Home Study Program - AORN Journal

Home Study Program

JUNE 2006, VOL 83, NO 6

Home Study Program Implementing a research utilization plan for prevention of deep vein thrombosis

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he article “Implementing a research utilization plan for prevention of deep vein thrombosis” is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, education program professional, Center for Perioperative Education. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is June 30, 2009. Complete the examination answer sheet and learner evaluation found on pages 1367-1368 and mail with appropriate fee to

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

AORN Customer Service

A minimum score of 70% on the multiplechoice examination is necessary to earn 2.5 contact hours for this independent study. One contact hour is equal to 50 minutes.

c/o Home Study Program 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711 or fax the information with a credit card number to (303) 750-3212. You also may access this Home Study via AORN Online at http://www.aorn.org/journal/homestudy/default.htm.

BEHAVIORAL OBJECTIVES After reading and studying the article on implementing a research utilization plan for prevention of deep vein thrombosis (DVT), nurses will be able to

1. explain why DVT prevention is important for surgical patients, 2. describe the DVT prevention options that were identified in the literature review,

3. discuss the components of the evidence-based practice change, and 4. identify barriers to compliance with the evidence-based practice change.

Purpose/Goal: To educate perioperative nurses about using evidencebased research to implement a practice change for deep vein thrombosis prevention.

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Wicklin — Ward — Cantrell

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Home Study Program Implementing a research utilization plan for prevention of deep vein thrombosis Sharon A. Van Wicklin, RN; Karen S. Ward, RN; Shirley W. Cantrell, RN

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ll nurses want to know that they are providing their patients with the best possible care, but the information in hospital policy and procedure manuals frequently lags behind the latest research. As developments in care are presented at conferences or published in journals, nurses can identify research results that offer promising treatment options for their patients. In the current hospital environment of staff member shortages and higher patient acuity, however, it can be difficult for nurses to keep up with their patient load, much less survey the research literature for recent developments in their particular specialty areas.1,2 Nonetheless, when research is used and changes are made that improve patient care outcomes, not only do patients benefit, but staff members are energized by the sense of accomplishment that comes from a job well done. In the interest of providing the best quality care, nurses must have a plan for implementing research findings in their work settings.

THE PROJECT The perioperative education coordinator at Williamson Medical Center, Franklin, Tenn, identified the occurrence of deep vein thrombosis (DVT) in surgical and medical patients as a problem at the facility. Services offered at the 185-bed hospital include comprehensive inpatient and outpatient services, 24hour emergency care, and preventive health screenings and wellness activities. No standardized method existed for nurses to assess patients’ need for

thromboembolic prevention modalities or to implement such interventions. Unless DVT prophylaxis was ordered by a physician, none was applied. Recent research on prevention and treatment of DVT indicates that often, this problem could be prevented with a thorough assessment and routine measures that nurses can carry out independently.3-5 Routinely screening for DVT and prophylactically treating DVT can significantly reduce the incidence of this potentially lethal problem.4-7 Using such research to create evidence-based practice can lead to improved patient outcomes.6 The perioperative education coordinator undertook a quality improvement project to • provide suggestions as to which nursing modalities represent the most effective and economical

ABSTRACT •

ENSURING USE OF BEST PRACTICES is crucially important in today’s health care system. Nurses can identify research results that offer promising new treatment options for their patients and should have a plan for implementing research findings.

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THE PERIOPERATIVE EDUCATION coordinator at one facility identified the occurrence of deep vein thrombosis as a significant problem. She conducted a literature review, created an education program for nurses, and implemented an evidence-based practice change.

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THIS ARTICLE DESCRIBES the steps in this process. Now, patients at the facility consistently are assessed for deep vein thrombosis and receive appropriate preventive treatment. AORN J 83 (June 2006) 1353-1362.

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DEFINITION OF TERMS

Applying Research in the Health Care Setting

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any related terms that reflect the present interest in integrating research findings into daily patient care are used almost interchangeably. Nurses hear terms such as research utilization, evidencebased practice, and best practices and may wonder what they really mean and how they differ. Although there are distinctions between these and other similar terms, all imply an investment in quality patient care.1 Research utilization commonly means “use of an individual research finding that improves care in a specific instance.”2(p35) Evidence-based practice is a more encompassing term. It suggests the use of a collection of study findings to help health care practitioners devise the best care possible for their patients.3-5 Knowledge from a variety of sources is considered and then implemented at the clinical level.6 The term best practices is more general in that it is the end result of a thorough investigation of, not only research or evidence-based studies, but current routines and experts’ opinions as to what will provide the very best in patient care. In short, “best practices has emerged as a descriptor of the clinical practices that result in the best outcomes as well as the processes used to select those clinical practices.”4(p48)

care team members, the physicians requested that a team of nurses from many specialties revise and implement a method for hospital-wide DVT prophylaxis, which included evidence-based practice changes.

LITERATURE REVIEW

Deep vein thrombosis and PE are major causes of morbidity and mortality associated with many common medical conditions and surgical procedures. Approximately 1. A DiCenso et al, “Evidence-based nursing: Rationale and resources,” 600,000 hospital admisWorldviews on Evidence-Based Nursing 2 (January-March 2004) 69-75. sions are related to DVT, 2. D F Polit, C T Beck, Nursing Research: Principles and Methods, seventh ed and of these patients, (Philadelphia: Lippincott, Williams and Wilkins, 2003). 50,000 to 200,000 will 3. D S Pravikoff, A B Tanner, S T Pierce, “Readiness of US nurses for evidencedevelop a PE. Pulmonary based practice,” American Journal of Nursing 105 (September 2005) 40-52. embolism is the third 4. S Prevost, “Defining evidence-based best practices,” Furthering the most common cause of Profession (Unit 1) 47-65. death in the United States 5. L Parsons, “Spinal cord injury nursing and evidenced-based practice,” SCI Nursing 21 (Winter 2004) 192-193. and the highest incidence 6. S Brown, “Evidenced-based practice: A short tour,” National Association of of PE occurs in patients Orthopaedic Nurses, http://www.orthonurse.org/images/pdf/ebptour.pdf who already are hospital(accessed 10 April 2006). ized for other health problems.8 A study conducted in 2000 determethods of protecting perioperative patients from DVT and pulmonary mined that 48% of hospitalized patients who developed DVT or PE had not embolus (PE), • compare those suggestions with received prophylaxis.9 Autopsy results methods already in place in the peri- demonstrated that as many as 60% of patients who died in the hospital have operative department, and • develop and implement a uniform had a PE, but the diagnosis was missed hospital-wide protocol for surgical in about 70% of cases. The cost of DVT and medical patients related to the and PE also is of great concern, considering that more than $2.9 billion are prevention of DVT and PE. The perioperative education coordi- spent annually in treatment costs.10 PATHOPHYSIOLOGY OF DVT. Virchow’s Triad nator first conducted a literature review to identify current and new concepts helps identify patients who are at the related to DVT prevention and treat- greatest risk of experiencing DVT.7 ment. She then developed an education Patients undergoing surgical proceprogram for staff members that incorpo- dures are at a high risk of incurring DVT rated these concepts. After the educa- because they are very likely to suffer tion program was presented to all health from all three components of the triad—

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Figure 1 • All three components of Virchow’s triad (eg, venous stasis, vessel wall damage, coagulation changes) increase the risk of thrombosis.

venous stasis, vessel wall damage, and coagulation changes. (Figure 1) Venous stasis usually is related to one of three causes: • decreased velocity of blood flow through the vessels, • venous dilation and7,11pooling, or • venous obstruction. Decreased velocity most commonly is caused by immobility. Immobility also causes venous pooling, which in turn results in venous dilation and congestion. Venous pooling also may occur in conditions such as heart failure or when peripheral vascular valves are incompetent or under pressure (eg, during pregnancy). Venous obstruction slows the flow of blood and may result from peripheral vascular disease, trauma or crush injuries, or tumors.11 When a vessel wall is injured, the endothelial lining, which under normal conditions is a smooth, negatively charged layer of surface proteins, loses its negative charge and becomes rough, causing platelet aggregation and adhesion, as well as triggering the production of clotting factors. Damage, in the form of microtears in the vessel wall, can occur from distension and venous stasis as well as from the direct insult of trauma, surgery, sepsis, or burns.3 Blood coagulability can be increased by various factors, such as • the aging process or • any disease or disorder that • increases clotting factors, • decreases inhibitor levels, or • decreases the fibrinolytic system components. The blood coagulation process is activated by many factors, such as surgery, trauma, burns, and myocardial infarction, as well as by the infusion of plasma clotting factors. All postoperative patients experience some change in fibrinolytic activity, which varies with the extent of the surgery. Estrogen therapy, indwelling vascu-

lar catheters, inflammatory bowel disease, lupus erythematosus, nephrotic syndrome, primary proliferative polycythemia, and thrombocytosis also interfere with clotting and lysis of clots.3,11 Malignancies associated with hypercoagulability and DVT formation include adenocarcinoma, advanced gastrointestinal cancers, brain tumors, breast cancer, and pancreatic cancer. Deficits in the coagulation modulators (ie, antithrombin III, protein S, protein C) also predispose the patient to thrombus formation. Conditions that affect the competency of the vessel valves such as varicosities, pregnancy, and obesity also can affect the coagulation process. PREVENTION AND TREATMENT OPTIONS. Prevention and treatment options consist of mechanical or physical prophylaxis to reduce venous stasis and restore function of the natural calf-muscle pump. These methods may be used alone or in conjunction with pharmacological methods but all methods require rigid adherence to protocol. Nurses can positively affect outcomes in mechanical or physical DVT prophylaxis simply by educating patients regarding the importance of physical therapy and early movement (eg, ambulation, leg elevation, foot flexing, active and passive range of motion exercises).12 These activities help break the cycle of immobility and increase circulation. AORN JOURNAL •

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Deep breathing exercises promote pulmonary circulation. Routine nursing interventions, such as encouraging patients to avoid dehydration by drinking adequate quantities of fluids, also are important in preventing increased blood viscosity, which hastens blood clot formation.13 These techniques alone, although effective, are not sufficient to prevent venous thrombosis, however, so more aggressive methods are required to increase venous blood flow sufficiently to prevent the occurrence of DVT. Early clinical research into DVT resulted in the development of compression stockings with features designed specifically to ensure correct blood flow.3 Gradient pressure Compression increases venous velocity and clearance. Many restockings are searchers agree that comeffective only if pression stockings can reduce a postoperative patients wear patient’s risk of DVT.5,6 Compression stockings the stockings reduce venous stasis, providing a safe, simple, continuously— and relatively inexpensive method of prophyfrom before laxis for low-risk patients. The static compression surgery through provided by the stockings also plays an important the recuperation role in reducing vessel wall damage. In spite of period. this evidence, there is a persistent problem with implementing the use of preventive treatment.9 To maintain the effectiveness of compression stockings, nurses should • educate patients to ensure compliance with treatment, • select correctly fitting compression stockings for patients, and • ensure that patients wear the compression stockings continuously. To achieve maximum benefit, com-



pression stockings must fit properly. It is essential that each patient be measured correctly according to the manufacturer’s instructions and be provided with the proper size compression stockings. Compression stockings are uncomfortable if they are too large or too small, and compression stockings that do not fit correctly will not produce the desired effect. In fact, compression stockings that are too tight, bunch up, or roll down create a tourniquet effect behind the knee that impedes venous return and leads to venous pooling and clot formation. Furthermore, peroneal nerve palsy can occur with increased pressure on the peroneal nerve. Patient comfort is more likely to improve compliance during the immediate postoperative period as well as during the recuperation period, which occurs after the patient leaves the health care facility.14 The effectiveness of knee-high compression stockings is similar to that of thigh-high stockings, but knee-high stockings fit better, wrinkle less, and are more comfortable for the patient.15 Manufacturer recommendations state that any patient with a thigh circumference greater than 32 inches should be fitted with knee-high rather than thigh-high stockings.15 Nurses should use whichever stocking style provides the best fit and the most comfort for the patient. Many facilities consider cost as a determining factor when choosing knee-high versus thighhigh compression stockings. Compression stockings are effective only if patients wear the stockings continuously. Compression stockings should be placed on medical patients at the time of bed confinement or on surgical patients before surgery, and they should be worn throughout the recuperation period. Medical and surgical patients today are more acutely ill but are discharged sooner than patients were in the past. Although the length of hospital stay has changed, the etiology of thromboembolic


disease has not. The risk for DVT for postoperative patients continues for four to six weeks after discharge from the health care facility.9 Another mechanical treatment is intermittent pneumatic compression (IPC), which unlike stockings provides dynamic compression. Intermittent pneumatic compression involves wrapping knee-high or thigh-high cuffs around a patient’s legs. The cuffs are connected to a pneumatic pump that inflates and deflates sequentially, mimicking the normal pumping action of the heart. Intermittent pneumatic compression devices prevent thrombosis by • providing a “milking” action that replaces the normal function of the calf-muscle pump, thus preventing venous pooling and • increasing fibrinolytic activity, which may involve the release of plasminogen activators by endothelial cells. This increase is important because fibrinolytic shut-down occurs during surgery and can persist for 24 to 48 hours postoperatively.9 Using an IPC device preoperatively, intraoperatively, and postoperatively helps counter this shut-down effect. Intermittent pneumatic compression has been studied widely and shown to be effective with no side effects or complications in patients at moderate and high risk of DVT.3,5,7 Impulse technology, a form of IPC better known as the “foot pump,” is based on the discovery of a plexus of veins along the plantar arch (Figure 2), which forms a powerful physiological venous pump in the foot. During weight bearing, the foot flattens the plantar arch and stretches and collapses the plantar veins, moving blood up the deep calf veins to the heart, which enhances overall circulation of the limb. The discovery of this physiological pump led to the development of the foot pump, a mechanical device that mimics normal ambulation and the action of the plantar

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venous plexus. The technology works to prevent DVT by increasing blood velocity, which reduces venous stasis and inhibits platelet aggregation. Plantar IPC has been investigated and used extensively with all types of surgical patients.16,17 Results indicate that this impulse technology is as effective and might even be more effective than other, more extensive (ie, bulkier thigh-high or knee-high) IPC devices.16,17 Early and continuous use is an important component in the proper use of all IPC devices. To be effective, the device must be used continuously except when the patient is ambulating, undergoing physical therapy, or receiving routine skin assessment. Like compression stockings, IPC should be initiated at the time of bed confinement for medical patients and before induction of anesthesia for surgical patients, and it should be continued throughout the immediate postoperative period or until the patient is fully ambulatory. Pharmacological intervention has proven to be useful in preventing and treating DVT. A prophylactic anticoagulant regimen works rapidly to inhibit the blood from clotting when the regimen is started before or immediately after surgery or on the first day of hospitalization for a medical illness. Standard prophylaxis consists of minidoses of unfractionated

Figure 2 • The plexus of veins along the plantar arch forms a powerful physiological venous pump in the foot. Pressure on this plexus flattens the plantar arch and stretches and collapses the plantar veins, moving blood up the deep calf veins to the heart.

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or low-dose, molecular-weight heparin until the patient is ambulatory or discharged from the health care facility. Prophylaxis may begin at the time of bed confinement for medical patients or up to two hours before skin incision for surgical patients. Numerous clinical trials have verified the efficacy of this treatment.6,7,10 Although low-dose anticoagulant therapy often is used for prophylaxis, full anticoagulant therapy is necessary to treat existing DVT.7,11 Intermittent pneumatic compression provides effective prophylaxis against two risk factors of Virchow’s triad (ie, venous stasis, coagulation changes). Used with compression stockings, which provide prophylaxis against venous stasis and vessel wall damage, all three factors of the triad are addressed. Adding pharmacological prophylaxis provides even greater insurance against DVT development.

AN EVIDENCED-BASED PRACTICE CHANGE Making an evidence-based practice change requires patience and persistence on the part of the nurse who identifies the need to implement the change. To be successful, a three-pronged approach is useful—education, implementation, and policy change. Education of staff members, including nursing personnel, physicians, and all others on the health care team, is the first goal. When all staff members have been educated regarding the evidence-based practice change, staff members begin the implementation phase. Finally, policies and procedures must be developed to ensure long-term use of the new practice. If policy and procedure changes do not occur after education and implementation, then the practice is dependent on the particular staff members involved and will not endure when those individuals are gone. EDUCATION. Although, the perioperative nurse educator did not make assumptions regarding existing levels of staff

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member knowledge, most staff members had some knowledge of DVT. The nurse identified what information on the subject was new, compelling, and backed by research and made the latest findings available to staff members in both formal and informal methods. She developed educational presentations to highlight existing and new information on DVT, ensuring that it was inclusive without causing anyone to feel he or she was being “talked down to.” She created Although electronic slide presentations, which she delivered low-dose at several staff meetings. Time was allotted for a anticoagulant question-and-answer and discussion period. These therapy often exchanges among staff members helped to reinis used for force salient information and heightened awareness prophylaxis, full of the problem. Although perioperative anticoagulant personnel know that DVT is a potential problem, the therapy is educational sessions increased their awareness of necessary to the problem. To be effective, a DVT prevention treat existing program must focus on two requirements. First, deep vein prophylactic therapy interventions must be initiated thrombosis. in accordance with the patient’s disease and degree of risk. Second, the prophylactic regimen must be applied for the entire time the patient is at risk. For the surgical patient, the perioperative and immediate postoperative periods are recognized as very high-risk periods. Medical patients also are at risk throughout hospitalization until hospital discharge. Deep vein thrombosis prophylaxis can reduce the risk if applied continuously throughout these periods. When staff members are more aware of AORN JOURNAL •

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the risk of DVT in all patients, consistent intervention is much more likely. Physicians also were included in the educational process. Although they did not need information on basic pathophysiology, some of the newest research was made available to them. They also were given information on what nurses can and are eager to do for the care and treatment of this patient population. Enlisting the physician group of the health care team was a necessary component for success of the overall plan. It became clear that patients also would benefit from receiving some basic information. Providing information about DVT to patients helped The protocol increase compliance and allowed patients to parchange also ticipate in their plans of care, particularly with provided self-assessment of risk. Through anecdotal obsersignificant vation of patient responsopportunities for es to the teaching that the nurses provided, it was noted that when patients collaboration understood why they were being asked to wear because it compression stockings or take certain medications, involved and most were much more affected almost willing to follow the treatment regimen. IMPLEMENTATION. Impleevery nurse, menting a standardized physician, and DVT prophylaxis protocol is a difficult but potenpatient. tially rewarding nursing intervention project that is designed not only to improve the quality of patient care, but also to save lives. The protocol change also provided significant opportunities for collaboration because by nature, it involved and affected almost every nurse and physician; it also involved and affected almost every patient. Use of a standardized risk-assessment tool made incorporation of DVT assessment more efficient. For this project, a tool previously designed and published was introduced for facility-wide use.18 The manufacturer provided the forms on



preprinted pads at no charge. The standardized assessment tool included a comprehensive list of risk factors relevant to DVT and PE as well as a method that allowed health care practitioners to categorize patients according to the level of risk: • low risk if only one factor is present, • moderate risk if two factors are present, and • high risk if more than three factors are present. The assessment tool also listed recommended protocols for prophylaxis categorized according to the patient’s level of risk. Staff members increased the frequency of their assessments for DVT risk and became more focused in their efforts to decrease the possibility of occurrence. It is likely that there will be subsequent modifications to this tool, making it more specific to the needs of the health care facility. As staff members become familiar with routine use of the instrument, suggestions for changes appropriate to the health care facility can be incorporated.

POLICY DEVELOPMENT The policy and procedure developed for this medical center involved a computer-alert program for obtaining physicians’ orders for DVT prophylaxis. Staff members now enter patient information into the computer based on the • initial nursing assessment, • subsequent nursing assessment, or • independent physician request. Recommended orders such as • early ambulation, • properly fitted compression stockings, • IPC devices, and • anticoagulation therapies then are automatically generated for physician approval through computer recognition of numerous DVT-specific risk factors built into the program. Addressing all areas of Virchow’s triad was the rationale for recommending the use of combined treatment modalities as part of a hospital protocol for preventing DVT. This protocol included • applying properly fitting compression stockings,


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administering anticoagulation therapy as ordered by the physician, and • having patients continuously use plantar IPC devices preoperatively, intraoperatively, and postoperatively. Based on the review of research literature, continued use of compression stockings alone and in combination with IPC devices and anticoagulation therapy was recommended. Knee-high compression stockings, however, were given greater consideration to achieve better fit, improved comfort, and increased cost savings. At the time this article was written, the facility cost for thigh-high compression stockings was approximately $6 per pair, and knee-high compression stockings cost only $3 per pair. Considering these dollar figures and the surgical case load at this regional medical center switching from thigh-high compression stockings to knee-high stockings for the majority of surgical patients alone would amount to an annual cost reduction of more than $6,200. In addition, use of properly fitting cotton socks was implemented as standard procedure for physicians who prefer not to use compression stockings under plantar IPC boots.

COMPLIANCE PROBLEMS As in most situations, knowing and doing can be two different things. Staff member compliance with implementing the risk management measures was a significant issue. One of the problem areas was in taking time to properly measure and fit compression stockings. Simply looking the patient over and making an educated guess as to what size is required often results in ill-fitting stockings and subsequent noncompliance on the part of the patient. Applying stockings that are too tight on a patient is a common problem when measurements are not the basis of the size selection. Other staff member compliance issues also were connected with taking the time to implement risk management in the most complete way. It is imperative that the circulating nurses ensure that IPC devices are turned on and running before induction of anesthesia. It also is incumbent on the nurse to determine if orders for preventative

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measures have been provided and, if not, to obtain appropriate orders from the physician. Patient education takes nursing time, and it is easy for nurses to get too busy to explain the issues to the patient, thus endangering patient compliance. Often nurses just remove the IPC cuffs or boots and compression stockings when the patient complains rather than providing the patient and his Simply looking at or her family members with the knowledge that the patient to would help them understand the importance of make an educated DVT prophylaxis devices. guess as to what Although it often is difficult for nurses to find size is required, time for thorough patient education, it is time well often results in spent. Knowing the importance of this education ill-fitting may help nursing staff members discover that stockings; the time spent in this activity pays off in desubsequently, creased complications. Compliance with these the patient may issues on the part of the nurse leads to compliance be noncompliant on the part of the patient.

SEEING POSITIVE RESULTS

with wearing the stockings.

Every patient deserves to benefit from best practices in nursing care. It is well worth the effort to implement a practice change that research has demonstrated will create the most favorable outcomes for patients. Evidence-based nursing practice consists of reviewing current literature to find a solution to a patient care question that must be answered. The results of that search then must be compiled and presented to fellow team members so that new and improved processes designed for high-quality patient care can be developed and implemented. Initially, some physicians and nurses and perhaps even some patients resisted the practice changes. Providing staff member and patient education and clearly demonstrating the

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importance and cost-effectiveness of DVT prophylaxis over the cost of treatment after the fact, however, allowed the practice change to gain acceptance in a very short time period. Realizing the effect that evidence-based practice can have on patient outcomes helps sustain the hard work it takes to implement change. Knowing that patients are correctly assessed for risk and appropriately provided with preventive measures that decrease the incidence of DVT is a great reward for ongoing efforts in applying research. Seeing positive results also may motivate other nurses to seek out new and better methods to enhance patient care. ❖ Sharon A. Van Wicklin, RN, BSN, CNOR, CRNFA, CPSN, is the perioperative education coordinator at Williamson Medical Center, Franklin, Tenn. Karen S. Ward, RN, MSN, PhD, COI, is a professor and associate director of Online Programs at Middle Tennessee State University, School of Nursing, Murfreesboro, Tenn. Shirley W. Cantrell, RN, MSN, PhD, is an associate professor at Middle Tennessee State University, School of Nursing, Murfreesboro, Tenn.

NOTES 1. D S Pravikoff, A B Tanner, S T Pierce, “Readiness of US nurses for evidence-based practice,” American Journal of Nursing 105 (September 2005) 40-52. 2. E Parrish, “Pulling together to document evidence,” Reflections on Nursing Leadership 31 no 2 (2005) 28-29. 3. A Arnold, “DVT prophylaxis in the perioperative setting,” British Journal of Perioperative Nursing 12 (September 2002) 326-332. 4. R Autar, “The management of deep vein thrombosis: The Autar DVT risk assess-



ment scale re-visited,” Journal of Orthopedic Nursing 7 (August 2003) 114-124. 5. L Bonner, “The prevention and treatment of deep vein thrombosis,” Nursing Times 100 (July 20-26, 2004) 38-42. 6. D W Ramzi, K V Leeper, “DVT and pulmonary embolism: Part II. Treatment and prevention,” American Family Physician 69 (June 15, 2004) 2841-2848. 7. M Day, “Recognizing and managing deep vein thrombosis,” Nursing 33 (May 2003) 36-42. 8. S Sharma, “Pulmonary embolism,” eMedicine, http://www.emedicine.com/med /topic1958.htm (accessed 4 April 2006). 9. “About deep-vein thrombosis and pulmonary embolism” Coalition to Prevent Deep-Vein Thrombosis, http://www.prevent dvt.org/aboutDVT/index.asp (accessed 26 April 2006). 10. Tyco Healthcare, Preventing Venous Thromboembolism: A Guide to Nursing Intervention (Mansfield, Mass: The Kendall Company) Videotape. 11. L Sprizza, A Witko, “The ABCs of DVT,” MEDSURG Nursing 12 (December 2003) 403-405. 12. P Davis, “DVT prevention . . . is it possible?” Journal of Orthopaedic Nursing 8 (February 2004) 58-59. 13. K Ball, “Deep vein thrombosis and airline travel—The deadly duo,” AORN Journal 77 (February 2003) 346-358. 14. K A Robertson et al, “Patient compliance and satisfaction with mechanical devices for preventing deep venous thrombosis after joint replacement,” Journal of the Southern Orthopaedic Association 9 (Winter 2000) 182. 15. T Benko et al, “Graduated compression stockings: Knee-length or thigh-length,” Clinical Orthopaedics and Related Research 383 (February 2001) 197-203. 16. J Deagle, J Allen, R Mani, “A nurse-led ambulatory care pathway for patients with deep venous thrombosis in an acute teaching hospital,” International Journal of Lower Extremity Wounds 4 (June 2005) 93-96. 17. R J Lipchik, “A concise guide to preventing and treating pulmonary embolism,” The Journal of Respiratory Diseases 25 (May 2004) 200-209. 18. Thrombosis Risk Assessment for Surgical and Medical Patients (Mansfield, Mass: The Kendall Company, 1998).