Evidenced based patient safety project/Nursing Protocol and Procedures

Nursing Protocol and Procedures
Name: MCD Protocol
Scope: Organization-wide Page 1 of 12
Patient care is revised to meet the individual patient needs.
DISCLAIMER: This policy was developed solely for the use of Children’s Hospital of Chicago Medical Center and
its affiliates (“Medical Center”). The information contained herein shall not be relied upon by individuals or
entities outside Medical Center for accuracy, timeliness, or any other purpose.
PURPOSE:
To outline the nursing management for the prevention of deep vein thrombosis and venous
thromboembolism in patients who are thirteen years (13) of age or older.
DEFINITIONS:
Thromboembolism: Blood clot in an artery or vein is known as thromboembolism.
Deep Vein Thrombosis (DVT): Development of thrombosis in one of the deep veins of the
extremities, frequently the iliac or femoral veins or major upper extremity veins. These clots can
break off from the vein, travel through the heart, and lodge in the arteries of the lungs, causing a
potentially fatal pulmonary embolism.
Pulmonary Embolism (PE): A thrombus that breaks free from a vein, travels through the
veins, reaches the lungs, and lodges in a major or minor pulmonary vessel. A pulmonary
embolism is a potentially fatal condition that may cause death within minutes to hours.
Mechanical Compression device (MCD): A mechanical device that is used for pneumatic
compression, applied via a cuff that inflates and deflates uniformly. The cuff may be applied to
the extremity.
Thrombophlebitis: The formation of a venous clot accompanied by inflammation of the vein
wall. This may be the result of trauma to the vessel wall, hypercoagulability of the blood, or
infection. Intra or post-operative venous stasis, prolonged sitting, standing, or immobilization or
a long period of IV catheterization (eg. PICC line) may also cause thrombophlebitis.
Venous Thromboembolism (VTE): A condition including DVT and PE.
Venous thrombosis: A condition that occurs when a clot forms within a vein without
inflammation.
Nursing Protocol and Procedures
Name: MCD Protocol
Scope: Organization-wide Page 2 of 12
Patient care is revised to meet the individual patient needs.
DISCLAIMER: This policy was developed solely for the use of Children’s Hospital of Chicago Medical Center and
its affiliates (“Medical Center”). The information contained herein shall not be relied upon by individuals or
entities outside Medical Center for accuracy, timeliness, or any other purpose.
Supportive Data
The prevalence of blood clots in pediatric patients is on the rise. Nearly 80% of blood clots in
this population occur in the hospitalized setting and about 1 in 200 hospitalized pediatric patients
develop blood clots. Considering the long-term morbidity of blood clots, prevention is vital. It is
recommended that every child thirteen (13) years of age or older be assessed for the need of
MCD sleeves. If the patient is under the age of thirteen (13), application of MCD sleeves and
devices are per Physician/APN discretion only.
EQUIPMENT LIST:
Mechanical Compression Sleeves
Mechanical Compression Device
SECTION TITLES:
A. Pre-Procedural Patients
B. Intra-Procedural Patients
C. Post-Procedural Patients
D. Non-Procedural Patients
Nursing Protocol and Procedures
Name: MCD Protocol
Scope: Organization-wide Page 3 of 12
Patient care is revised to meet the individual patient needs.
DISCLAIMER: This policy was developed solely for the use of Children’s Hospital of Chicago Medical Center and
its affiliates (“Medical Center”). The information contained herein shall not be relied upon by individuals or
entities outside Medical Center for accuracy, timeliness, or any other purpose.
DVT Risk Factor Assessment Sheet
Directions: For patients 13 years of age or older review the risk factors listed below.
Total the number of Major and Minor Risk factors. YES = 1 point NO = 0 point
Major Risk Factor of 1 point or more = Place MCD Sleeves on the patient
Minor Risk Factor of 3 points or more = Place MCD Sleeves on the patient
Possible Risk Factors Yes / No
Major Risk Factors
Personal history of blood clot Yes / No
Personal history of known thrombophilia (clotting disorder) Yes / No
History of blood clots in immediate family (mother, father, brother, sisters, aunts, uncles, grandparents) Yes / No
Immobilization (bed ridden/wheel chair bound) for at least 72 hours prior to or following the
admission/procedure
Yes / No
Major orthopedic fractures: hip and/or pelvis Yes / No
Pregnancy or Post-Partum Period Yes / No
Morbid obesity (BMI >40 kg/m2) Yes / No
History of Anticoagulant Therapy Yes / No
TOTAL NUMBER OF MAJOR RISK FACTORS ________points
Minor Risk Factors
General Anesthesia Yes / No
Patient on Birth Control Pills / Hormone Therapy Yes / No
Scheduled Surgery time > 1hour Yes / No
Orthopedic fractures: Lower Extremity Yes / No
Disease etiology predisposing to DVT:
Crohn’s Disease/Ulcerative Colitis
Nephrotic Syndrome
SLE (Lupus)
Sepsis
Diabetes
Yes / No
Cancer Yes / No
Obesity (BMI>30- to 40 kg/m2 Yes / No
Scheduled surgery on the limb that has a central venous catheter Yes / No
Patients receiving Genitourinary, Gynecological or Extremity Surgeries Yes / No
TOTAL NUMBER OF MINOR RISK FACTORS ________points
Nursing Protocol and Procedures
Name: MCD Protocol
Scope: Organization-wide Page 4 of 12
Patient care is revised to meet the individual patient needs.
DISCLAIMER: This policy was developed solely for the use of Children’s Hospital of Chicago Medical Center and
its affiliates (“Medical Center”). The information contained herein shall not be relied upon by individuals or
entities outside Medical Center for accuracy, timeliness, or any other purpose.
CONTENT:
A. PRE-PROCEDURAL PATIENTS
STEPS NURSING MANAGEMENT
Assess the patient for risk
factors for DVT/VTE
The pre-procedure nurse (including all in-patient nurses) will
assess all patients thirteen (13) years of age or older using the
‘DVT Risk Factor Assessment Sheet’.
If the pre-procedure patient has any 1 or more Major Risk Factors
or has 3 or more Minor Risk Factors the patient is at risk for
DVT/VTE. Follow below steps.
Note: MCD use for patients under the age of thirteen (13) will be
to the discretion of the Physician/APN and will need an order
prior to application.
Locate and obtain
equipment and supplies.
Locate and obtain equipment and supplies:
• MCD sleeves can be obtained from Central Supply and on
the units’ equipment store rooms.
• MCD machines can be obtained from unit equipment store
rooms and VIP. They will also be stored in the Intra-
Procedural (OR) areas and in the PACU/Recovery areas.
Orders For In-Patient Nurses:
If patient meets criteria from DVT Risk Factor Assessment
Sheet obtain order from Physician/APN before placing MCD
sleeves on patient. If no order has been obtained before the
patient leaves the in-patient area place the MCD sleeves on
the patient’s bed.
For Procedural Department Nursing Staff:
No orders needed from Physician/APN if patient meets
minimum from DVT Risk Factor Assessment Sheet.
Note: If the patient is under the age of thirteen (13),
application of MCD sleeves is per Physician/APN orders only.
Nursing Protocol and Procedures
Name: MCD Protocol
Scope: Organization-wide Page 5 of 12
Patient care is revised to meet the individual patient needs.
DISCLAIMER: This policy was developed solely for the use of Children’s Hospital of Chicago Medical Center and
its affiliates (“Medical Center”). The information contained herein shall not be relied upon by individuals or
entities outside Medical Center for accuracy, timeliness, or any other purpose.
Application Prior to applying the MCD sleeves remove ALL clothing
including undergarments (except- for patient’s hospital gown)
Measure the size of patient’s calf to determine appropriate MCD
sleeve size and ensure that the MCD sleeves are applied properly
per the manufacturer’s instructions.
In order to apply the compression sleeves:
• Place sleeves over the lower extremity(s) below the knee.
• Overlap the edges of sleeves and secure with the Velcro.
• If the sleeve is too wide, fold one edge of the sleeve
lengthwise until an appropriate fit is obtained. Overlap
the edges of the sleeves and secure with the Velcro.
• The compression sleeve may be applied to just one
extremity if needed.
Note:
In order to provide effective DVT prevention, the MCD
sleeves must be applied PRIOR to the patient receiving
anesthesia.
Documentation Document the application of MCD sleeves in the patient’s Pre-
Procedure Checklist:
• Click ‘Yes’: If the patient meets criteria and sleeves were
placed on patient
• Click ‘No’: If the patient does not meet criteria or the
proceduralist does not want sleeves placed on patient
• Click ‘N/A’: If the patient is under 13 years of age
B. INTRA-PROCEDURAL PATIENTS
STEPS NURSING MANAGEMENT
Arrival in the Intra-
Procedural area
If the patient arrives in the Intra-Procedural area with MCD
sleeves applied:
• Confirm that the MCD sleeves are applied on the patient
properly.
• Obtain the mechanical compression device (located and
stored in the intra-procedure sub-sterile room(s)).
• Connect the device to the MCD sleeves
• Turn the mechanical compression device to ‘ON’.
Nursing Protocol and Procedures
Name: MCD Protocol
Scope: Organization-wide Page 6 of 12
Patient care is revised to meet the individual patient needs.
DISCLAIMER: This policy was developed solely for the use of Children’s Hospital of Chicago Medical Center and
its affiliates (“Medical Center”). The information contained herein shall not be relied upon by individuals or
entities outside Medical Center for accuracy, timeliness, or any other purpose.
If the patient arrives in the Intra-Procedural area with MCD
sleeves on cart:
• Obtain confirmation from the proceduralist for the
application of the MCD sleeves and device and follow
above steps for application.
Transfer of patient to
procedural table
After transferring the patient to the procedural table, confirm
placement of MCD sleeves and device.
• Ensure that the MCD sleeves and device is turned on
(prior to induction of general anesthesia or prior to
regional anesthesia has been administered) and is
functioning properly (including that the tubing is not
kinked or twisted)Avoid when possible extreme degrees
of flexion and internal rotation of the hip and knee during
the procedure as this may cause a tourniquet effect to
occur.
• Avoid the use of Trendelenburg positioning when
possible because of the potential reduction in the blood
flow rate to the legs.
Documentation Document the following in the ‘Equipment Log Section’ in the
patient’s intra-procedural record:
• Presence of a MCD machine and sleeves.
Document the following in the ‘Skin Assessment’ section in the
patient’s intra-procedural record:
• Skin assessment under the compression sleeves.
Departure from the intraprocedural
area
Prior to leaving the intra-procedural area:
• Remove the mechanical compression device from the
mechanical sleeves (while keeping the sleeves on
patient). Ensure that you keep the connection hose with
the mechanical compression device. This connection
hose is NOT disposable.
• Wipe the mechanical compression device and connection
hose with the hospital approved germicidal agent.
• Return the mechanical compression device and
connection hose to the appropriate intra-procedural room.
(Note: All mechanical compression devices are labeled
with room numbers for return.)
Nursing Protocol and Procedures
Name: MCD Protocol
Scope: Organization-wide Page 7 of 12
Patient care is revised to meet the individual patient needs.
DISCLAIMER: This policy was developed solely for the use of Children’s Hospital of Chicago Medical Center and
its affiliates (“Medical Center”). The information contained herein shall not be relied upon by individuals or
entities outside Medical Center for accuracy, timeliness, or any other purpose.
C. POST-PROCEDURAL PATIENT
STEPS NURSING MANAGEMENT
Arrival in the Post-
Procedural Area
Ensure that the MCD sleeves are properly positioned and have
not rolled down the leg during transfer, as this may cause a
tourniquet effect to occur.
Reapply the MCD
Machine to the sleeves
Assess patient
Orders
Obtain a new MCD machine and re-connect it to the MCD
sleeve. Ensure:
• Proper connections and no kinked or twisted tubing
• That the MCD is only removed for short periods of time.
• That the MCD does not hinder ambulation efforts.
Assess patient at least every 8 hours for:
• Skin integrity: Assess extremity(s) by removing the
compression sleeves for ten (10) minutes every 8 hours.
• Neurovascular CMS check (While the MCD is in use and
not in use)
Continuous use of MCDs is recommended and any interruption
of therapy for a substantial length of time should be at the
discretion of the Physician/APN.
The MCD sleeves should be removed immediately and
Physician/APN notified if the patient experiences tingling,
numbness or pain.
If the post-procedure patient is being admitted to an in-patient
floor and does not have an order yet for MCD use, obtain
Physician/APN order.
Documentation
Education
Document the application of MCD sleeves in the patient’s
record.
Educate the patient and family on:
• Purpose of therapy
• Problems that should be reported to nursing staff (i.e.
tingling, numbness, pain, sleeves have rolled down
patient).
• Importance of early ambulation (if applicable- as directed
per Physician/APN) in preventing post-procedural
development of DVT / VTE.
• To not to stand or walk with the MCD sleeves on.
Nursing Protocol and Procedures
Name: MCD Protocol
Scope: Organization-wide Page 8 of 12
Patient care is revised to meet the individual patient needs.
DISCLAIMER: This policy was developed solely for the use of Children’s Hospital of Chicago Medical Center and
its affiliates (“Medical Center”). The information contained herein shall not be relied upon by individuals or
entities outside Medical Center for accuracy, timeliness, or any other purpose.
Discontinuation MCDs can be discontinued if:
• There is Physician/APN order
• When the patient becomes fully ambulatory
• If the patient experiences any adverse reactions such as
tingling, numbness, or pain. The Physician/APN must
then be notified.
Sleeves are disposable and are utilized for single patient use. The
machine and tubing will be placed in the unit soiled utility room
for cleaning by unit staff and then stored in unit’s clean
equipment store room.
D. NON-PROCEDURAL PATIENTS
STEPS NURSING MANAGEMENT
Assess the patient for risk
factors for DVT/VTE
The in-patient nurses will assess all patients thirteen (13) years
of age or older using the ‘DVT Risk Factor Assessment Sheet’.
If the patient has any 1 or more Major Risk Factors or has 3 or
more Minor Risk Factors the patient is at risk for DVT/VTE.
Follow below steps.
Note: MCD use for patients under the age of 13 will be to the
discretion of the Physician/APN.
Locate and obtain
equipment and supplies.
Locate and obtain equipment and supplies:
• MCD sleeves can be obtained from Central Supply and
on the units’ equipment store rooms.
• MCD machines can be obtained from unit equipment
store rooms and VIP.
Orders If patient meets criteria from DVT Risk Factor Assessment
Sheet obtain order for the application of MCD sleeves from
Physician/APN.
Note: If the patient is under the age of thirteen (13),
application of MCD sleeves is per Physician/APN orders
only.
Application Prior to applying the MCD sleeves remove ALL clothing
including undergarments (except- for patient’s hospital gown)
Nursing Protocol and Procedures
Name: MCD Protocol
Scope: Organization-wide Page 9 of 12
Patient care is revised to meet the individual patient needs.
DISCLAIMER: This policy was developed solely for the use of Children’s Hospital of Chicago Medical Center and
its affiliates (“Medical Center”). The information contained herein shall not be relied upon by individuals or
entities outside Medical Center for accuracy, timeliness, or any other purpose.
Connect Compression
Sleeves To Mechanical
Device
Measure the size of patient’s calf to determine appropriate MCD
sleeve size and ensure that the MCD sleeves are applied properly
per the manufacturer’s instructions.
In order to apply the compression sleeves:
• Place sleeves over the lower extremity(s) below the knee.
• Overlap the edges of sleeves and secure with the Velcro.
• If the sleeve is too wide, fold one edge of the sleeve
lengthwise until an appropriate fit is obtained. Overlap
the edges of the sleeves and secure with the Velcro.
• The compression sleeve may be applied to just one
extremity if needed.
Obtain a MCD machine and connect it to the MCD sleeve.
Insure:
• Proper connections and no kinked or twisted tubing
• That the MCD is only removed for short periods of time.
• That the MCD does not hinder ambulation efforts.
Assess patient
Documentation
Education
Assess patient at least every 8 hours for:
• Skin integrity: Assess extremity(s) by removing the
compression sleeves for ten (10) minutes every 8 hours.
• Neurovascular CMS check (While the MCD is in and not
in use)
Continuous use of MCDs is recommended and any interruption of
therapy for a substantial length of time should be at the discretion
of the Physician/APN.
The MCD sleeves should be removed immediately and
Physician/APN notified if the patient experiences tingling,
numbness or pain.
Document the application of MCD sleeves in the patient’s record.
Educate the patient and family on:
• Purpose of therapy
• Problems that should be reported to nursing staff (i.e.
Nursing Protocol and Procedures
Name: MCD Protocol
Scope: Organization-wide Page 10 of 12
Patient care is revised to meet the individual patient needs.
DISCLAIMER: This policy was developed solely for the use of Children’s Hospital of Chicago Medical Center and
its affiliates (“Medical Center”). The information contained herein shall not be relied upon by individuals or
entities outside Medical Center for accuracy, timeliness, or any other purpose.
tingling, numbness, pain, sleeves have rolled down
patient).
• Importance of early ambulation (if applicable- as
directed per Physician/APN) in preventing development
of DVT / VTE.
• To not to stand or walk with the MCD sleeves on.
Discontinuation MCDs can be discontinued if:
• There is Physician/APN order
• The patient becomes fully ambulatory
• If the patient experiences any adverse reactions such as
tingling, numbness, or pain. The Physician/APN must then
be notified.
Sleeves are disposable and are utilized for single patient use. The
machine and tubing will be placed in the unit soiled utility room
for cleaning by unit staff and then stored in unit’s clean equipment
store room.
DOCUMENTATION:
Documentation Document the following in the patient’s electronic medical
record:
• For procedural patients: Presence and assessment of
MCD sleeves in the ‘SIDe’ flowsheet, equipment log
section of intra-procedural record , and Pre-Procedure
checklist.
• For non-procedural patients: Presence and assessment of
MCD sleeves in the ‘SIDe’ flowsheet.
• Assessment of skin integrity, neurovascular CMS status,
and other pertinent patient findings, including
interventions, at least every 8 hours.
• Removal of compression sleeves for ten (10) minutes
every eight (8) hours.
• Patient and family education.
Nursing Protocol and Procedures
Name: MCD Protocol
Scope: Organization-wide Page 11 of 12
Patient care is revised to meet the individual patient needs.
DISCLAIMER: This policy was developed solely for the use of Children’s Hospital of Chicago Medical Center and
its affiliates (“Medical Center”). The information contained herein shall not be relied upon by individuals or
entities outside Medical Center for accuracy, timeliness, or any other purpose.
REFERENCES:
AORN (2010). Prevention of venous stasis: perioperative standards and recommended practices,
AORN 2010, 631-647.
Calhoon, M.J., et al. (2010, September). High prevalence of thrombophilic traits in children with
family history of thromboembolism. The Journal of Pediatrics, 157(3), 485-9.
Geerts, W.H. et al. (2004). Prevention of venous thromboembolism: the seventh ACCP
conference on antithrombotic and ahrombolytic therapy. Chest, 126(3 Suppl), 338S-
400S.
Goldenberg, N.A. & Bernard, T.J. (2010). Venous thromboembolism in children. Hematology/
Oncology Clinics of North America, 24,151-166.
Jackson, P.C., & Morgan, J.M. (2008). Perioperative thromboprophylaxis in children:
development of guidelines for management. Pediatric Anesthesia, 18(6), 478-487.
Monagal, P. & et al. (2008, June). Antithrombotic therapy in neonates and children: American
College of Chest Physicians Evidence-based Clinical Practice Guidelines. Chest, 133(6
Suppl), 887S-968S.
Raffini L., et al. (2011). Thromboprophylaxis in pedicatric hospital: A patient safety and
quality-improvement initiative. Pediatrics,127(5), e1326-1332.
Raffini L, Huang Y-S, Witmer C, et al. (2009). Dramatic increase in venous thromboembolism
in children’s hospitals in the United States from 2001 to 2007. Pediatrics, 24(4),1001-
1008.
Setty B., O’Brien S.H., & Kerlin, B.A. (2010, March). Pediatric venous thromboembolism:
redefining epidemiology [Abstract]. The National Conference on Blood Disorders in
Public Health, Atlanta, GA.
Young G., et al. (2009, September 23). Impact of inherited thrombophilia on venous
thromboembolism in children: a systematic review and meta-analysis of observational
studies. Circulation, 118(13),1373-82.
Nursing Protocol and Procedures
Name: MCD Protocol
Scope: Organization-wide Page 12 of 12
Patient care is revised to meet the individual patient needs.
DISCLAIMER: This policy was developed solely for the use of Children’s Hospital of Chicago Medical Center and
its affiliates (“Medical Center”). The information contained herein shall not be relied upon by individuals or
entities outside Medical Center for accuracy, timeliness, or any other purpose.
AUTHOR:
Christine Pytel, MSN, RN, CPN, CNOR
Leah S. Weidner, MBA, BSN, RN, CPN
DISTRIBUTION:
All patient care areas except Emergency Department, Inpatient Psych, Outpatient Department.
REVIEWED BY:
Marybeth Browne, MD
Laura Molenda, MBA, BSN, RN
Debra Harker, MBA, BSN, RN
Mary Hammes, BSN, RN, CNOR
Carol VanProoyen, MSN/MBA/HCM, RN, CPN
Frank Pulice, RN
Susan Kolakowski, RN
APPROVAL:
Housewide Nursing Protocol and Procedure Committee
APPROVAL DATE:
10/2012
EFFECTIVE
DATE:
10/2012
REVIEW DATE:
10/201