By Debra Wood, RN, contributor
For decades, nurses have been applying graduated compression stockings as a means to prevent deep vein thrombosis (DVT) in hospitalized patients. A new nursing study has found that these hose are often incorrectly used or fitted, putting patients at risk for potentially deadly blood clots.
“Incorrect use and sizing of graduated compression stockings is a problem nationwide, and I think we can say worldwide, too, based on the articles from other countries. But this problem hasn't received the attention it deserves,” said the study’s lead author, Elizabeth H. Winslow, Ph.D., RN, a research consultant at Presbyterian Hospital of Dallas.
“It’s a little like the ‘elephant in the living room,’” continued Winslow. “Our study is one of the first to systematically analyze the issue and provide specific recommendations to improve practice.” The results of the study were recently published in the September 2008 issue of the American Journal of Nursing.
When fitted properly, graduated compression stockings use pressure to enhance blood flow velocity and reduce the tendency of blood to coagulate, said fellow researcher Debra L. Brosz, MSN, RN, ONC, NEA-BC, an orthopedic unit nurse manager at Presbyterian.
“The prevention of venous thromboembolism is a Joint Commission quality initiative,” Brosz added. “Graduated compression stockings are one of the mechanical devices suggested for use in conjunction with pharmacological agents, so it is important that the stockings are sized and used correctly.”
The researchers conducted the study after hearing concerns from nurses about skin breakdown, binding and redness related to use of the stockings and as a follow-up to a 2004 quality improvement study that showed about 20 percent of the stockings were not used correctly or seemed to be of the wrong size.
Anecdotally, staff nurses also reported thigh-high stockings were more difficult to apply than knee-high stockings, and patients complained more about the thigh-length stockings.
“The nurses wanted to know whether the thigh-length stockings were associated with more problems than the knee-length,” Winslow said.
Winslow and Brosz decided to quantify and identify the specific problems with compression stockings so they could be rectified.
The researchers found the stockings were used incorrectly—such as wrinkles in the hose, rolled down stockings or the gusset in the wrong place—in 29 percent of cases and were sized incorrectly 26 percent of the time. The problems were more common with the thigh-length stockings. Twenty percent of patients didn’t understand the stockings’ purpose.
Nursing responsibility includes sizing the stockings, applying them, teaching the patient about the stockings and their purpose, and then removing the stockings and assessing the patient’s skin at least every 12 hours.
Contributing factors to the stockings’ misuse included nurses guessing at the size rather than measuring, because tapes and charts were not readily available. Researchers also found that some nurses felt the charts from the manufacturer were confusing. In addition, nurses sometimes delegated the task of sizing to the patient care technicians.
“I think some nurses don't appreciate the importance of the stockings in preventing DVT and the risk of not sizing and using them correctly,” Winslow said. “There may be some complacency in practice.”
Winslow and Brosz stopped the study with 142 participants early due to the large number of instances of incorrect use or sizing.
“We and the research assistants were uncomfortable continuing the study when we knew there were problems,” Winslow said. “We knew patients were at risk, and we knew we needed to do widespread education and do other interventions to improve practice. We felt we had enough data to have confidence in our findings, and to have other people have confidence in the findings, and to make recommendations to improve practice. We realized that both system and individual deficiencies contributed to the practice issues and needed to be addressed.”
Winslow and Brosz conducted numerous in-service training sessions at the hospital about sizing and correct use, and presented similar information at various conferences. They also developed a protocol, developed and distributed an evidence-based practice flyer, incorporated specific training in orientation and annual skill days, and created a one-page patient education sheet.
In addition, Presbyterian removed the thigh-length stockings from the unit stock, since other data suggests knee-highs are just as effective. They placed measuring tapes and sizing charts near the stored hose and added “TED stockings” to the incident reporting form, so nurses could check off if the stockings were a contributing factor. That way, the hospital can better track and correct problems related to the stockings.
“Incorrect sizing and use of the stockings is a nursing practice issue, which we can and must fix,” Winslow said. “I would like all nurses who care for patients with graduated compression stockings to appreciate the effectiveness of the stockings in preventing DVT when correctly sized and used and the serious problems if not sized and used correctly.”
Several physicians at the hospital changed their practice switching from ordering thigh-length graduated compression stockings to knee-length as a result of the nurses’ research, Brosz said. A recent survey at Presbyterian found no patients wearing thigh-length stockings.
Winslow and Brosz are planning a follow-up study to check on use and sizing of the stockings and to determine if practices have changed as a result of their educational efforts.
Brosz hopes more nursing schools and hospitals will provide education about the importance of proper sizing and use of graduated compression stockings. She also would like to see knee-length stockings become the standard, since it, she expects, it will result in better patient compliance and fewer complications.
“I think our article will publicize the problem and will galvanize nurses to improve practice and to do much-needed research on the topic,” Winslow concluded.
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