Which of the following are the correct places to measure a client for knee high anti embolism stockings?

Int Wound J. 2011 Feb; 8(1): 74–83.

Abstract

The objective of this study was to determine if anti‐embolism stockings are fitted and worn according to evidence‐based guidelines in surgical patients. The methodology is that an observational study was undertaken during January and February, 2010. An audit tool was constructed for the recording of information on a variety of parameters relating to the correct fitting and wearing of anti‐embolism stockings. The results show that eighty surgical patients were audited with a mean age of 66 years. Of these, 72·5% were ambulatory; 38·75% of patients had incorrect presentation of their stockings; 29% were fitted with the incorrect size for limb measurement and 70% of patients reported not receiving any information regarding the reason for anti‐embolism stocking use. Written information was not received by 100% of participants. For 82·5% of participants deep vein thrombosis (DVT) risk was not recorded. The garment size fitted (and/or limb measurement) was not recorded for 100% of patients. Daily routine skin inspection was noted for 29%. The findings of this study showed that anti‐embolism stockings were not fitted and worn according to evidence‐based guidelines. The author recommends a new recording tool be developed to ensure consistency of assessment and documentation regarding risk assessment, contraindications identification, and education and monitoring of patients wearing anti‐embolism stockings.

Keywords: Anti‐embolism stockings, Deep vein thrombosis, Surgical patient, Thromboembolism deterrent, Venous thromboembolism

INTRODUCTION

Deep vein thrombosis (DVT), defined as the formation of a blood clot in a deep vein (1) is a largely preventable complication of surgical procedures (2). Risk factors for post‐surgical DVT include the nature and duration of the surgery, sepsis, hydration, immobility and general anaesthesia (3). Orthopaedic surgery is reported to carry a higher risk of DVT 4, 5, 6, 7. The risk increases with age, obesity, malignancy and prior history of venous thrombosis, thrombophilic conditions or other venous disease (3). DVT can lead to post‐thrombotic venous disease and possibly pulmonary embolism, which may be fatal 3, 8, 9.

DVT formation is thought to be because of a change in the structure of the blood vessel as a result of direct trauma, a change in the coagulation mechanisms and/or stasis of the venous circulation resulting from immobility. These factors are known as Virchow's triad 10, 11. DVT is most common in the lower extremity (12) accounting for 89–96% of all cases. In the surgical patient who is non ambulant, anti‐embolism stockings are often used as mechanical prophylaxis of DVT in the lower limb either alone or in combination with other external compression devices or medications. Anti‐embolism stockings are reported to function by reducing the overall cross‐sectional area of the limb, increasing the velocity of venous flow, reducing venous wall distension and improving valvular function (10) thereby counteracting venous hypertension. Anti‐embolism stockings have been shown to reduce the relative risk of DVT in surgical patients by 60–80% 3, 10; however, they were not evaluated as an isolated venous thromboembolism (VTE) prophylactic measure so the results should be interpreted with caution. In addition, stockings must be correctly sized and fitted in order to achieve prophylactic benefit (13).

Anti‐embolism stockings are manufactured in a limited range of sizes, and fitting is by measurement of limb circumference at the ankle and/or calf (and thigh for thigh‐length stockings), according to manufacturer's instructions. The product material consists of 82% polyamide, 18% elastane and is latex‐free with an elasticated open‐toe design to allow inspection of the toes. The standard pressure gradient applied by the garment is 18 mmHg at the ankle, reducing to 8 mmHg just distal to the knee 14, 15, 16. This is the level of pressure unlikely to compromise tissue oxygenation, however this pressure profile may not represent the ideal profile for all clinical situations of DVT prevention (10). Cutaneous pressure reduces local blood flow (17) and the amount of reduction is proportional to the pressure being exerted. It has been suggested that a girth increase of 5 cm can double the cutaneous pressure exerted by the stocking (17) and possibly cause vascular compromise. An historical study (1980) by Lawrence and Kakkar (18) showed that pressures approaching 30 mmHg can produce tissue ischaemia in a person with arterial insufficiency, the pressure required to produce vascular occlusion is less than 20 mmHg (2).

There is no evidence to show whether knee‐length or thigh‐length stockings are superior in preventing DVT (19). In fact, thigh‐length stockings may be ineffective in reducing the venous pooling in that area as well as compromising the efficiency of compression at a lower level 20, 21. This may occur when patients are in a seated position which interferes with the pressure gradient and raises the popliteal‐stocking interface pressure (22). Thigh‐length stockings are also more likely to roll down (23). Rolled, bunched or folded stockings may subject the limb to localised constriction. The constriction, or torniquet effect, is reported to reverse the pressure gradient of the stocking which is integral to their function, causing the blood to stagnate distally (24). Toes may also be subjected to localised high pressure. This may result in overt skin damage. Complications because of anti‐embolism stockings (including pressure ulcers) are more likely to occur in medically compromised patients 2, 25 and there is an increased chance of slipping or falls (26).

Anti‐embolism stockings are contraindicated in patients with any of the following conditions: congestive cardiac failure/ pulmonary oedema, peripheral arterial disease (Ankle Brachial Index <0·8), peripheral neuropathy, ulceration, cellulitis, inflammatory skin disease, deformity, gross oedema affecting the lower limb or morbid obesity where correct fitting of the stocking cannot be achieved 2, 15, 27, 28. Ischaemic complications relating to anti‐embolism stocking use have been reported in the literature 2, 17, 29; however, there are no recently published high‐quality studies on this topic. A Cochrane review of graduated elastic compression stockings for the prevention of DVT (30) affirmed the value of the garments but reports that none of the reviewed studies addressed the complications associated with stocking use.

Guidelines for the prescription and use of stockings must be strictly followed. Leg measurements and skin integrity must be reviewed regularly in patients wearing these garments 2, 31, 32. However, there is no evidence to suggest how frequently monitoring should occur. In addition, no literature relating to valid parameters of which limb sites to assess were identified.

Austin Health spends approximately $88 000AUD per year on anti‐embolism stockings and they are placed on 90% of all surgical patients (L. Bujas, personal communication, 2009). Both knee‐length and thigh‐length stockings are used according to the type of surgery and Surgeon's preference. Coincidentally, during the course of this study, the brand used by the hospital changed from Mediven® thrombexin® 18 to Covidien T.E.D.™ which provides a greater range of sizes and an education booklet for patients, which is to be distributed to patients at the time of stocking issue, or during the post‐operative period.

Austin Health guidelines (last revised in 2007) apply risk stratification for DVT according to Best Practice Guidelines for Australia and New Zealand (5) with recommended prophylaxis according to identified risk factors. The associated clinical nursing standard details the anti‐embolism stocking application procedure and care, covering such points as identifying patients at risk of DVT; using a tape measure to ensure the appropriate size is fitted, selection of knee‐length or thigh‐length stockings according to medical orders; and ensuring that there are no bands of tightness. There is no mention of any patient education regarding anti‐embolism stocking use.

A quick review of patient records indicated a lack of documentation relating to the prescription, fitting and monitoring of anti‐embolism stockings; and an apparent lack of evidence as to what information, if any, is provided to patients regarding their use. A patient information sheet exists that was prepared by the Drug Utilisation Subcommittee in October 1999. The information herein relates specifically to DVT diagnosis, treatment and prevention but does not mention anything about anti‐embolism stockings.

Austin Health was selected to join over 40 hospitals from across Australia in a venous thromboembolism prevention programme aimed at helping hospitals improve assessment and management of patients at risk of developing venous thromboembolism. The programme was sponsored by the National Institute of Clinical Studies.

The programme, which was undertaken from November 2005 to November 2007, aimed to improve the assessment of all patients at risk, improve the use of preventative measures and integrate effective thromboprophylaxis systems into the core business of Australian hospitals (33).

As a result of this VTE prevention programme, Austin Health formulated VTE guidelines, a VTE risk assessment tool was applied, and a VTE prescribing box was inserted on the Austin Health medication chart.

At the time of completing this audit, the author was unaware that this programme had been completed.

It is anticipated that this study may stimulate such protocols to be further revised improved, and implemented into clinical practice.

METHODS

An audit of 80 adult surgical patients was conducted during January and February, 2010, on two surgical wards of Austin Health, a major teaching hospital in metropolitan Melbourne, Australia, for correct fit and wear of anti‐embolism stockings. The audit was conducted solely and independently by the author.

Ethics approval was received from the hospital's Human Research Ethics Committee and Monash University Human Research Ethics committee. Informed consent was obtained from each participant. Patients were eligible for inclusion if they were wearing anti‐embolism stockings, had undergone surgery and were present on the ward during the study period. Patients were audited once.

Exclusion criteria were: under 18 years of age (not recommended for anti‐embolism stocking use), unavailable at the time of the audit, medically unfit to participate (defined by a state of severe cognitive impairment or severe physical illness) and pregnant women (unlikely to be undergoing surgery).

Risk level for developing DVT for each patient was identified according to National Health and Medical Research Council guidelines, as high, moderate or low (26). Patients were evaluated for obvious contraindications to wearing anti‐embolism stockings, according to those stated in the literature. Any patients identified as such, and found wearing the stockings, immediately had their stockings removed, and this was communicated to ward staff. In the event of skin damage being identified, ward staff were notified and the stockings were removed or adjusted as appropriate.

As there was no suitable validated instrument identified in the literature, an audit tool was constructed based on relevant published recommendations (Appendix) for the recording of information on a variety of parameters, based on guidelines, for the correct fitting and wearing of anti‐embolism stockings; as well as information received about stocking use, and documentation in medical records relating to DVT risk assessment and stocking prescription and monitoring.

The anti‐embolism stockings were assessed for correct fit with particular attention to visible bunching, rolling, folding or repression of toes. The stockings were removed for limb measurement and skin inspection. The stockings were then replaced if sized appropriately. If the sizing was incorrect (too loose or too tight) this was recorded and reported to staff. The limbs were measured (cm) as per manufacturer's instructions and the condition of the stockings was documented. Visible skin damage was noted, including constricting bands around the toes, feet or legs demonstrated by linear indentation of the skin likely to be caused by the stockings, presentation of pressure areas, according to the European Pressure Ulcer Advisory Panel grading guidelines (34), likely to be caused by the stockings, noting the stage and location. Digital photographs were taken of any identified problems.

Patients were asked what information they had been provided about wearing anti‐embolism stockings and if they had a need to adjust the fit of the stockings or remove them for any reason other than showering. The incidence of DVT did not form part of the protocol for this study.

Medical records were examined for evidence of documentation relating to the provision, type issued and monitoring of anti‐embolism stocking use and any associated potential or actual problems. Medical records were also examined for evidence of documentation of any information provided to patients relating to the provision and monitoring of anti‐embolism stocking use and any associated potential or actual problems.

RESULTS

Demographics

Eighty patients were recruited to this study, of which 64% were female. The age range was 18–93 years with a mean age of 66 years.

DVT risk

Risk levels for developing DVT for this population were high (75%), moderate (21%) and low risk (4%). Eighty‐seven percent of patients did not have pre‐existing lower limb venous disease, and 91·25% had no prior episodes of DVT. Chemical thromboprophylaxis was used for 86% of participants. Ten percent of participants had identified contraindications to the use of anti‐embolism stockings.

Patient characteristics

Forty percent of patients were less than 3 days post‐surgery. Fifty percent of patients were resting in bed at the time of audit. Thirty‐seven percent of patients were sitting out of bed with their legs dependent. The level of mobility of 72·5% of patients was ambulatory.

Type and presentation of stockings

Only one patient had thigh‐length stockings, all other patients wore knee‐length stockings. Thirty‐nine percent of patients had incorrect presentation of their stockings, such as unacceptable positioning (​1a, ​1b), with the most common problems being partial exposure of toes and the upper band of the garment at mid calf level or below.

Incorrect presentation of anti‐embolism stocking.

Incorrect presentation of anti‐embolism stocking.

Thirty‐six percent of patients were fitted with the incorrect stocking size for limb measurement. In all these cases, stockings were fitted either one or two sizes larger than the required size for the limb measurement. Most garments were clean and dry, likely because of the short amount of time in use, however, the patients with soiled stockings (18%) were unaware of washing protocol or if replacements were available or necessary.

Adverse events

The most common problem identified was constriction of the skin below the knee (a ‘garter’ effect) in 25% of participants because of folding or bunching of the upper band (Figure 2). This was rectified with correct positioning of the garment in most cases. A stage 1 pressure ulcer was identified on the great toe in two cases (Figure 3). Eighty‐one percent of patients did not have to adjust or remove their stockings for any reason other than showering.

Constriction of skin at the upper band of the stocking.

Stage 1 pressure damage apex of left hallux.

Patient information

Seventy percent of patients reported not receiving any information regarding the reason for anti‐embolism stocking use. The majority of patients were also unaware of the duration of wear and possible problems with stocking use. Written information was not received by 100% of participants.

Documentation

Documentation data are shown in Figure 4.

Documentation in patient records.

Figure 5 shows the provision of space within Drug Chart to allow recording of VTE risk and type of stockings issued.

Provision of space within Drug Chart for recording of VTE risk and type of stockings issued.

DISCUSSION

The subject group chosen for this study was a convenience sample of patients on two surgical wards of a metropolitan Melbourne teaching hospital. Eighty‐five percent of patients wore these stockings for up to 1‐week post‐surgery, which is a relatively short period of time for complications from wearing the stockings to develop, so it is not surprising that a low number of skin markings were identified. At this early stage, if contraindications were discovered, the stockings could be removed before major pressure problems developed.

It has been stated that medical patients who have comorbidities and longer admissions are more likely to develop skin problems with wearing anti‐embolism stockings 2, 25. However; in the two cases where stage one pressure ulcerations were identified, the presence of diagnosed comorbidities was not examined by the author.

A number of factors conspired to reduce the efficacy of the anti‐embolism stockings in this study population:

Patients' position

One‐third of patients were sitting out of bed with their legs dependent which is reported to interfere with the pressure gradient and raise the popliteal‐stocking interface pressure 10, 22. Patients should therefore be advised to raise their legs if sitting out of bed.

The ambulant status of patients is known to reduce the risk of DVT (16) bringing in to question the therapeutic indication for these garments in patients who are ambulant. It is understood, however, that increased mobility addresses only one aspect of Virchow's triad 10, 11. If patients are assessed to be ‘low risk’ for DVT and ambulant, the need for therapeutic stockings should be reconsidered, but there are no high‐quality studies to support this proposition.

Stocking fit

In two‐thirds of patients the incorrect size of stocking was fitted, with most of these being one or two sizes larger, which also negates their functionality. There was no evidence that the limbs of these patients had been measured. In order to be effective, the manufacturer recommends measuring limbs, with instructions provided, and the correct size then fitted. This information should then be documented in the patient's care plan. Efforts need to be made to improve this practice.

Patient education

Patients were largely uninformed about reasons for anti‐embolism stocking wear, potential length of wear and possible problems with wear. Patients may have been told prior to surgery and not remembered. More is required to ensure that information relating to all health care procedures is documented, as per recommendations (35).

No written information was received by any patient. This is poor practice in relation to an important healthcare intervention. Now that the hospital has changed brands of anti‐embolism stockings, the accompanying education material can be issued to every patient, improving awareness and knowledge and outcomes.

Documentation

Documentation was extremely poor in terms of DVT risk assessment, reason for wear, length of wear and potential or actual problems with wear. This area requires improvement.

No general surgical patients had documentation that daily routine skin inspection was undertaken.

Although guidelines exist for the prescription, supply and wear of anti‐embolism stockings, it is apparent that these guidelines are currently not being followed in this clinical setting , despite the previous funded broad‐based VTE prevention programme.

RECOMMENDATIONS

On the basis of these findings, it is suggested that a form be specifically designed and approved for the recording of information relating to the prescription of anti‐embolism stockings and placed in the patient's medical record in a prominent position. Such information should include, but not be limited to

• 1

  DVT risk

• 2

  Limb measurement

• 3

  Size fitted

• 4

  Noted contraindications or problems identified

• 5

  Education material issued and discussed

• 6

  Additional thromboprophylactic measures and

• 7

  Care planning post‐discharge.

The development of this form will require input from the staff that will use the form, to ensure that the form is easy to use, and contains the most important information without overburdening their already busy workload. In addition, an education programme for all staff, updated regularly, will be necessary to ensure that all relevant staff are made aware of the need for this form and understand how and when to use it. This would make it more likely that documentation would be more consistent and that adequate attention would be paid to practice issues around this therapeutic modality.

LIMITATIONS

The limitations to this study include:

• 1

  Small, isolated sample from which it is unlikely the results can be extrapolated as the sample may not be truly representative of a wider population.

• 2

  This study may not capture a true picture of stocking use. These patients were not followed over time so no temporal relationship between stocking use problems with wear can be established from this study.

• 3

  There is no standardised procedure for limb measurement. This is partly overcome by having the same person do all the measuring.

RECOMMENDATIONS FOR FURTHER RESEARCH

It is suggested that further research focus on:

• 1

  Assessing the effectiveness of the education material provided with the Covidien brand of stockings now supplied by Austin Health.

• 2

  Auditing patients regarding the issue of education material and learning outcomes.

• 3

  Evaluating the knowledge and practice of nursing and medical staff in the area of prescribing and fitting anti‐embolism stockings and monitoring patients.

• 4

  Evaluating the value and safety of anti‐embolism stockings in other patient groups such as general medical and rehabilitation, where the stockings are often worn for longer periods and comorbidities exist.

• 5

  Whether anti‐embolism stockings have any therapeutic value for low and moderate risk surgical patients who may be on anticoagulant medication.

CONCLUSION

The use of anti‐embolism stockings for the prevention of DVT in surgical patients has not been as intensively studied as pharmacotherapeutic agents and there are many unanswered questions. However, they continue to be widely prescribed and applied with limited attention to possible contraindications or complications, poor provision of education and information, poor monitoring and poor documentation regarding their use. Guidelines for the prescription and use of anti‐embolism stockings must be strictly followed for this health care intervention to be effective, and patients and staff to be confident and educated regarding evidence‐based practice for VTE prophylaxis.

This study has highlighted deficiencies in clinical practice at one Melbourne hospital regarding the issue and monitoring of anti‐embolism stockings worn by surgical patients. Overall, they were not fitted and worn according to evidence‐based guidelines. Education of patients and documentation was lacking. On the basis of the findings of this study, the author recommends a new recording tool be developed to ensure consistency of assessment and documentation regarding risk assessment, contraindications identification, and education and monitoring of patients wearing anti‐embolism stockings.

ACKNOWLEDGEMENT

This project was completed as part of the requirements of the Master of Wound Care course, Monash University.

Table 1

Audit Tool: Anti‐embolism stockings

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