A Critical Reflection of the Joanna Briggs Institute Guideline for Venous Thromboembolism Prevention - Research Paper Example

A Critical Reflection of the Joanna Briggs Institute Guideline for Venous Thromboembolism Prevention Abstract Venous thromboembolism (VTE) is medically considered to have serious effects on health. For this reason, numerous guidelines have been proposed to reduce the risks associated with its development. The Joanna Briggs Institute developed a best practice guideline for the prevention of post-operative venous thromboembolism to provide information on the effectiveness of graduated compression stockings (GCS) in patient undergoing surgical procedures. While the guideline’s purpose was clearly stated, the scope of the guideline was inadequately described. The use of systematic methods to gather and apply evidence in the formulation of recommendations was not clearly presented. Moreover, not enough details were provided to establish the effectiveness of their recommendations. The presentation of recommendations, risk stratification, and treatment alternatives was generally clear and organized. Though nursing knowledge is increased by the information contained in the guideline, the inadequacy of the information renders the implementation of this particular guideline difficult. The need for an effective guideline is increasingly becoming a necessity as new evidences as discovered in various health care research. It is of the essence that organisations, such as the Joanna Briggs Institute, provide regularly updated guidelines that are comprehensive and clearly presented. Venous Thromboembolism Guideline: A Critical Reflection Venous Thromboembolism (VTE) is a serious health threat, with multitude of new cases appearing in Europe and the United States every year. The rising incidence and the typical asymptomatic nature of VTE, with serious impact on health, present an essential requirement for suitable prevention methods for this condition. Excessive coagulability, venous stasis, and vein wall injury are the primary risk factors associated with the development of VTE, which comprises deep vein thrombosis (DVT) and pulmonary embolism (Arcelus & Caprini, 2009). As a result, most methods used to prevent this condition employ the use of mechanical devices, pharmacotherapy, or both. Mechanical devices, such as graduated compression stockings attempts to decrease vein dilatation and promote venous flow. Compression stockings reduce venous stasis by the application of graded levels of compression to the calf and ankle (Nasim & London, 2009). Pharmacotherapy is based on the use of anticoagulants, such as low-molecular weight heparin (LMWH) to inhibit coagulation (Ellonen, 2005). Since 1986, numerous randomised controlled trials and approximately 25 evidence-based guidelines on the advantages and safety of preventive measures for VTE have been published (Welch, 2010). In 2007, the National Institute for Health and Clinical Excellence (NICE) issued guidelines on reducing the risk of VTE in surgical inpatients. This document formed the foundation for the development of best practice guidelines for the prevention of post-operative venous thromboembolism, published by the Joanna Briggs Institute (JBI) in 2008. Scope and Purpose The purpose of the guideline is to provide information concerning the effectiveness of graduated compression stockings in the prevention of post-operative venous thromboembolism (Joanna Briggs Institute [JBI], 2008). Although the objective given is specific, it failed to identify for whom the guideline is intended. Moreover, there was no sufficient information on how these guidelines would benefit patients who are at risk of developing VTE. Clinical questions that should serve as a guide in determining appropriate clinical decisions were not provided. Instead, the use of subheadings was utilized to provide information and instructions for clinicians to follow. No additional details were given for the recommendations. The target patient population for the guideline was adequately and clearly described. The information sheet described that the interventions were meant for individuals at high risk for VTE which includes patients more than 18 years old, undergoing orthopeadic, general, gynaecological (not elective), urological, cardiothoracic, neurological, or peripheral vascular surgery. The document also mentioned specific patient conditions wherein these guidelines would be contraindicated. Some examples of these conditions are pulmonary oedema, congestive cardiac failure, and arteriosclerosis. Rigour of Development The guidelines on venous thromboembolism published by the National Institute for Health and Clinical Excellence (NICE) in 2007 as well as the best evidence from the latest healthcare literature, such as systematic reviews, meta-analyses, evidence-based guidelines, and randomised controlled trials, were used as references for the development of this guideline by the Joanna Briggs Institute (2008). The specific methods on how evidences from these sources were gathered were not discussed. Moreover, there was no information about the specific criteria used for choosing relevant evidences to include in the formulation of the guidelines. Likewise, methods used for the development of their recommendations were not provided. The information sheet failed to disclose strategies on how final decisions were reached, and how disagreements were resolved. There was no discussion on the health benefits, side effects, and risks of the recommendations. The guidelines failed to mention the common complications associated with the use of graduated compression stockings in the prevention of VTE, namely, skin breaks, pressure ulcers, and skin necrosis (The CLOTS Trials Collaboration [CLOTS], 2009). Very few details were given regarding treatment options. They recommended that the use of regional anaesthesia be considered in addition to other methods of prevention, along with the patient’s preference and patient’s specific condition (JBI, 2008). They also recommended the use of intermittent pneumatic compression (IPC), or foot impulse devices, as treatment alternative for surgical inpatients. Evidences from several studies were presented such as the effectiveness of thigh-length stockings versus knee-length stockings, the use of GCS with IPC, and the concomitant use of pharmacotherapy with mechanical devices. Very few supporting evidence were presented for each of the recommendations, and no link was provided to the specific studies on which they were based. The procedure for updating the guideline was not discussed. It does state, however, that this particular set of guidelines supersedes a previous publication in 2001 on the same subject, to establish that it reflects the latest available research. It did not specify whether the review panel regularly updates the information since its release in 2008. Clarity and Presentation Some of the recommendations on the size and fitting of the graduated compression stockings were clear and specific. The recommended stockings profile was “approximately 18mmHg at the ankle, 14 mmHg at the midcalf, and 8 mmHg at the upper thigh” (JBI, 2008, p. 1). Unfortunately, some of the other guidelines were less clear. The literature states that some patients require more frequent skin assessment but failed to specify which type of patients require such, and how often they should be assessed. In terms of leg measurements, the guideline fails to quantify how much weight gain indicates the need for re-fitting. Patients who underwent cardiac surgery, for instance, normally gain weight post-operatively due to swelling but returns to their regular weight after a few days (Winslow & Brosz, 2008). Information is provided with regards to both mechanical interventions and pharmacotherapy for the prevention of VTE. Drug dosages were not provided, except for patients who underwent hip fracture surgery, where low-molecular weight heparin (LMWH) or fondaparinux was recommended to be taken for 4 weeks. The main recommendations are easily recognized; they are summarized as a bulleted list in a coloured box at the very first page. However, no additional learning tools were provided with the guideline. Discussion The guideline presented by the institute on the prevention of VTE was generally straightforward, yet lacking in details, explanations, and supporting evidence. As nursing care should focus primarily at preventing VTE, it is vital for nurses to frequently update their knowledge. The use of an effective evidence-based guideline can have a beneficial effect on the prevention of VTE by enhancing knowledge of assessment procedures, risk factors, and the use of mechanical prophylaxis (Beck, 2006). While the guideline presented information that increased nursing knowledge, it was limited in the sense that a procedure for risk assessment, which is a key nursing responsibility, was not fully discussed. Best practice guidelines are commonly regarded initially with some form of resistance. Some healthcare practitioners believe that clinical decisions and individualized patient care is set aside when guidelines are instituted (Timmermans & Mauck, 2005). Moreover, the institution of guidelines usually means increase in healthcare costs. However, the recommendations presented in the JBI guideline are cost-effective in patients at risk for VTE. Costs associated with preventive measures using graduated compression stockings and other devices are considerably lower than the cost of diagnosis and treatment. One of the major drawbacks in the implementation of this guideline is motivating the nursing staff to successfully perform VTE risk assessments. Although this forms a big part of a nurses’ job, it is difficult to institute with the JBI guideline due to the inadequacy of the risk assessment tool. For instance, when a patient is assessed to be at risk for pressure ulcers, the nurse may perform an independent nursing intervention, such as turning the patient every 2 hours (Catania et al., 2007). In the case of risk assessment for VTE, the absence of a standard assessment tool would make it difficult for nurses to implement the appropriate nursing interventions in accordance with the best practice guideline. The implementation of guidelines is gradually becoming important in health care practice as new knowledge and evidences are generated from various medical studies. Organisations, such as the Joanna Briggs Institute, will thus have a vital obligation to ensure that their guidelines are comprehensive, regularly updated, and clearly presented. References Arcelus, J. I. & Caprini, J. A. (2009). Mechanical Prevention of Venous Thromboembolism. In E. J. Van Beek, H. R. Buller, and M. Oudkerk (Eds.), Deep vein thrombosis and pulmonary embolism. West Sussex, UK: John Wiley & Sons. Beck, D. (2006). Venous thromboembolism (VTE) prophylaxis: Implications for medical-surgical nurses. MEDSURG Nursing, 15(5), 282-287. Catania, K., Huang, C., James, P., Madison, M., Moran, M. & Ohr, M. (2007). PUPPI: The pressure ulcer prevention protocol interventions. The American Journal of Nursing, 107(4), 44-52. Ellonen, M. (2005). Prevention of Venous Thrombosis. In I. Kunnamo. (Ed.), Evidence-based medicine guidelines. West Sussex, UK: John Wiley & Sons. Joanna Briggs Institute. (2008). Graduated compression stockings for the prevention of post-operative venous thromboembolism. Best Practice, 12(4), 1-4. Nasim, A. & London, N. J. (2009). Venous Thromboembolic Disease. In R. Donnelly and N. J. London. (Eds.), ABC of arterial and venous disease. (2nd ed.). West Sussex, UK: John Wiley & Sons. National Institute for Health and Clinical Excellence. (2007). Venous thromboembolism: Reducing the risk. London, UK: NICE Publications. The CLOTS Trials Collaboration. (2009). Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke: A multicentre randomized controlled trial. Lancet, 373(9679), 1958–1965. Timmermans, S. & Mauck, A. (2005). The promises and pitfalls of evidence-based medicine. Health Affairs, 24(1), 18-28. Welch, E. (2010). Venous thromboembolism: A nurse’s guide to prevention and management. West Sussex, UK: John Wiley & Sons. Winslow, E. H. & Brosz, D. L. (2008). Graduated compression stockings in hospitalized postoperative patients: Correctness of usage and size. The American Journal of Nursing, 108(9), 40-50. Read More