Running head: INTERMITTENT COMPRESSION DEVICES

Use of Intermittent Compression Devices in Patients at a High-risk for DVTs

Anthony Cline
University of South Florida

INTERMITTENT COMPRESSION DEVICES

Abstract
Clinical Problem: The occurrence of deep vein thrombosis (DVT) in patients that
remained immobile after a stroke is higher than a normal bed bound patient. Using
pharmacological thromboprophylaxis is regarded as the primary intervention for DVTs,
but cannot be used in patients who are at a higher risk for bleeding. The use of
intermittent compression devices (ICD) is implemented to decrease the occurrence of
DVTs in bed bound and limited mobility patients.
Results: Randomized controlled trials were used to determine if the use of ICDs are
effective in the prevention of DVTs in high-risk patients. According to the CLOTS 3
study, which trialed 2876 patients; the use of intermittent pneumatic compression devices
(IPCD) is an effective form of prophylaxis for prevention of DVT (p=0.001) (Dennis et
al., 2013). In the second trial reviewed, the use of IPCDs was shown to increase venous
blood flow, thus preventing the formation of venous stasis, which decreases the
occurrence of DVTs (p<0.001) (Broderick et al., 2014). The third trial reviewed a device
named the Venowave, a mechanical compression device for continued use in the home
setting. The Venowave was proven effective in the prolonged prevention of DVTs in the
outpatient setting (p=0.008) (Sobieraj-Teague et al., 2012).
Conclusion: DVTs are primarily a concern in those patients who are bed bound for long
periods of time or have limited mobility. This increases the risk of DVT. Lowering the
occurrences of DVTs in patients reduces the risk for complications such as pulmonary
embolisms and postthrombotic syndrome. The use of ICDs to decrease this risk in
patients who are unable to be treated with pharmacological interventions has been proven
to be a highly effective form of thromboprophylaxis.

INTERMITTENT COMPRESSION DEVICES

Use of Intermittent Compression Devices in Patients at a High-risk for DVTs

Acute care facilities use evidence-based practice to reduce the risk for further
complications and reduce total health care costs for every patient visit. There is a large
impact on the patients quality life if they develop a DVT and about one-half will have
long term complications such as swelling, pain, and scaling in the affected limb.
According to the Centers for Disease Control and Prevention (CDC, 2010), 60,000100,000 Americans die every year from DVT/PE and the first symptom of 25% of those
affected is death. In high-risk patients, how does use of intermittent compression devices
compared to no use of thromboprophylaxis impact the prevention of deep vein
thrombosis within six months? To show the importance of this practice, three randomized
controlled trials and hospital guidelines have been used to support this practice. The staff
and faculty at Sarasota Memorial Hospital are dedicated to quality and compassionate
patient care and are open to new practice changes back by evidence based practice. To
put this change of practice in effect it will take a collaborative effort from the
neurosurgeons, neuro physicians, ICU nurses and floor nurses with assistance from
nursing assistants and techs. Nurse clinical educators, library staff, and nursing leadership
will need to be in agreement with the change of practice outlined in the project to get the
best dissemination of the data and evidence.
Literature Search
The search for randomized controlled trials pertaining to this PICOT question
were conducted in CINAHL and PubMed. The keywords used in the search were DVT,
stroke, deep vein thrombosis, venous thrombosis embolism, pneumatic compression
device, and intermittent compression device, in varying combinations.

INTERMITTENT COMPRESSION DEVICES

Literature Review
The purpose of this study is to reduce the occurrence of deep vein thrombosis in
post stroke and neurosurgical patients with the use of intermittent compression devices
such as the Venowave, and intermittent pneumatic compression sleeves. The study will
review three different randomized controlled trials and one clinical practice guideline to
validate the change in practice.
The trial by Dennis et al. (2013) took place in multiple hospitals and has a very
large experimental group. It took place over four years with a control group and
experimental group totaling 2876 volunteer patients at 105 hospitals in the United
Kingdom. The trial showed a decrease in occurrence of DVTs by 3.6% in favor of
intermittent pneumatic compression (IPC) devices (p=0.001) when compared to patients
without any IPC devices. This trial fits the patient population with immobilized poststroke patients. This is the third trial of its kind using the similar parameters and all three
trials produced the same results. The large population and the span of this trial make it a
very strong source for data to show that intermittent pneumatic compression devices are
very effective for use in prevention of DVTs. The results from this trial are conclusive
enough to put intermittent compression devices into use in daily patient care.
Broderick et al. (2014) compared the use of neuromuscular electrical stimulation
(NMES) and intermittent pneumatic compression (IPC) devices to no
thromboprophylaxis at all. The calf IPC showed a peak velocity of 125.6 cm/s and
ejection volume of 12.3 ml compared to no IPC of 80.7 cm/s and 8.5 ml respectfully. The
patients selected were of similar medical health and demographic. The trial showed a
strong result with the NMES and IPC devices increasing venous blood flow (p<0.001)

INTERMITTENT COMPRESSION DEVICES

compared to no ICD use. The patient group is not an exact fit for the high-risk population
but this trial has strong evidence of an effective thromboprophylaxis in any patient that
could be applied to the patient population of the PICOT question. Another downside to
the trial is the small trial group of only 30 patients. While this trial doesnt directly
support the use of intermittent compression devices as thromboprophylaxis of DVTs, the
information supports venous flow in the lower extremities, which will reduce the
occurrence of DVTs. This trial shows that intermittent compression devices, specifically
intermittent pneumatic compression devices, are effective for increasing venous blood
flow, which can help prevent DVTs.
Sobieraj-Teague et al. (2012) conducted a trial using a product called the
Venowave. It is a small, portable compression device that allows for use in the hospital
and also after the patient is discharged. It differs from intermittent pneumatic
compression devices in that it is a sequential compression pump that massages the
patients calf to promote venous blood flow. It is beneficial to the patient because they
can stay on the thromboprophylaxis regime well after leaving the hospital with minimal
to no risk. This trial fits the criteria of the PICOT question for population with
neurosurgical patients. One of the downsides of this trial is the small pool of cases used
with only 75 patients using the Venowave devices. This trial does support the outcome of
a decrease in DVT occurrence in high-risk patients of 4.0% when intermittent
compression devices are used compared to 18.7% with no IPCs (p=0.008). In summary,
the trials show that intermittent compression devices are effective in the prevention of
DVTs in high-risk patients.
The guidelines set forth by Sarasota Memorial hospital (Horiuchi et al., 2014)

INTERMITTENT COMPRESSION DEVICES

dictate that the patient will be screened for risk of developing a deep vein thrombosis
upon admission to the hospital. Depending on what category the patient falls into; the
admitting nurse will then initiate a protocol outlined in the policy. A patient who is low
risk, score of one or less, will only require early ambulation. A patient who scores two or
higher is considered moderate or high risk and will require intermittent compression
devices unless contraindicated. High risk patients, score of three or higher, will also
receive pharmacologic prophylaxis but neurosurgical and some stroke patients, only IPC
devices and TED hose will be used.
Synthesis
Dennis et al. (2013) showed the use of intermittent compression devices in
admitted stoked patients lowered the rate of developing a deep vein thrombosis
(p=0.001). Broderick et al. (2014) showed the use of intermittent pneumatic compression
greatly increased venous blood flow and blood volume in the lower extremities compared
to no compression (p<0.001). Sobieraj-Teague (2012) did a study on a new product
called a Venowave and the results from this trail show the Venowave is effective in
preventing deep vein thrombosis in patients compared to no device (Table 1).
Using these three trials in conjunction is evidence enough to show that
mechanical thromboprophylaxis is an effective measure at preventing deep vein
thrombosis. Dennis et al. (2013) was the third trial in a series dedicated to deep vein
thrombosis prophylaxis. One thousand eight hundred ninety patients made it through the
trial and made their follow-up appointment, which makes this trial one of the largest
studies pertaining to DVTs. With 955 patients in the trial group and 935 patients in the
control group, the results showed the use of intermittent pneumatic compression devices

INTERMITTENT COMPRESSION DEVICES

is effective in the prevention of DVTs (8.5% with DVT, 12.1% with DVT, respectfully).
The Broderick et al. (2014) trial was originally used to compare neuromuscular electronic
stimulation to other calf compression devices like intermittent pneumatic compression
devices. This study is being included in the review because it shows how effectively the
intermittent pneumatic compression devices increase blood flow in the lower extremities.
Since venous stasis is a risk factor of deep vein thrombosis, this trial has excellent data
showing the increase of blood flow volume and velocity compared to the control (12.3
ml, 125.6 cm/s, and 2.1 ml, 10.8 cm/s, respectively) (Broderick et al., 2014). The
Venowave is not a device that would be used at an acute care facility but rather at the
patients home or an out patient facility. The device caused a reduction in the occurrence
of deep vein thrombosis of 18.7% in the control group to 4% (Sobieraj-Teague, 2012).
The evidence gathered from the three randomized controlled trails and the one
clinical guideline support the decision to change the current standard of practice to the
one outlined in the project. All post stroke and neurosurgical patients should receive
intermittent pneumatic compression devices while admitted to the hospital to prevent the
occurrence of deep vein thrombosis and the complications associated such as pulmonary
embolisms and postthrombotic syndrome. After discharge from the hospital, and once
more supporting trials have been completed, patients should receive the Venowave to
continue their thromboprophylaxis therapy while they are at home or a nursing facility
until they are able to return to a lifestyle that facilitates ample ambulation and activities
of daily living. This change in practice will decrease patient hospitalization times,
hospital costs and overall patient satisfaction.
Proposed Practice Change

INTERMITTENT COMPRESSION DEVICES

All nurses should put intermittent pneumatic compression devices on stroke

patients as soon as they arrive to the unit and they will remain on the patient until the
patient is ambulating frequently or is discharged. After more research is conducted the
patient will be educated on the use of the Venowave and the patient will wear them until
their doctor clears them to stop and with sufficient amount of ambulation. Nurses will
ensure patient compliance and education on why the IPC is beneficial in prevention of
deep vein thrombosis. Nurses will document any changes in condition, patient
demographic data and any information that can benefit future studies to promote
advancement in evidence based practice. The practice can be changed at a late date as
more research is completed on the subject and data is found to warrant a change
Change Strategy
All physicians, surgeons, and nursing staff involved need to be in agreement with
the change this project solicits. There is ample evidence to prove how effective
intermittent compression devices are in prevention of deep vein thrombosis. All project
team members will present the data to physicians and nurses in units affected by the
changes. In addition to the presentations, project team members will be available to
doctors and nursing staff that have any questions during the roll out of the changes. If by
chance the physician or nursing staff has any doubts to the change being effective, the
project team will be able to present them with conclusive evidence found during the
project. The project is in line with current guidelines from Sarasota Memorial Hospital
and uses the IOWA evidence based practice model for implementation into the clinical
setting. The project team will work closely with nurse managers and charge nurses to
ensure compliance and proper documentation in the patients record.

INTERMITTENT COMPRESSION DEVICES

Roll Out Plan

Steps

Definition

Step 1
Identify Triggers

Identification of a clinical
problem
o The occurrence of DVTs
is of importance to the
facility because they cost
the facility money and
reduce patient clinical
outcomes.

Timeframe

Completed, January 2015

Step 2
Gather &

There is sufficient evidence

found in the 3 randomized
controlled trials to support the
chance in policy.

The change is appropriate for

adoption in practice because the
evidence supports a lower rate of
DVTs, which improve patient
outcomes, and decrease hospital
stay time that in turn saves the
hospital money.

Synthesize

Completed, March 2015

Evidence

Step 3
Pilot the Change

Step 4

Disseminate the
Evidence

Share the results of the project

with NTI and local Sigma Theta
Tau chapters to spread the
success with other healthcare
professionals.

September 2015

October 2015

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Project Evaluation
Great efforts will be taken to make sure the new project variables are recorded
accurately and facilitate proper data synthesis. Data will be collected on post stroke and
neurosurgical patients that are given intermittent compression devices as deep vein
thrombosis prophylaxis. The data will be compared to the occurrences of deep vein
thrombosis in patients who did not receive intermittent compression devices. Patient data
will also be recorded after discharge from the hospital to track the occurrence of deep
vein thrombosis in patients who receive the Venowave. The project will require a
decrease of DVT occurrence of 3% or greater to be considered successful.
Dissemination of EBP
As mentioned earlier, all local hospital staff affected by the change will be asked
to go to a presentation on the findings by the project team. The hospital staff will have
project members available for any questions, concerns, or clarification of the change
being implemented. Encouraging hospital team members to the validity of this practice
will help with the project become a standard for care for all providers. Project members
will send out emails and policy updates to make sure the evidence based practice stays in
line with the most current research.
The project findings can then be presented at forums such as National Teaching
institute and Critical Care Exposition (NTI), Sigma Theta Tau, and other nursing
evidence based practice conferences to ensure wide availability to the region and rest of
the country. The project can be sent to journals to be published to help promote the
adoption of this practice nationwide and make one standard of care.

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References
Broderick, B., O'Connell, S., Moloney, S., O'Halloran, K., Sheehan, J., Quondamatteo,
F., ... Laighin, G. (2014). Comparative lower limb hemodynamics using
neuromuscular electrical stimulation (NMES) versus intermittent pneumatic
compression (IPC). Physiological Measurement, 35, 1849-1859. doi:
10.1088/0967-3334/35/9/1849
Centers for Disease Control and Prevention. (2015, March 20) Deep vein thrombosis
(DVT) / pulmonary embolism (PE) blood clot forming in a vein. Retrieved
March 20, 2015, from http://www.cdc.gov/ncbddd/dvt/data.html
Dennis, M., Sandercock, P., Reid, J., Graham, C., Forbes, J., & Murray, G. (2013).
Effectiveness of intermittent pneumatic compression in reduction of risk of deep
vein thrombosis in patients who have had a stroke (CLOTS 3): A multicentre
randomised controlled trial. The Lancet, 382 (9891), 516-524. doi:
http://dx.doi.org/10.1016/S0140-6736(13)61050-8
Horiuchi, T., Giovino, A., Reynolds, K., Cropper, S. (2014, April). DVT/VTE nursing
protocol prevention. Unpublished internal document, Sarasota Memorial Hospital.
Sobieraj-Teague, M., Hirsh, J., Yip, G., Gastaldo, F., Stokes, T., Sloane, D., ...
Eikelboom, J. (2012). Randomized controlled trial of a new portable calf
compression device (Venowave) for prevention of venous thrombosis in high-risk
neurosurgical patients. Journal of Thrombosis and Haemostasis, 10, 229-235. doi:
10.1111/j.1538-7836.2011.04598.x

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Table 1
Literature Table
Reference

Aims

Design and Sample

Measures
Broderick, B., O'Connell, S.,
Compares
Randomized 31 healthy
Moloney, S., O'Halloran, K.,
venous blood controlled
volunteers;
Sheehan, J., Quondamatteo, F., flow between trial
each person
... Laighin, G. (2014).
using
was tested
Comparative lower limb
neuromuscular Measures:
with NMES
hemodynamics using
electrical
Venous blood and IPC at
neuromuscular electrical
stimulation
flow velocity different
stimulation (NMES) versus
and
and volume time
intermittent pneumatic
intermittent through
intervals
compression
pneumatic
popliteal vein
(IPC). Physiological
compression upon device
Measurement, 35, 1849-1859. devices.
contraction.
doi: 10.1088/09673334/35/9/1849
Dennis, M., Sandercock, P.,
Compares
Reid, J., Graham, C., Forbes, J., stroke patient
& Murray, G. (2013).
outcomes
Effectiveness of intermittent
when using
pneumatic compression in
IPC versus no
reduction of risk of deep vein IPC.
thrombosis in patients who have
had a stroke (CLOTS 3): A
multicentre randomised
controlled trial. The Lancet,382
(9891), 516-524. doi:
http://dx.doi.org/10.1016/S01406736(13)61050-8

Outcomes /
statistics
NMES and
IPC both had
a significant
and similar
increase in
venous blood
flow velocity
and volume.

Randomized 2876 stroke Intermittent

controlled
patients; 955 compression
trial
complete the devices are an
full trail
effective
Measures:
with IPC; prophylaxis
Stroke
935
for deep vein
patients
completed thrombosis.
either wore the full trial
the an IPC without IPC.
device or
nothing.

Sobieraj-Teague, M., Hirsh, J., Compares

Randomized 150 patients Venowave is
Yip, G., Gastaldo, F., Stokes, T., neurosurgical controlled
started study an effective
Sloane, D., ... Eikelboom, J.
patients
trial that took but only 59 prophylaxis
(2012). Randomized controlled outcomes
place over a control
for DVTs in
trial of a new portable calf
using the
year and a
group and neurosurgical
compression device (Venowave) Venowave
half.
54 trial
patients.
for prevention of venous
compression
group
thrombosis in high-risk
device versus a Measures:
patients
neurosurgical patients. Journal control group Study
completed
of Thrombosis and
of no device. continued
the study.
Haemostasis, 10, 229-235. doi:
until 7 days

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10.1111/j.15387836.2011.04598.x

13
post-op or
symptoms of
VTE.