Running head: PICOT PROPOSAL 1

Picot Proposal
Alyssa Blumenthal
University of South Florida




















PICOT PROPOSAL 2
University of South Florida College of Nursing
NUR 4169C EBP for the Baccalaureate Prepared Nurse
PICOT Proposal Form
Briefly describe the
opportunity for clinical
improvement.
In post-surgical patients the use of intermittent compression
stockings reduces the risk of deep vein thrombosis, however there
is no reliable evidence existing about its effectiveness in patients
who have had a stroke and are immobile. This research assesses
the effectiveness of intermittent compression stockings for an
immobile patient who has had a stroke versus the effectiveness of
gradual compression stockings. The trial suggests that the use of
intermittent compression stockings for a patient who has suffered
a stroke and is immobile is effective in reducing the risk of deep
vein thrombosis and possibly improving survival in said patient
population while GCS is not as effective.
Why is this issue important
for your clinical setting or
organization?
Although the standard of care is for all patients to utilize
intermittent pneumatic compression stockings, during their
hospitalization, many patients choose not to use them due to
finding them uncomfortable and a variety of other personal
reasons. Especially on a neurological floor it is vital that patients
who have suffered a stroke and are immobile are using
intermittent pneumatic compression stockings to reduce their
risk of developing deep vein thrombosis. The use of gradual
compression stockings while also utilized greatly have been
shown to increase skin breakdown, ulcers and necrosis and are
proven to be less effective than IPC devices.
List 1-2 background
pertinent questions.
Do intermittent pneumatic compression stockings reduce an
immobile stroke patients risk of developing deep vein thrombosis
and improve survival rate more so than graduated compression
stockings?
State the PICOT question.

In patients aged 60-100 years of ago who have had a stroke and
are immobile does the use of intermittent pneumatic compression
devices reduce the risk of deep vein thrombosis versus the use of
graduated compression stockings during their hospital stay and
10 days following discharge?
P The patients average between 60 and 100 years of age, have
had a stroke and are immobile.
I The indicated intervention is to use either gradual
compression stockings or intermittent pneumatic compression
devices based on what evidenced based practice determines is
more effective for this patient population.
C- This study compares the use of gradual compression stockings
versus intermittent pneumatic compression devices.
O The expected outcome is a reduction in the prevalence of
deep vein thrombosis for patients who have experienced stroke
and are immobile.
T- During hospitalization and ten days following discharge
PICOT PROPOSAL 3


Describe the ideas you
have for solving the
problem.

Currently the standard of care is for all hospitalized patients to
utilize intermittent pneumatic compression stockings during their
stay. However, for immobile stroke patients it is especially crucial
for them to utilize IPC stockings while at the hospital and also
following their discharge. If evidence based practice indicates
that regulating the use of IPC stockings for immobile stroke
patients during their stay and providing immobile stroke patients
with IPC stockings upon discharge reduces the risk of developing
DVT and improves survival rate it should be incorporated into
the standard of care. This would enable the hospital to reduce the
percentage of DVT related complications in a patient population
that is at very high risk.
What do you hope to
achieve?

I would like to incorporate a strict regulation of the use of
intermittent pneumatic compression stockings in the immobile
stroke patient population during their hospital stay as well as
provide these patients with IPC machines to take home upon
discharge and thus use daily. The primary goal is to achieve
decreased rates of DVT in this patient population.



How will you measure the
outcome of your practice
improvement?


The outcome of this change will be measured by assessing the
rates of DVT in immobile stroke patients who use IPC stockings
versus those patients who do not use IPC stockings as well as
those who just use graduated compression stockings. The results
will be compared and evaluation will be made on the effectiveness
of IPC stockings in this patient population.

Identify the members of
your proposed project team
by position or job title and
their roles.

Clinical Nurse supervisor- The nurse supervisor can provide the
IPC stocking machines and incorporate the new regulation into
the standard of care for the neurological floor.
Charge nurse- The charge nurse can track the use of the IPC
stockings being used by the patient population being monitored
and enforce rules and regulations regarding patient teaching and
usage.
Staff Nurses- Staff nurses will teach patients the importance of
using IPC stockings and encourage the continued use of them. If
patient is not alert and oriented the nurse will put IPC stockings
on the patient at all appropriate times. The nurse will also
document the use of the IPC stockings.
Institution where the
project might be
implemented in the future.
Intermittent pneumatic compression stockings can be used in
almost all clinical, medical and nonmedical settings; inpatient or
outpatient. This includes hospitals, homes and assisted living
facilities.
PICOT PROPOSAL 4




List 3 peer reviewed
research papers that will
provide the evidence for
the PICOT


1. Dennis, M., Sandercock, P., Reid, J., Graham, C.,
Forbes, J., & Murray, G. (2013). Effectiveness of
intermittent pneumatic compression in reduction of risk
of deep vein thrombosis in patients who have had a
stroke (CLOTS 3): a multicentre randomised controlled
trial. Lancet, 382(9891), 516-524. doi:10.1016/S0140-
6736(13)61050-8

2. Dennis, M., Sandercock, P., Reid, J., Graham, C.,
Murray, G., Venables, G., & ... Bowler, G. (2009).
Effectiveness of thigh-length graduated compression
stockings to reduce the risk of deep vein thrombosis
after stroke (CLOTS trial 1): a multicentre, randomised
controlled trial. Lancet, 373(9679), 1958-1965.
doi:10.1016/S0140-6736(09)60941-7

3. Taniguchi, S., Fukuda, I., Daitoku, K., Minakawa, M.,
Odagiri, S., Suzuki, Y., & ... Ohkuma, H. (2009).
Prevalence of venous thromboembolism in neurosurgical
patients. Heart & Vessels, 24(6), 425.
doi:10.1007/s00380-008-1135-9





PICOT PROPOSAL 5
Annotated Bibliography
Dennis, M., Sandercock, P., Reid, J., Graham, C., Forbes, J., & Murray, G. (2013). Effectiveness
of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients
who have had a stroke (CLOTS 3): A multicentre randomised controlled trial. Lancet,
382(9891), 516-524. doi:10.1016/S0140-6736(13)61050-8

The CLOTS 3 trial was conducted between December 8, 2008 and September 6, 2012.
2,876 patients were enrolled in 94 centers in the United Kingdom. The participants were a broad
representation of immobile stroke patients admitted to the hospital. The median age was 76. In
this trial patients were randomly allocated to receive IPC or no IPC. At 7-10 days patients were
given a compression duplex ultrasound of both legs and then when necessary 25-30 days after
enrollment. For 6 months patients were monitored for DVT. The results of this trial showed that
IPC is an effective method of reducing the risk of DVT and possibly improving survival in a
wide variety of patients who are immobile after stroke.
The strengths of this study are that it accounts for a very prevalent and specific patient
population however a weakness may lie in the fact that due to the average age of the population
under study, many patients may have underlying medical conditions which could contribute to
premature death and thus make it more difficult to analyze the findings.
This journals source is the Lancet which is the worlds leading independent medical
journal. This study will be used to validate the effectiveness of pneumatic compression stockings
versus the use gradual compression stockings in preventing DVTs in immobile stroke patients.


PICOT PROPOSAL 6

Taniguchi, S., Fukuda, I., Daitoku, K., Minakawa, M., Odagiri, S., Suzuki, Y., ... Ohkuma, H.
(2009). Prevalence of venous thromboembolism in neurosurgical patients. Heart & Vessels,
24(6), 425. doi:10.1007/s00380-008-1135-9

The purpose of this study was to determine the prevalence of venous thromboembolism
in neurosurgical patients. All patients under study received standard thromboprophylaxis by
using graded compression stockings with or without intermittent pneumatic compression. No
patients received thrombolytic therapy due to possible risk of intracranial bleeding.
The trial was conducted on thirty-seven patients who were screened by ultrasonography
for deep vein thrombosis on an average of 12 days postoperatively from neurosurgery. The
prevalence of DVT was 5/37. The incidence of pulmonary embolism was 3/5 in patients having
deep vein thrombosis. By accounting for the prevalence of DVT in neurosurgical patients this
study helps to determine the basis for the need of improvement.
A weakness in this source is that it does not specify the type of neurosurgery the patient
is receiving and therefore it may not be indicative for stroke patients. The strength in this source
is that it determines the prevalence of DVT in neurosurgical patients, which helps to develop a
baseline for this research.




PICOT PROPOSAL 7
Dennis, M., Sandercock, P., Reid, J., Graham, C., Murray, G., Venables, G., ... Bowler, G.
(2009). Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep
vein thrombosis after stroke (CLOTS trial 1): A multicentre, randomised controlled trial. Lancet,
373(9679), 1958-1965. doi:10.1016/S0140-6736(09)60941-7

This trial assessed the effectiveness of thigh-length gradual compression stockings to
reduce deep vein thrombosis after stroke. The trial was a blind, random controlled trial of 2,518
patients who were admitted the hospital for acute stroke and who were immobile following the
stroke. This study is almost identical in nature to the first study done using intermittent
pneumatic compression stockings however this study uses gradual compression stockings in the
prevention of deep vein thrombosis.
The result of this study was that the use of thigh-length gradual compression stockings in
patients hospitalized with acute stroke was not effective in preventing deep vein thrombosis. This
is important data for research because it shows the importance of using intermittent pneumatic
compression devices for this patient population rather than gradual compression stockings.
A strength of this study is that it provides a straight forward comparison for the use of
IPC stockings versus the use of GCS and it also determined that in some instances, GCS may
cause skin breaks, ulcers, blisters and skin necrosis.
This study was also conducted by Lancet, a very reliable source.








PICOT PROPOSAL 8