Quality improvement report

Surgeon-led improvement in compliance with use of sequential compression devices in a neurosurgery patient population

Abstract

Introduction Sequential compression devices (SCDs) are the mainstay of mechanical prophylaxis for venous thromboembolism in perioperative neurosurgical patients and are especially crucial when chemical prophylaxis is contraindicated.

Objectives This study aimed to characterise and improve SCD compliance in neurosurgery stepdown patients.

Methods SCD compliance in a neurosurgical stepdown unit was tracked across 13 months (August 2022–August 2023). When not properly functioning, the missing element was documented. Compliance was calculated daily in all patients with SCD orders, and then averaged monthly. Most common barriers to compliance were identified. With nursing, we implemented a best practice alert to facilitate nursing education at month 3 and tracked compliance over 9 months, with two breaks in surveillance. At month 12, we implemented a patient-engagement measure through creating and distributing a patient-directed infographic and tracked compliance over 2 months.

Results Compliance averaged 19.7% (n=95) during August and 38.4% (n=131) in September. After implementing the best practice alert and supply chain upgrades, compliance improved to 48.8% (n=150) in October, 41.2% (n=104) in March and 45.9% (n=76) in April. The infographic improved compliance to 51.4% (n=70) in July and 55.1% (n=34) in August. Compliance was significantly increased from baseline in August to October (z=4.5838, p<0.00001), sustained through March (z=3.2774, p=0.00104) and further improved by August (z=3.9025, p=0.0001).

Conclusion Beyond an initial Hawthorne effect, implementation of the best practice nursing alert facilitated sustained improvement in SCD compliance despite breaks in surveillance. SCD compliance nonetheless remained below 50% until implementation of patient-engagement measures which were dependent on physician involvement.

What is already known on this topic

  • It has been well established that deep venous thromboses (DVTs) and venous thromboembolisms (VTEs) remain a leading cause of preventable hospital mortalities. Whereas sequential compression devices (SCDs) are included in many approaches to combating the risks of DVT/VTE development, reported compliance rates have been historically low where studied.

What this study adds

  • This study highlights that ordering SCDs is insufficient and that nursing-focused measures alone are inadequate at achieving increased compliance, mandating the greater engagement of the surgical providers as well as a focus on patient-directed interventions.

How this study might affect research, practice or policy

  • At institutions where DVT/VTE prevention is paramount, this study offers novel, easily reproducible interventions with recommendations that can help shape practice, increase compliance and culminate in decreased rates of VTEs.

Introduction

Venous thromboembolism (VTE) affects 1 220 000 people annually,1resulting in 60 000–100 000 deaths annually,2 costing 10 billion dollars a year according to the Center for Disease Control’s current reporting.3 VTE is the leading cause of preventable hospital deaths in the USA,4 where even asymptomatic deep venous thromboses (DVTs) diagnosed by ultrasonography were associated with a threefold increased risk of short-term all-cause death.1 5 Unfortunately, whereas 70% of hospitality-acquired VTEs are preventable,6–8 fewer than half of hospital patients have prophylactic measures implemented.9 This is especially worrisome in the neurosurgical population where VTEs remain the greatest preventable cause of morbidity and mortality with an approximate incidence of 16% (ranging 0%–34%).10 Increased risk is inherent to this population given the types of procedures and limited postoperative mobility.11 12 Based on these statistics, the onus remains on the neurosurgical team to ensure every mitigating measure is implemented to prevent serious postoperative complications that can extend the length of stay, cost of hospitalisation and ultimately morbidity and mortality.

The American College of Chest Physicians (ACCP) deems patients at low to moderate risk for VTE when undergoing spine surgery, at high risk (~5%) when undergoing craniotomy for nonmalignant or vascular disease, and at very high risk (>10%) when there is a malignant disease.13 From a biochemical standpoint, neurosurgical patients are at increased risk given the enhanced release of prothrombotic proteins (eg, fibrinopeptide A, fibrinogen, factor VIII, thromboplastin) during brain tumour resection, endothelial injury from traumatic brain and spinal cord injuries, as well as the manipulation of central nervous system tissue during surgery.12 There are three lenses from which prophylaxis efforts may be focused: chemical (subcutaneous heparin or low molecular weight heparin), organic (mobility and physical therapy) and mechanical (sequential compression devices (SCDs) and/or compression stockings).

Aggressive chemical prophylaxis may be challenging for neurosurgical patients to tolerate given the risks of serious haemorrhagic complications14–16 Furthermore, mobility is not always an option for every patient, and facilities may not have the staffing numbers for physical therapy to overcome baseline functioning or prescribed postoperative barriers. Conflicting concerns for VTE and bleeding complications often render standardised DVT prophylaxis unachievable. A study reviewing survey responses from 370 board-certified neurosurgeons found that SCDs and mobility served as the only primary means of VTE prophylaxis used by 27.2% of responders for elective craniotomies and 26.5% of respondents after spine surgery.17 The ACCP and North American Spine Society have recommended mechanical prophylaxis with SCDs over subcutaneous heparin, low-molecular-weight heparin or no prophylaxis at all for patients post craniotomy or spine surgery.18 Thus, unless a patient is at greater risk for VTE, with haemostasis established, maximising the use of mechanical prophylaxis with SCDs is paramount.

SCDs consist of inflatable sleeves that are placed on the lower extremities and attached to a machine, to provide intermittent pressure on the legs and promote circulation. SCDs are routinely ordered on admission to a medical and/or surgical unit. However, the presence of the order does not necessarily reflect the availability and use of SCDs. This study aimed to improve compliance in our neurosurgical stepdown patient population. This entailed first characterising our compliance and identifying common barriers to compliance. We then designed and implemented interventions to overcome those barriers and assessed the impact on SCD compliance.

Methods

We first performed a prospective observational study to determine baseline compliance with SCDs. Additional patient consent to procedure was not sought, for the actions of this study fell within the limits of the generalised consent to care and treatment obtained for all hospitalised patients on registration prior to admission. From August to September 2022, we tracked which neurosurgical patients in stepdown units who had SCDs ordered actually had the SCDs on and properly functioning. Our tertiary academic medical centre uses the Kendall SCD 700 series compression therapy pump. These patients included those for whom the neurosurgery team was a primary or a consulting service assisting the trauma and neurology teams. We noted compliance during morning rounds each day between 6:00 and 7:00 hours Eastern Standard Time. Compliance was documented when patients were lying in bed with SCD wraps on, tubing connected and machine powered on. When not on or properly functioning, we documented the missing element from the SCD apparatus. Missing elements included leg wraps not on, tubing disconnected, machine not on, any combination of these or the absence of any or all of the previous elements. Compliance was calculated daily as the percentage of patients who were SCD compliant out of all patients with SCD ordered. Patients were excluded from the daily count if they were out of bed in a chair, up walking, in the midst of transport or otherwise off the ward. The daily compliance percentages were then averaged over each month. Patients were excluded if not in the surgical stepdown unit, not being managed or followed by the neurosurgery primary or consulting team, respectively, with occlusive DVTs of the lower extremities, or with severe safety concerns precluding the use of the SCDs.

We identified the most common barriers to compliance based on this surveillance. After conferring with bedside registered nurses (RNs) and certified nursing assistants (CNAs), an interdisciplinary meeting was held with nursing management and educators. After discussion of various approaches to improve compliance, it was collaboratively decided to design and implement a best practice alert to address the most salient barriers to compliance as follows.

We have recently had some issues with patients not having their SCDs on when they are ordered for them.

A few reminders about SCD boots:

Why we use them

  • SCDs are used is most postsurgical patients due to their increased risk of developing blood clots. This increased risk comes from a combination of the natural inflammatory response caused by surgery and possbile reduction in mobility postoperatively.

  • In addition to SCDs, we use subcutaneous heparin and encourage mobility in our postoperative patients as much as possible to reduce the risk of developing a blood clot during their postoperative course.

When to use them

  • All patients who are ordered for SCDs should have them in place while in bed, regardless of how frequently they are up and walking.

  • Even if a patient is ambulatory, their risk of developing a blood clot during their postoperative course is increased because they are likely still not at their usual (preoperative) level of mobility.

  • Please encourage patients to wear their SCDs as much as possible, unless there is an overt contraindication, such as a DVT in one of their extremities.

Patient refusal of SCDs

  • If a patient refuses their SCDs, please take this as an opportunity to provide the patient education on the importance of them and encourage them to use them whenever possible.

  • If the patient still refuses after receiving education, please page the primary care team to inform them of the refusal in addition to documenting refusal on the daily cares flowsheet.

Operational issues

  • If you need to order an SCD machine, please enter a non-patient transport request for it in Epic.

  • If there are significant delays (>4 hours) or the machine arrives without the necessary equipment to function (missing tubing), please file an RL report so that we can better track the issues with machine availability and work to rectify this issue.

The best practice nursing alert provided education not only on the medical rationale for the use and application of SCDs but also provided clear guidance on how to deal with patient refusal (including escalation to the medical team) as well as operational and/or equipment-related issues. Furthermore, supply inventory was reorganised such that the tubing was stored with the machines, and orders for machines specifically included both items. At the beginning of October 2022, the Best Practice Alert was distributed among staff: It was emailed to RNs and CNAs, it was posted in their lounges, displayed at nurse workstations, and discussed during day and night shift huddles. These multiple modalities were intended to maximise impact on RNs/CNAs with different learning styles and increase the length of face time they would have with this information in their shifts, to continuously shape new practice behaviours. Additionally, delivery and transportation staff were educated about the necessary elements for delivering SCDs when ordered by nursing staff. This was done by identifying the relevant staff members and then engaging in multiple collaborative discussions to review the SCD system as a whole, in addition to the separate elements. The impact of this intervention was tracked through October. A break in surveillance occurred from November 2022 to February 2023. Active surveillance resumed in March–April 2023. A subsequent break in surveillance occurred from May to June 2023. These breaks were envisioned to allow for a washout of the Hawthorne effect and test the staying power of the intervention.

We then identified residual patient-originating barriers, namely patients removing their SCDs and not replacing them by their own volition. A bilingual patient-engagement measure was implemented via the creation and distribution of a patient-directed infographic/memo as detailed below.

SCDs or ‘squeezy boots’

  • May first be placed during your surgery prior to going to sleep.

  • Used in postsurgical/trauma patients due to the increased risk of developing blood clots.

  • SCDs should be in place while in bed, even when you sleep, regardless of how frequently you are up and walking.

  • Even if you are fairly active in the hospital, your risk of developing a blood clot is increased because you are likely still not at your usual (preoperative) level of mobility.

  • You can either remove/replace the warps or disconnect/reconnect the tubing from the wraps when getting out of bed.

  • They may be uncomfortable but are important to prevent life-threatening blood clots in your legs.

  • Feel free to ask your nurse, patient care assistant or doctor for help.

Dispositivos de compresión secuencial (SCDs) o ‘squeezy boots’

  • Primero se colocará durante su cirugía antes de irse a dormir.

  • Utilizado en pacientes posquirúrgicos/trauma debido al mayor riesgo de desarrollar coágulos de sangre.

  • Los SCD deben estar en su lugar mientras está en la cama, incluso cuando duerme, independientemente de la frecuencia con la que se levante y camine.

  • Incluso si es bastante activo en el hospital, su riesgo de desarrollar un coágulo de sangre aumenta, porque es probable que todavía no tenga su nivel de movilidad habitual (preoperatorio).

  • Puede quitar/reemplazar los urdimbres o desconectar/volver a conectar los tubos de los urdimbres al levantarse de la cama.

  • Pueden ser incómodos, pero son importantes para prevenir coágulos de sangre potencialmente mortales en las piernas.

  • No dude en pedir ayuda a su enfermera, asistente de atención al paciente, o médico.

The patient infographic was first distributed to preoperative patients by the surgical schedulers during their review with the patients regarding surgical scheduling logistics, and then daily to patients in the surgical stepdown unit by inpatient team members starting in July 2023. Active observations continued from July to August 2023. Significance in compliance percentages was calculated using the z-score test for two population proportions. The differences were deemed significant when the p value was less than 0.05.

Patient and public involvement

Patients were involved at various stages of this study, during initial observation, after implementation of the intervention and when assessing for residual patient-related barriers to compliance. Patients were asked why they did not have SCDs in place when observed to assess for common patient-specific barriers to compliance needing to be addressed. After implementation of the patient-directed infographic, patients were educated on the use of SCDs, the risk associated with DVTs and encouraged to take ownership of their implementation. Initial observations and postintervention results have been shared with the various stakeholders responsible for achieving SCD compliance.

Results

There was a total of 529 observations (n) over the course of this study (table 1). These were done on a total of 223 patients. Most patients included in the study were on the primary neurosurgery service, 73.54% (n=164 summed up across months of study) and the male (n=129) to female (n=94) ratio was 57.85%.

Table 1
|
Patient characteristics and most common missing elements

Baseline compliance, prior to intervention, averaged 19.7% (n=95) during August, and 38.4% (n=131) in September. The most common missing elements noted were noted to be related to the SCDs themselves and included displaced or missing wraps, missing machines, machines with disconnected tubing or lacking apparatus set up (table 1). Initially, attention was directed towards the identification of nursing-related barriers. These were elicited during multidisciplinary discussions and included nursing misconceptions about the reason for and importance of SCDs, at the need for SCDs placement whenever stationary regardless of ambulatory function, and concerns related to nursing assessment of patient eligibility and/or tolerability.

After implementation of the best practice nursing alert and supply chain upgrades, compliance improved to 48.8% (n=150) in October, 41.2% (n=104) in March and 45.9% (n=76) in April. Compliance was significantly increased from baseline in August to October (z=4.5838, p<0.00001). The significant difference was sustained through March (z=3.2774, p=0.00104) and April (z=3.6699, p=0.00024) (figure 1), despite a break in surveillance between October and March.

Figure 1
Figure 1

SCD compliance graph. SCD, sequential compression device.

Residual patient-directed barriers were identified, including wraps being removed by patients and/or machines being turned off by patients secondary to equipment malfunctions that were not resolved in a timely fashion. After implementation of the patient-directed SCD infographic to improve patient engagement, compliance was 51.4% (n=70) in July and 55.1% (n=34) in August. This improvement over baseline compliance was significant in both July (z=4.2750, p<0.00001) and August (z=3.9025, p=0.0001).

Discussion

At the beginning of our study, SCD compliance was far less than expected. Data collection alone doubled compliance, with the improvement possibly attributable to the Hawthorne effect, whereby behaviour is modified by the awareness of being observed. Implementation of the best practice nursing alert resulted in further improvement in SCD compliance that was sustained, despite breaks in surveillance. SCD compliance nonetheless remained just below 50%. Implementation of patient-directed infographic to enhance patient engagement ultimately improved SCD compliance to over 50%. At best, this study achieved 55% compliance with prescribed SCDs. While it may be difficult to conceptualise anything less than full compliance, SCD compliance levels in our study are on par with other studies where compliance was reported to be 58% in a postoperative, gynaecological population19 and 53% in trauma patients at another tertiary centre.20

The various stages of this project highlighted how multifaceted the barriers to compliance are, and thus the need for the neurosurgeons to lead a multifaceted approach to interventions not only addressing equipment issues but also nursing and patient engagement. Where failure to deliver tubing with the SCD machine was rectified early on in this study, delays in delivery of the intact apparatus were especially felt by nursing staff. The machine used at our institution, the Kendall SCD 700 series compression therapy pump, is customisable, allowing for calf versus foot compression, setting total duration and unilateral settings. This degree of customisation increased the complexity and frequency of alarming in the setting of malfunction. This led to an increased tendency for the machine to simply be turned off by staff to make it stop alarming. Solutions for this problem could include greater education beyond uses of the power button or use of a non-customisable machine, such as the ALP—alternating leg pressure machine where the only options are power on and power off.

Distribution of the best practice alert achieved significant and sustained improvement highlighting the impact of nursing engagement and collaborative implementation of measures to improve SCD compliance. Despite a promising boost, it was met with less than hoped for returns, possibly due to nursing turnover and staff heterogeneity, with the nursing staff consisting of a mix of veterans, travellers and floats from other units. Staff heterogeneity required repeat redistribution of best practice alerts, regular physician-to-nurse communication, patient engagement and nurse to nurse focused communication concerning use of the SCD machine (figure 2).

Figure 2
Figure 2

RN-prepared note at shift change. RN, registered nurse.

After nurse-focused interventions achieved their maximal effect, patient-focused interventions that allowed for achieving maximal SCD compliance rates were implemented. Creation of an SCD infographic to be given to patients likely acted in multiple ways to enhance patient engagement. Distribution of the infographic at the time of surgical scheduling for elective cases allowed patients to become familiar with SCDs ahead of hospitalisation. Distribution of the infographic to patients while on stepdown thus prompted attendings, residents and physician assistants to reinforce the importance of SCDs with patients, such that it became more apparent to patients that this constituted part of the ‘doctor’s orders’. Additionally, the process of sharing the infographic with patients also served as another reminder to nursing staff, of the need and/or importance of SCD use. Finally, this intervention provided patients with a way to take some control over a portion of their care.

Strengths of this study included its prospective design and clear, easy-to-implement, reproducible interventions as provided. The project took place at a tertiary medical centre with a patient population characteristic of large urban teaching hospitals so results are likely generalisable to other similar populations. The length of observation spanned multiple months with breaks in observation to allow discernment between a Hawthorne effect21 and lasting systemic impact. There may have been an initial change in nursing practice after daily study observation, highlighting the potential for physician providers to inspire system change. In this case, it would be expected that compliance would fall back to below the initial 20% after a break in surveillance. However, an improvement up to 40% was sustained, suggesting that lasting habits were made. Where other studies have failed to engage nursing staff early,22 much of this study’s success can be attributed to working in collaboration with nursing to identify barriers, devising and implementing the interventions. It was felt that early nursing buy-in was crucial to the improvement achieved since nurses are responsible for executing the orders placed and more likely to do so when engaged as part of the provider team. It was also felt that the creation of an SCD-specific best practice nursing alert and its incorporation as a routine aspect of nursing and CNA education would enhance long-term sustainability of compliance beyond its original introduction. The interventions in this study also included patient and physician engagement measures that not only enhanced compliance during the study but also raised awareness of the need for continued surveillance. By taking a multipronged and/or multidisciplinary approach and incorporating interventions at various levels to improving compliance, a system of checks and balances was created in order to enhance future sustainability.

This study, however, is not without its limitations. The duration for which SCDs should be used remains unclear. Where the American College of Obstetricians and Gynecologists recommends that devices be ‘used continuously until ambulation and discontinued only at the time of hospital discharge’, the practice bulletin also directs that devices ‘be continued until the patient is fully ambulatory’ a concept that is vague and does not give guidance as to how much time fully functioning patients need SCDs in place when not ambulating.23 Studies have reported that SCDs should be functioning for 18–21 hours a day to achieve optimal effect.24 This goal disregards how much time patients may be out of bed, ambulating to a chair, the restroom, working with physical therapy or undergoing bathing or linen changes.

Because our study included only once daily observations, we cannot speak to the total amount of time patients spent with SCDs in place. Some studies have used timers to pinpoint total duration of use25 or made six observations a day,20 neither of such practices was feasible in this study. However, it should be noted that the timing of our observations, between 6:00 and 7:00 hours, was best able to reflect overnight use when patients were most expected to be in bed and not up and about, getting changed, working with physical therapy or other activities. Another limitation of this study is that there are no data on whether the improved SCD compliance achieved better DVT prophylaxis and fewer VTE events, noting the degree of mismatch, where the incidence of an asymptomatic DVT detected by duplex ultrasound is 0.9% vs 2.6% of patients developing symptomatic PE.26 Without routine ultrasound and CT pulmonary angiograms, true incidence and the impact of improved SCD compliance cannot be fully appreciated. However, more than half of blood clots occurring after discharge have been directly linked to a recent hospitalisation or surgery.27 Furthermore, this study indicated that 40% of postoperative patients in the Department of Veterans Affairs hospitals have suffered VTEs while inpatient. Consequently, the need to mitigate inpatient risk cannot be overstated, as the full clinical significance of improved compliance may go unrecognised.

Lastly, this study aimed at improving compliance by changing the practices of staff and patients who were functional enough to engage in their own healthcare, in addition to addressing operational issues and increasing physician awareness. The study did not examine changes in knowledge-base stemming from the educational aspect of the implemented interventions. For example, with respect to nursing, it remains unclear if the best practice alert best addressed causative knowledge gaps, or if its distribution only reinforced the need for order compliance. Further study could examine the impact of the best practice alert on nursing perceptions of the SCDs and/or additional barriers to nursing compliance, including the use of additional educational tools.

Additional work is needed to further improve SCD compliance that ultimately remains low. This could be directed towards improvement in any of the areas impacting compliance and will likely require a higher level of system-wide interventions and further team-led changes, with physicians needing to maintain the highest levels of engagement. For example, a different SCD machine could be used with simpler display, less frequent alarms and/or wireless sleeves without tubing. The best practice nursing alert could be discussed by physicians and reviewed at hospital-wide nursing conferences, rather than those limited to the stepdown floor, increasing global nursing awareness of SCD compliance. At another institution, the authors are studying incorporating the best practice alert into the electronic medical record and making SCDs an automated order for postoperative patients. Finally, the patient-directed infographic could also be included in the hospital’s standardised preoperative pamphlet for elective cases and could also be posted along with the standard posters reminding patients about incentive spirometry and/or the iCOUGH protocol.

Conclusions

This study is the first to draw attention to the potential for low SCD compliance in a neurosurgery patient population. Data collection alone increased SCD compliance, likely due to the Hawthorne effect. Neurosurgeon led collaboration with implementation of the best practice nursing alert likely facilitated the sustained improvement in SCD compliance despite the breaks in surveillance. Where the impact plateaued below 50% compliance, the implementation of a patient-directed intervention resulted in further improvement of SCD compliance and allowed for achieving majority compliance above 50%. Residual barriers remain, including issues related to the type of SCD machine used and patient functional status. Further study is underway to replicate this study in a patient population with a different SCD machine and functional status, to confirm whether the physician-championed interventions are generalisable.