemented to
reduce the heavy risks and burdens associated with fatigue
induced impairments in performance.

Article #4 ( Munayfah Aldhafeeri) Sagherian, K., Clinton, M.
E., Abu-Saad Huijer, H., & Geiger-Brown, J. (2017). Fatigue,
work schedules, and perceived performance in bedside care
nurses. Workplace health & safety, 65(7), 304-
312.https://doi.org/10.1177/2165079916665398
This article explores the effects of working overtime, chronic
and acute fatigue, inflexible working schedule, and cognitive
functioning on nurses and how these factors can negatively
impact on nursing practice –leading to unfavorable patient
outcomes. Descriptive cross-sectional research design was used
by the researchers whereby a sample of 77 bedside nurses were
involved in the study. Every nurse was issued with a
questionnaire to fill in information regarding work schedules,
fatigue, and perceptions regarding the nursing performance. The
study findings indicated that acute and chronic fatigue led to
poor physical and mental performance of nurses –hence
resulting into constant medical errors. Moreover, lack of enough
rest altered the cognitive functioning of nurses –resulting into
poor concentration when providing patient care. All other
studies related to the article supported the findings of this
research. The recommendations for this research is the use of a
different sampling methods whose sample size will be a
representative of the entire RNs population. Secondly, future
researches should be more inclusive by involving more medical
professionals in the hospital. Finally, a different research design
should be used in order to realize better results.
Article #5 (Brandi Offield)
Caruso C. C. (2014). Negative impacts of shiftwork and long
work hours. Rehabilitation nursing : the official journal of
the Association of Rehabilitation Nurses, 39(1), 16–25.
doi:10.1002/rnj.107
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4629843/#idm1
40559828717056title

This article uses a descriptive quasi-experimental approach to
discuss the relationship between lack of sleep and working long
hours, with the detrimental effects it has on nurses and patients
in regards to safety and health. The article incorporates many
different types of studies and instruments to validate that
working long hours and not receiving adequate sleep, are
directly related to slower reaction time, decreased ability to
concentrate, poor health behaviors, diseases, and work related
injuries and mistakes. Recommendations for this article would
be to conduct a study of nurses who do get an adequate amount
of sleep each night to show whether working long hours is
directly related to the detrimental effects listed or is working
long hours only directly related to not receiving an adequate
amount of sleep.
References
Abdelbaset M. Saleh, Nabil J. Awadalla, Yosr M. El-masri, &
Wafaa F. Sleem. (2014). Impacts
of nurses’ circadian rhythm sleep disorders, fatigue, and
depression on medication
administration errors. Retrieved from
direct=true&db=edsbas
&AN=edsbas.F8CC962F&site=eds-live&scope=site
Bae, S.H, & Fabry, D. (2014). Assessing the relationships
between nurse work hours/overtime
and the nurse and patient outcomes: systemic literature review.

Nursing outlook, 62(2),
138-156.
Caruso C. C. (2014). Negative impacts of shiftwork and long
work hours. Rehabilitation nursing : the official journal of the
Association of Rehabilitation Nurses, 39(1), 16–25.
doi:10.1002/rnj.107
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4629843/#idm1
40559828717056title
Ferri, P., Guadi, M, Marcheselli, L., Balduzzi, S., Magnani, D.,
& DiLorenzo, R. (2016). The
impact of shift work on the psychological and physical health of
nurses in a general
hospital: a comparison between rotating night shifts and day
shifts. Risk management and
healthcare policy, 9, 203.
Perry, L., Lamont, S., Brunero, S., Gallagher, R., & Duffield, C.
(2015). The mental health of
nurses in acute teaching hospital settings: a cross sectional
survey. BMC nursing, 14(1),
15.
Vilde H. Bernstrøm, Daniele Evelin Alves, Dag Ellingsen, &
Mari Holm Ingelsrud. (2019).
Healthy working time arrangements for healthcare personnel
and patients: a systematic
literature review. BMC Health Services Research, (1), 1.

https://doi-org.ezproxy.hsutx.edu:4443/10.1186/s12913-019-
3993-5
Thompson, B. J. (2019). Does work-induced fatigue accumulate
across three compressed 12 hour shifts in hospital nurses and
aides? PLoS ONE, (2). Retrieved from
direct=true&db=edsgov&AN=edsgcl.573035248&site=eds-
live&scope=site
Sagherian, K., Clinton, M. E., Abu-Saad Huijer, H., & Geiger-
Brown, J. (2017). Fatigue, work schedules, and perceived
performance in bedside care nurses. Workplace health & safety,
65(7), 304-312. https://doi.org/10.1177/2165079916665398

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