Introduction
Venous thromboembolism (VTE) is a condition in which blood clots within veins causing partial or complete blood vessel obstruction. It primarily manifests as deep vein thrombosis (DVT) and pulmonary embolism (PE), both of which can be fatal [1]. As a common complication, VTE poses a considerable mortality risk, ranking as the third leading cause of cardiovascular disease-related death, following acute myocardial infarction and stroke [1]. Considering the lack of effective treatments, the incidence of VTE in hospitalized patients ranges from 10 to 40%, and it is 40–60% in major orthopedic surgeries [2]. In China, cancer patients face a substantial risk of VTE, with incidence rates ranging from 40 to 80%, if no prevention measures are adopted [3]. Similarly, thoracic surgery patients not receiving perioperative VTE prophylaxis demonstrate a postoperative VTE rate of 11.5% [4], significantly impacting patient outcomes and quality of life.
Studies have revealed that 50% of venous thrombosis in surgery patients occurs in the early phase during the operation [5‐7]. This is caused by several factors such as intraoperative surgical trauma, anesthesia, special surgical positions, and hypothermia contribute to thrombosis risks [6‐10]. Venous thromboembolism prophylaxis reduces rates of VTE by 55–70% [11]. Existing VTE prevention methods include basic, drug, and mechanical prevention [1]. While basic preventive measures form the foundation for comprehensive VTE prophylaxis, their efficacy is limited [9, 10]. Pharmacologic prevention, such as with low molecular weight heparin, is highly effective but contraindicated during surgery due to the heightened risk of bleeding [12]. Mechanical methods for bleeding control are a cornerstone of safe surgery. They effectively complement and, in some cases, even replace drug-based preventive measures. This approach minimizes the risk of intraoperative bleeding [13]. In mechanical prophylaxis, various auxiliary devices and instruments are employed to reduce the risk of venous thrombosis. Common mechanical methods include intermittent pneumatic devices (IPC), graduated compression stockings (GCS), and venous foot pump (VFP). Previous studies have shown that elastic stockings are not contraindicated in surgery due to reduced circulation rate, application of muscle relaxants, and the increased risk of falls. Hence, IPC is preferred because the surgical procedures are unaffected [10, 14, 15]. National and international guidelines advocate for the early and continuous use of IPC during and post-surgery until discharge [8‐15].
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Although mechanical prevention methods offer a relatively high safety profile, careful assessment and standardized application of IPC devices are essential during surgery to mitigate risks of adverse events, such as skin ulceration and pressure necrosis. These methods are contraindicated in specific patient populations. Currently, the utilization of intraoperative IPC has not been included in hospitals’ surgical nursing routines. There are various challenges including the lack of uniform norms for IPC usage timing, duration, pressure settings, frequency, and process management; unclear indications and contraindications for IPC device use intraoperatively; insufficient knowledge among clinical nurses regarding the use of IPC devices; and a lack of evidence-based utilization standards, leading to low clinical execution rates and compliance.
The growing emphasis on VTE prevention underscores the urgent need for developing standardized intraoperative IPC utilization. This research utilized the Joanna Briggs Institute’s Practical Application to Clinical Evidence Model to implement best practice guidelines for intraoperative IPC in our clinical setting. By synthesizing existing evidence, this study will develop a standardized framework for intraoperative IPC implementation across various healthcare settings. This framework emphasizes prevention and management strategies for VTE while providing practical guidance for clinical application. Additionally, it seeks to strengthen IPC-associated knowledge training, foster multidisciplinary collaboration among medical staff, promote the integration of evidence-based knowledge, improve standard execution rates, and enhance medical staff compliance in the operating room. The ultimate goal is to ensure the safety of IPC treatment, effectively reduce intraoperative IPC-associated adverse events, and mitigate the risks of intraoperative VTE.
Methods
The project was approved by the Ethics Committee of our hospital (2022-001-12). All patients had signed informed consent for the trial. For convenience, 22 operation rooms were selected from a hospital in Xiangyang, China. Patients who underwent surgeries from January 2023 to October 2023 in the selected operating rooms were enrolled. To ensure that the subjects were representative, the participants were selected from eight different surgical departments, including general surgery, orthopedics, neurosurgery, obstetrics, gynecology, cardiothoracic surgery, urology, otolaryngology surgery and stomatology. Inclusion criteria: ① age ≥ 18 years old, hospital stay ≥ 2 days; ② elective surgery patients; ③ informed consent and voluntary participation in the study; ④ ability to tolerate ultrasound examination. Exclusion criteria: (any of the following were excluded): ① VTE diagnosed before surgery; ② local anesthesia; ③ patients who did not complete the relevant examinations before surgery. Additionally, 109 professional operating room nurses (four with master degrees and 105 with bachelor degrees) were enrolled. The performance of the proposed evidence-based practice was evaluated based on the control test of the nurses before and after and the non-concurrent control test of patients.
In this project, we employed the Joanna Briggs Institute’s JBI PACES and GRiP tools to effectively translate research evidence into practical clinical applications. The tools are applied in three stages: (1) establishment of project teams and development of review indicators based on the best evidence for a baseline review; (2) based on the results of the baseline review, the project team designed different strategies to address non-compliance issues and barriers identified in the baseline audit; (3) follow-up review to evaluate the outcomes of interventions applied to improve practice, and identify practice issues that need to be addressed in future studies.
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Phase 1: Stakeholder engagement (or team establishment) and baseline audit
Team establishment
The project was supervised by the director of the nursing department, who provided the coordination and support. In the operating room, the chief nursing officer acted as the deputy team leader, responsible for project coordination and promotion. Moreover, three chiefs of surgical nurses and seven sub-specialty heads in the operating room acted as project members, organizing training, analyzing barriers, developing EBP, applying evidence, and collecting data. Three nursing research experts, all with master’s degrees and training in evidence-based practices, were responsible for evidence retrieval, quality assessment, summarizing evidence, data analysis, and report writing.
Audit criteria
Three operating room nursing researchers with expertise in evidence-based nursing independently assessed the quality of included studies. Disagreements were resolved through consensus-building discussions involving corresponding authors (operating room nursing managers with evidence-based methodology training) and additional evidence-based medicine experts. A total of 11 articles met the literature inclusion criteria, including six guidelines [8, 9, 14, 16‐18], three expert consensus articles [8, 15, 19], one systematic evaluation [20], and one RCT [21]. The evidence-based project team systematically extracted relevant evidence content and sources, following high-grade, high-quality, and latest publication principles to extract evidence [22]. The extracted evidence covered pre-use assessment (assessor, assessment tool, assessment content, indications, contraindications), pneumatic compression instrument selection (type, mode, pressure), pneumatic compression process management (timing of compression, duration, and frequency of compression, method of use, precautions for use), and observation and management complication, amounting to a total of 22 best evidence. We conducted a baseline review on the 12 best evidence-based review indicators to determine the adherence to best practice recommendations. Table 1 shows the audit criteria, samples, and methods for intraoperative IPC (see Table 1).
Table 1
Review criteria and methods for the prevention of venous thrombosis by intraoperative IPC
Item | Audit criteria | Sample | Method to evaluate compliance to best practice | ||
|---|---|---|---|---|---|
Evaluation before use | Staff | 1. Nurses shall use IPC as suggested by the doctors, and confirmed with the surgical doctors and anesthesiologists before execution | Baseline audit=372 patients Follow-up audit=405 patients | Direct perioperative observation Checking soft copy of medical advice and medical record Considered as `YES’ when IPC was used as suggested by the doctors, and its utilization was executed after confirmation with surgical doctors and anesthesiologists | |
Tool | 2. Nurses shall conduct risk assessment of venous thrombosis by using the Scale of Risk Assessment for Venous Thrombosis in the Operating Room, and determine the risk level based on the scale and the results of Caprini risk assessment | Baseline audit=372 patients Follow-up audit=405 patients | Direct perioperative observation Healthcare Record Considered as `YES’ when the Scale of Risk Assessment for Venous Thrombosis in the Operating Room was used for risk assessment of venous thrombosis | ||
3. Ultrasound examination of lower limb venous was conducted before surgery, as suggested by the surgical doctors | Baseline audit=372 patients Follow-up audit=405 patients | Checking soft copy of medical advice and medical record Considered as `YES’ when ultrasound examination of lower limb venous was conducted before surgery | |||
Content | 4. Before utilization of IPC, nurses shall thoroughly evaluate equipment utilization, patient compliance, lower limb skin integrity and contraindication of IPC | Baseline audit=372 patients Follow-up audit=405 patients | Direct perioperative observation Considered as `YES’ when equipment utilization, patient compliance, lower limb skin integrity and contraindication of IPC were thoroughly evaluated | ||
Equipment | Type | 5. Nurses shall determine the type and mode of IPC based on the patient preference, surgical method, and position arrangement, as well as the practical conditions | Baseline audit=372 patients Follow-up audit=405 patients | Direct perioperative observation Considered as `YES’ when appropriate type and mode of IPC were selected Considered as `NO’ when inappropriate type and mode of IPC were selected | |
Pressure | 6. A dedicated device was used for thrombus prevention, wherein no pressure adjustment module was present on the main panel. The default pressure was assumed to be within the designated range: pressure (35–40 mmHg) was applied to the thighs and/or calves, inflate the legging for approximately 10 s per time, and then relax for 1 min. Repeat the cycle for several times. | Baseline audit=372 patients Follow-up audit=405 patients | Direct perioperative observation Considered as `YES’ when pressure, frequency, and interval of IPC were in the designated ranges | ||
Process | Moment | 7. IPC can be used before anesthesia for patients with moderate or high risk levels of venous thrombosis, provided that relevant contraindications had been excluded. IPC should be maintained during and after surgery | Baseline audit=372 patients Follow-up audit=405 patients | Direct perioperative observation Considered as `YES’ when IPC was applied before anesthesia and not terminated during or after the surgery Considered as `NO’ when IPC was not conducted before anesthesia or terminated during or after the surgery | |
Duration and frequency | 8. For patients undergoing surgery with high risks of thrombosis, the IPC was used twice and each time lasted for 40 min | Baseline audit=372 patients Follow-up audit=405 patients | Direct perioperative observation Considered as `YES’ when the duration and frequency of intraoperative IPC were correct | ||
Method | 9. Medical staff were trained for IPC utilization | Baseline audit=372 patients Follow-up audit=405 patients | Training plan managed by the clinical nursing educator Considered as `YES’ if the medical staff had received training on the standard use of IPC | ||
Notes | 10. Nurses should ensure that the IPC pumps are connected as designed and that the legging is free from folds. Specifically, wrap the legging around the thin and flat pant. When fixing the sleeve, leave a gap of two fingers between the leg compression band and the calf. When fixing the legging, leave a gap of two fingers between the leg compression band and the calf. The connecting tube was arranged on the outer side of the legging and keep it warm. | Baseline audit=372 patients Follow-up audit=405 patients | Direct perioperative observation Considered as `YES’ when the IPC pump was connected as designed and the legging was comfortable and safe | ||
11. During IPC, legging/foot cover and tubes should be thoroughly checked after intraoperative position change | Baseline audit=372 patients Follow-up audit=405 patients | Direct perioperative observation Considered as `YES’ when legging/foot cover and tubes were thoroughly checked after intraoperative position change Considered as `NO’ when egging/foot cover and tubes were not thoroughly checked after intraoperative position change | |||
Complication | Observation and treatment | 12. Nurses should conduct dynamic intraoperative evaluation and observe limb conditions. In addition, nurses shall evaluate and report skin discoloration, blisters, pressure injury, circulatory disorders, and skin allergies of lower limbs, as well as osteomental compartment syndrome. In these cases, IPC shall be terminated and the adverse events shall be reported. | Baseline audit=372 patients Follow-up audit=405 patients | Direct perioperative observation Healthcare Record Considered as `YES’ when dynamic intraoperative evaluation was conducted, limb conditions were observed, and adverse reactions/events were recorded | |
Baseline audit
A baseline review was conducted from January to March 2023, encompassing 372 surgical patients and 109 operating room nurses from our hospital’s central operating room. The review assessed three key areas: process adherence to IPC guidelines, patient outcomes including hemodynamic changes, venous thrombosis, and IPC-related adverse events, and nurse knowledge and practices regarding IPC and venous thrombosis prevention. The details were as follows.
Process level Execution rates of different indicators for preventing surgical venous thrombosis by intraoperative IPC were recorded as Y for behaviors that conform, N for those that did not conform, and NA for those that were not applicable. Execution rate = number of people who chose Y/ (total number of people who chose Y + N) × 100%. Data collection methods included interviews, on-site verification, and review of electronic medical record systems.
Patient level(1) Intraoperative IPC-associated adverse event rate
Patients undergoing intraoperative IPC were monitored for signs of impaired limb blood flow, including skin temperature and color changes, dorsalis pedis pulse status, and the presence of pain, numbness, itching, or discomfort. The presence of skin discoloration, blisters, pressure injuries, lower limb circulatory disturbances, skin irritation, and osteo-facial compartment syndrome in the patient’s lower limbs were considered indicative of IPC-associated adverse events. (2) Occurrence rate of VTE: Patients were monitored for swelling, pain, and elevated skin temperature of the affected limb for three days post-operation. If there is an abnormality, a Color Doppler ultrasound examination is performed to determine the occurrence of thrombosis. Diagnostic criteria for DVT included low or no echoes in the venous lumen on color ultrasound, the inability of the probe to adequately deflate the pressurized venous vessel, and a “cut-off” or “track” blood flow signal. The occurrence rate of lower limb deep venous thrombosis = number of cases in the group/total number of patients in the group x 100%. (3) Venous hemodynamics indicators: At two-time points, one before the induction of anesthesia and another 10 min after stable extubation, our group’s ultrasound-trained anesthesiologist employed a color Doppler ultrasound machine to examine the femoral and popliteal veins in the bilateral lower limbs of each patient. The diameter and the mean velocity of blood flow were measured and recorded. Blood flow velocity measurements were obtained at two time points for comparative analysis. A convenience sample of 50 patients underwent ultrasound examinations both pre- and post-EBP. Due to operational constraints, ultrasound examination was limited to 50 participants selected from eight surgical departments: general surgery, orthopedics, neurosurgery, obstetrics and gynecology, cardiothoracic surgery, urology, otolaryngology, and stomatology.
Practitioner level A self-designed test paper was used to assess the mastery of evidence related to preventing surgical venous thrombosis by intraoperative IPC among 109 medical staff before and after EBP (Questionnaire 1: Questionnaire about preventing venous thrombosis through intraoperative intermittent pneumatic compression). The test covered risk factors associated with VTE, patients’ VTE assessment content and methods, indications and contraindications for VTE mechanical prevention, intraoperative IPC usage, intraoperative IPC-associated adverse effects, and treatment countermeasures. Comprising 20 multiple-choice questions, in five aspects, the test had a maximum score of 100 points, and a score ≥ 80 indicated qualification.
Phase 2: Design and implementation of strategies to improve practice (Getting Research into Practice),
Barrier analysis
Based on the results of the baseline review, the project team held an expert meeting to analyze the barriers within the hospital’s specific clinical context. The barriers were identified and analyzed as follows: (1) lack of awareness and insufficient attention by the medical staff in the operating room to the best evidence for the prevention of intraoperative venous thrombosis in patients with intraoperative intermittent pneumatic compression; (2) lack of operational procedures and management systems related to the prevention of intraoperative venous thrombosis in patients with intraoperative intermittent pneumatic compression; (3) lack of assessment tools and insufficient awareness of assessment: the special “Operating Room Venous Thrombosis Risk Assessment Scale” was not developed and applied, and the “Surgical Caprini Venous Thrombosis Risk Assessment Model” failed to address many of the key intraoperative thrombosis high-risk factors, making it impossible to carry out accurate and effective assessment; before the use of intraoperative IPC, the surgical team had the problems of untimely assessment, insufficient awareness of assessment, and insufficient assessment execution; (4) the surgeons who used IPC during the surgery did not issue the medical prescription in a timely manner, and had the problems of insufficient awareness and low execution, affecting the operating room nurses’ compliance with the medical prescription for the use of IPC during the surgery. (5) The surgeons did not conduct comprehensive preoperative ultrasound screening of lower limb veins, affecting the standardized use of IPC during surgery; (6) insufficiently equipped pneumatic compression devices: the current operating rooms were not equipped with enough IPC models and equipment. Thus, it was inconvenient to place the tubing when IPCs were used for the patients in the lateral position during surgery, and it was difficult to use both legs simultaneously, which increased the risk of intraoperative acquired pressure injuries; (7) poor cooperation among the nurses in the operating room, the surgeons and anesthetists, and lack of multidisciplinary team management.
Practice change
We established action plans based on the analyzed barriers, required resources and strategies to be implemented to overcome these barriers. Two rounds of expert consultations were conducted with twelve operating room nursing specialists from four tertiary hospitals in Hubei province. These specialists held positions as deputy chief nurses or above and possessed at least nine years of operating room experience. The aim of these consultations was to assess the feasibility and importance of proposed action strategies. The significance and feasibility of the plan were evaluated using a 5-point Likert scale (1: not feasible/important, 5: very feasible/important). Initial feedback from twelve expert nurses was unanimous regarding the plan’s importance, but three identified feasibility concerns, rating it as a 2. These experts suggested refinements to procedure presentation, training methods, and the Operating Room Venous Thrombosis Risk Assessment Scale. Incorporating this feedback led to a revised plan, which was then re-evaluated. The revised plan garnered unanimous approval from all twelve experts, with both importance and feasibility rated at the highest level (5 points). This endorsement validated the plan’s significance and practicality, paving the way for its implementation.
(1) Evidence-based development of standard operating procedures for intraoperative use of IPCs.
An evidence-based practice group was established, and the core group of evidence-based practice organized surgeons, anesthesiologists, and specialist nurses in the operating room to conduct on-site discussions and combined with the best evidence for FAME evaluation to reach a consensus on the process and goals and to establish clinically relevant processes and management measures, including the operational procedures, management processes, and adverse event management processes for the use of IPC for the prevention of venous thrombosis during surgery. ① Based on evidence and IPC product manuals, a “Standard Operating Procedure for Intraoperative Use of IPC” was developed to introduce the best evidence to clarify the specific time points of intraoperative pressurization, duration, and frequency of pressurization, pressure settings, and usage precautions, and organize and incorporate them all into the operating procedure. Meanwhile, simplified versions of the operating procedure were developed to form a flowchart to be posted on the IPC device to realize visual management. ② The information exchange and collaboration between medical staffs were enhanced, and the updated management processes were implemented, which included the assessment, use and observation records. During preoperative visits, the operating room nurses utilized a self-made “Operating Room Venous Thrombosis Risk Assessment Scale” to perform initial risk scoring. They reminded the surgeon to prescribe based on this pre-scoring and conducted preoperative ultrasound screening of the lower limb veins. Upon entering the operating room, the surgeon performed a thorough risk assessment, patient evaluation, and equipment check according to the “Mechanical Prevention Assessment Checklist” to enhance the accuracy of the assessment. During the operation, IPC was applied as per the surgeon’s prescription, following the “Operation Procedure for the Standardized Use of IPC During Surgery” for standardized procedures. I addition, the duration, start and end times of IPC pressurization, any adverse reactions experienced by the patient, and the measures taken during surgery were recorded in the “Operating Room Venous Thrombosis Risk Assessment Scale.”
(2) Development of an Operating Room -Specific Venous Thrombosis Risk Assessment Scale.
The multidisciplinary evidence-based practice team conducted an evidence-based “Summary of the Best Evidence on Venous Thrombosis Risk Factors in the Operating Room”, compiled the high-risk factors for intraoperative venous thrombosis in the operating room, constructed an initial pool of entries, and formed the operating room-specific “Operating Room Venous Thrombosis Risk Assessment Scale (Adult Version)” by Delphi expert enquiry. The Scale was validated in 210 surgical patients in the clinical practice, and had good reliability and predictive value. The Cronbach’s ɑ coefficient of the scale was 0.831. The content included 17 items in three dimensions: patient-related factors (age, BMI, comorbidities, past medical history and family history), surgical/operational-related factors (operation time, operation mode, operation type, anesthesia mode, ASA classification, and operation position), and intraoperative special circumstances (intraoperative hypothermia, intraoperative tourniquet, pneumoperitoneum pressure, bone cement, blood product infusion, expected bleeding volume, and central venous catheterization). Furthermore, the “Operating Room Venous Thrombosis Risk Assessment Scale” was embedded into the nursing documentation system to achieve informatization and systematization, clear the assessment tool and assessment time, and standardize related nursing documentation writing.
(3) Online + offline training of the team containing surgeons, nurses, and anesthetists on evidence-based project knowledge.
Key elements of the “Standard Operating Procedure for Intraoperative Use of IPC” were incorporated into an instructional operating room video, emphasizing precautions based on surgical type, modality, and patient positioning. This video was uploaded to the “Palm Medicine Classroom” for integrated online learning among surgeons, nurses, and anesthetists. In addition, the standard operating procedure was translated into on-site assessment criteria for operating room nurses. Offline workshops were conducted to enhance knowledge of IPC indications, contraindications, assessment tools, timing, venous thrombosis prevention strategies, and the importance of ongoing education and evaluation. Based on the best evidence, the VTE prevention system for the operating room, training and assessment standards, quality assessment standards, and nursing documentation standards were developed and updated regularly; the nurse manager periodically supervised the implementation of the system, inspected and supervised the actual operation and implementation of the staff in each position through the process of inspection, and conducted on-site assessment.
(4) Introduction and improvement of IPC equipment.
Two types of IPC equipment were introduced to the department, and IPC devices at a ratio of 1:1 were configured in 22 operating rooms. To meet the different surgical positions such as lithotomy position, lateral position, the IPC device was improved, including the modification of the IPC style to meet the different intraoperative positions, the increase of the internal liner of the sleeve, and the reduction of the occurrence of pressure injuries, allergies and other adverse events, and patents was applied.
(5) Conducting evidence-based practice facilitation sessions and strengthening multidisciplinary teamwork.
The evidence-based practice group, led by the director of the nursing department and co-chaired by the chief nurse of the operating room, placed significant emphasis on promoting evidence-based practice through strong leadership. A thrombosis management specialist was appointed to introduce the best evidence and update the procedures accordingly. A multidisciplinary team participates in meetings to interpret the evidence and delineate specific roles, timelines, and tasks for each step of the process. The team emphasized the importance of preoperative lower limb ultrasound screening based on preoperative assessment results, and the need for a physician’s order prior to intraoperative intermittent pneumatic compression (IPC) use, to be documented by the anesthesiologist. Surgeons were tasked with understanding and adhering to IPC protocols without compromising surgical workflow, while operating room nurses were responsible for effective communication and collaboration with the surgical team throughout the procedure.
Phase 3: Follow-up audit post-implementation of change strategy
Following the implementation of evidence-based practice, a second round of quality review, identical in content to the baseline review phase, was conducted from August 2023 for two months. This review involved 109 nurses working in the central operating room and 405 patients who underwent surgery in the same operating room during this period. Due to the limitations of operating room capacity and clinical conditions, it was not feasible to perform ultrasound examinations on all patients for venous blood fluid mechanics analysis. Instead, 50 participants were selected from eight operating rooms associated with general surgery, orthopedics, neurosurgery, obstetrics and gynecology, cardiothoracic surgery, urology, otolaryngology, and stomatology for ultrasound examination.
Data were entered and analyzed using the SPSS 24.0 software. Measurement data, conforming to normal distribution, were presented as the mean ± standard deviation. A t-test was employed to compare the two groups, while count data were described using frequency and percentage. The chi-square test was used to compare two groups, with statistical significance set as P < 0.05.
Results
Process level
Execution rates of different indicators by surgical nurses before and after EBP
After the evidence-based practice, all review indicators were significantly improved (P < 0.01); 9 of the indicators reached 100%, and the standard implementation rates of five indicators increased from 0 to 100%. Overall, the efficacy of the clinical practice was significant (see Table 2).
Table 2
Execution rates of different indicators before and after EBP
indicators | Before EBP (%) (n = 372) | After EBP (%) (n = 405) | X2 | P value |
|---|---|---|---|---|
Indicator 1 | 184 (40) | 344 (85) | 112.061 | < 0.001 |
Indicator 2 | 0 | 405 (100) | 777.000 | < 0.001 |
Indicator 3 | 167 (45) | 397 (98) | 275.091 | < 0.001 |
Indicator 4 | 216 (58) | 405 (100) | 212.504 | < 0.001 |
Indicator 5 | 201 (54) | 405 (100) | 238.702 | < 0.001 |
Indicator 6 | 0 | 405 (100) | 777.000 | < 0.001 |
Indicator 7 | 0 | 405 (100) | 777.000 | < 0.001 |
Indicator 8 | 0 | 405 (100) | 777.000 | < 0.001 |
Indicator 9 | 0 | 405 (100) | 777.000 | < 0.001 |
Indicator 10 | 257 (69) | 397 (98) | 121.869 | < 0.001 |
Indicator 11 | 149 (40) | 405 (100) | 340.509 | < 0.001 |
Indicator 12 | 186 (50) | 405 (100) | 202.084 | < 0.001 |
Patient level
(1) Intraoperative IPC-associated adverse event rate.
Before EBP, nine cases of IPC-associated adverse events, including four cases of skin redness, three cases of skin allergy, and two cases of lower limb circulation disorder, were observed, resulting in an occurrence rate of 2.4%. No IPC-associated adverse events were recorded after EBP, and the difference was statistically significant (X2 = 9.913, P < 0.01), indicating a positive clinical practice effect.
(2) Risk of intraoperative VTE before and after EBP.
Two cases of intraoperative venous thrombosis events were observed before EBP, resulting in an occurrence rate of 0.53%. No venous thrombosis events were recorded after EBP; the difference was not statistically significant (X2 = 2.171, P = 0.141 > 0.05). However, a statistically significant difference in intraoperative venous hemodynamics between the two groups during surgery (P < 0.05) (see Tables 3, 4 and 5).
Table 3
Baseline data of the two groups before and after evidence-based practice
Item | Control (n = 50) | Experimental (n = 50) | Statistical value | P |
|---|---|---|---|---|
Age | 50.64 ± 11.49 | 52.16 ± 10.30 | -0.697a | 0.488 |
BMI | 20.51 ± 2.28 | 21.15 ± 2.37 | -1.376a | 0.172 |
Operation duration | 4.26 ± 1.25 | 4.44 ± 1.33 | -0.699a | 0.486 |
Hypertension | 0.078b | 0.779 | ||
Yes | 8 | 7 | ||
No | 42 | 43 | ||
Diabetes | 0.211b | 0.646 | ||
Yes | 2 | 3 | ||
No | 48 | 47 | ||
Intraoperative blood loss | 0.379b | 0.538 | ||
≤ 500 mL | 45 | 43 | ||
> 500 mL | 5 | 7 |
Table 4
Bilateral femoral vein blood flow velocity and vascular diameter size before and after EBP (\(\:\stackrel{-}{\mathbf{X}}\)±s)
indicators | right lower limb | left lower limb | ||
|---|---|---|---|---|
differential femoral vein blood flow velocity (cm/s) | vascular diameter (cm) | differential femoral vein blood flow velocity (cm/s) | vascular diameter (cm) | |
Before evidence application (n = 50) | 7.18 ± 0.43 | 0.47 ± 0.12 | 6.96 ± 0.71 | 0.56 ± 0.21 |
After EBP (n = 50) | 3.12 ± 0.60 | 0.79 ± 0.09 | 3.47 ± 0.89 | 0.82 ± 0.11 |
t value | 38.785 | -14.527 | 21.575 | -7.683 |
P value | < 0.001 | < 0.001 | < 0.001 | < 0.001 |
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Table 5
Bilateral popliteal vein blood flow velocity and vascular diameter size before and after EBP (\(\:\stackrel{-}{\mathbf{X}}\)±s)
indicators | right lower limb | left lower limb | ||
|---|---|---|---|---|
differential popliteal vein blood flow velocity (cm/s) | vascular diameter (cm) | differential popliteal vein blood flow velocity (cm/s) | vascular diameter (cm) | |
Before evidence application (n = 50) | 5.82 ± 1.59 | 0.69 ± 0.24 | 4.97 ± 1.68 | 0.65 ± 0.24 |
After EBP (n = 50) | 2.65 ± 1.04 | 0.89 ± 0.14 | 2.31 ± 0.81 | 0.86 ± 0.13 |
t value | 11.759 | -4.989 | 10.050 | -5.526 |
P value | < 0.001 | < 0.001 | < 0.001 | < 0.001 |
Practitioner level
Mastery of knowledge of standardized utilization of intraoperative IPC by surgical nurses before and after EBP
Following EBP, surgical nurses demonstrated a knowledge score for preventing surgical venous thrombosis through standardized utilization of intraoperative IPC of (93.34 ± 3.64), exeeding the pre-EBP (67.55 ± 5.45). The difference in scores before and after training was statistically significant (P < 0.01).
Discussion
EBP improves surgical nurses’ execution rates for evidence
Many scholars recognize the importance of mechanical prevention of thrombosis in surgical patients, advocating for its implementation earlier during surgery or even before anesthesia [23]. Despite this awareness, there are no standardized, evidence-based guidelines detailing the timing, duration, pressure settings, frequency, and other specifics of IPC use. Furthermore, the stringent aseptic conditions mandated within the operating room, compounded by the intricate nature of surgical interventions, pose substantial obstacles to the consistent adherence to IPC protocols [24]. Consequently, surgical nurses and physicians face difficulties in acquiring knowledge, confidence, and proficiency in the standardized use of intraoperative IPC.
The nursing department initiated evidence interpretation meetings to promote EBP and enhance collaboration among physicians, nurses, and anesthesiologists in applying evidence. Leveraging leadership for change, the department also conducted barrier analyses and formulated corresponding strategies to ensure EBP implementation. Post-EBP, execution rates for 12 indicators increased from 0 ~ 69–85%~100%, with 9 pieces of evidence achieving a clinical execution rate of 100%. This suggests improved application of most evidence in clinical practice and underscores the viability of EBP, demonstrating clinical practitioners’ recognition of the best evidence. These experiences and results serve as valuable references and inspiration for operating rooms in other medical institutions.
EBP reduces intraoperative VTE risk and IPC-associated adverse events
A comprehensive system for risk assessment and prevention of venous thrombosis in hospitalized patients has been established globally [25]. Despite advancements, the intraoperative phase remains a critical area for refining risk assessment and prevention strategies for venous thrombosis. The absence of standardized venous thrombosis risk assessment tools and intraoperative prevention protocols, coupled with inconsistent mechanical prophylaxis practices, contributes to ongoing challenges in this domain. In this study, IPC during surgery was conducted in line with the best evidence: (1) pre-operative assessment: for IPC use during surgery, the surgical team needs to make use of professional risk assessment tools and ultrasound screening to evaluate the patient’s condition, thrombosis risk, and indications and contraindications for IPC use before surgery; (2) pneumatic compression instrument selection: For IPC use during surgery, patients’ factors, surgical modality, type of surgery and positioning method should be considered when choosing the type, mode, and pressure of the device; (3) pneumatic compression process management: For the use of IPC during surgery, pneumatic compression process management needs to be strictly carried out, strictly adhering to the timing, duration, and frequency of compression, along with necessary precautions; (4) observation and management of complication: For the use of IPC during surgery, the surgical team is able to observe and manage intraoperative IPC-associated complications in a timely and effective manner. Post-EBP significantly reduced intraoperative VTE risk and IPC-associated adverse event rates (P < 0.05), indicating significant improvement in preventive effectiveness.
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EBP enhances surgical nurses’ knowledge of standardized utilization of intraoperative IPC
In this study, the scores of surgical nurses’ knowledge of standardized utilization of intraoperative IPC significantly increased after applying EBP (P < 0.05). This suggests that EBP effectively improved surgical nurses’ knowledge about standardized intraoperative IPC utilization. Before EBP, despite growing awareness of thrombosis, surgical nurses in the operating theatre did not fully understand the significance of intraoperative risk assessment and early prevention of thrombosis. The related knowledge remained at the superficial cognitive level, lacking systematic training and work guidelines [26, 27].
An evidence-based team was convened to conduct a comprehensive literature search, appraise study quality, extract relevant data, and grade the evidence. This systematic process informed the development of best practice guidelines for the prevention and management of intraoperative infection. It aimed to continuously standardize the intraoperative IPC risk assessment, operational procedures, and management points, making intraoperative venous thrombosis mechanical prevention more standardized, reasonable, and safe. Surgical nurses must possess a thorough understanding and proactive attitude toward intraoperative risks as the primary individuals responsible for intraoperative patient management. To ensure the safety and effectiveness of mechanical prevention during surgery, the surgical team should receive ongoing training and education. They need to understand the indications and contraindications for using IPC, acquire comprehensive knowledge about the procedure, and master the methods for observing and managing IPC-associated complications.
Conclusion
VTE prevention within the operating theatre plays a crucial role in managing VTE in surgical patients. In clinical practice, the medical personnel in the operating room should combine the specific clinical situation, adhere to individualization principles, judiciously apply evidence, and regularly update, train, supervise, analyze, and improve practices to ensure the safety of intraoperative mechanical prevention. However, a systematic evaluation of intraoperative VTE mechanical prevention instruments conducted abroad [28] suggests that IPC may exhibit superiority over GCS when employed as a single preventive device. Furthermore, the combination of IPC and GCS may prove more effective than GCS alone, particularly in high-risk patient populations. However, additional high-quality studies are advovated to explore the clinical relevance and address safety issues. These studies should specifically investigate the combination of mechanical prevention methods, compare them with IPC alone, and address high-risk surgical environments where drug-based prevention is contraindicated.
The limitations associated with this study, Selection bias exists in this study because complete random sampling was not observed owing to limitations such as operation room conditions and availability, complicated team coordination and limited manpower. Instead, convenience sampling was adopted based on practical conditions of different departments. To maximize the representativeness of the enrolled samples, patients were collected from eight different surgical departments (General Surgery, Orthopedics, Neurosurgery, Obstetrics and Gynecology, Cardiothoracic Surgery, Urology, Otolaryngology, and Stomatology) as 95% of operations in this hospital are performed in these departments. By adopting this approach, the selection bias was partially reduced.It is recommended that in the subsequent period, relevant studies with large samples, multi-centers and random sampling can be further conducted to verify clinical effectiveness and promote subsequent clinical practice.
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Acknowledgements
The authors gratefully acknowledge the invaluable contributions of all the reviewers who participated in the review process. We would also like to thank MJEditor (https://www.mjeditor.com/) for editing the language of the manuscript.
Declarations
Ethics approval and consent to participate
This project has been approved by the Ethics Committee of Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science (No. 2022-001-12). All participants have signed informed consent forms.
Consent for publication
Not Applicable.
Competing interests
The authors declare no competing interests.
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