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Evaluation of clinical nursing practice guideline

for preventing deep vein thrombosis in
critically ill trauma patients

Article in Australasian Emergency Nursing Journal · November 2010

DOI: 10.1016/j.aenj.2010.08.291

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Australasian Emergency Nursing Journal (2011) 14, 232—239

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RESEARCH

Evaluation of a clinical nursing practice guideline for

preventing deep vein thrombosis in critically ill
trauma patients
Praneed Songwathana, RN, PhD ∗, Kesorn Promlek, RN, MNS a,
Kanitha Naka, RN, PhD b

Department of Surgical Nursing, Faculty of Nursing, Prince of Songkla University, Hat Yai, Songkhla 90112, Thailand

Received 22 March 2011; received in revised form 5 August 2011; accepted 22 September 2011

KEYWORDS Summary Deep vein thrombosis (DVT) is the third leading cause of morbidity in critically ill
Clinical nursing trauma patients but it can be prevented by performing appropriate risk assessment and pre-
practice guideline; ventive strategies. The purpose of this study was to evaluate of implementing a clinical nursing
DVT prevention; practice guideline (CNPG) for preventing DVT in critically trauma patients at Songklanagarind
Critically trauma Hospital. The CNPG content with 37 items initially developed from evidence-based knowledge
patient related to DVT and its prevention was validated and approved by the consensus of an expert
panel. The ‘expert panel’ consisted of a clinical (critical surgical patients) nurse specialist, a
trauma surgeon, a medical doctor who experts in developing CNPG, and two surgical care nurse
educators. The revised 30 from 37 items were tested for reliability thereafter and yielded of
0.90 and 1.00, respectively. Forty-two nurses participated in this study. The effectiveness of
this CNPG was evaluated in terms of (1) feasibility and difficulty of using the CNPG, (2) nurse’s
satisfaction in implementation of CNPG, and (3) the patient’s femoral blood flow velocity before
and after 7 days. Results have shown that 23 items were performed by more than 90% of nurses
and there were 7 items performed at rates lower than 90%. 79% of nurses rated their satis-
faction at high (M = 8.06, SD = 0.96). There were no differences in femoral venous blood flow
velocity before and after 7 days and without signs of DVT. The findings indicated that the use of
evidence-based clinical practice guidelines for deep vein thrombosis prevention could enhance
the quality of care in terms of early detection for DVT and maintaining blood flow velocity in
those patients who are at risk. Further study could be explored to confirm its effectiveness with
the large sample size.
© 2011 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights
reserved.

∗ Corresponding author. Tel.: +66 081 542 9170; fax: +66 074 286 421.
E-mail addresses: praneed.s@psu.ac.th (P. Songwathana), kesorn.p183@gmail.com (K. Promlek), kanitha.n@psu.ac.th (K. Naka).
a Tel.: +66 081 898 8400.
b Tel.: +66 074 286 516; fax: +66 074 286 421.

1574-6267/$ — see front matter © 2011 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.aenj.2011.09.002
CNPG in preventing DVT
Introduction
Deep vein thrombosis (DVT) is one of the most common,
preventable complications of major surgery and traumatic
injuries. Although treatment is available, prevention of DVT
is more effective in promoting positive patient outcomes1
and is an important aspect of nursing care. DVT prevention
is important because DVT is often asymptomatic and difficult
to detect.1 In addition, DVT can travel to the lung and cause
pulmonary emboli (PE).2 Previous studies have shown that
the incidence of DVT in multisystem trauma patients, par-
ticularly orthopedic trauma, head injury or spinal trauma,
ranges from 50% to 65%.3 Further, 64% of surgical patients
who are critically ill4 develop venous thromboembolisms
(VTE). There are variations in DVT rates due to different
case mixes, quality of care, screening practices and data
capture.5
In Thailand, however, very few studies report the inci-
dence of DVT and underreporting is a major contributing
factor. For example, results of a 6-year study in Siriraj
Hospital, Bangkok indicated that 33% of vascular surgery
patients developed DVT6 and a study at Ramathibodi Hos-
pital, Bangkok showed that 10.15% of patients admitted
to the surgical intensive care unit (ICU) developed DVT at
6-month follow up.6 Virchow’s triad describes three main
causes of DVT: (1) stasis of venous circulation, (2) trauma
to veins or endothelial damage, and (3) blood coagulation
factors or hypercoagulability.7 Controlling these factors is
critical to DVT prevention and requires knowledge and effec-
tive decision making related to DVT prophylaxis. Various
non-pharmacological and pharmacological DVT prevention
strategies are available, however, the best strategy to use
will depend on the patient’s risk for DVT.8
Although evidence based consensus guidelines for pre-
vention of DVT have been available, guidelines for DVT
prevention remain underused in nursing. The use of a pro-
tocol or guideline for prevention of DVT may save lives
by PE prevention.9,10 In the literature, guidelines relating
to DVT prevention have focused on DVT risk assessment
and prophylaxis of anticoagulant administration in hospi-
talized high risk patients.2—4 The Association of Operating
Room Nurses guideline for prevention of venous stasis is
a resource recommended for use since it includes nursing
interventions and expected patient outcomes. However, for
use in the care of multiple trauma patients, this guideline
requires modification based on variations in organizational
resources such as facilities and treatment offered in the
local context, and design for a specific group of patients,
such as postoperative patients.11 A clinical nursing prac-
tice guideline (CNPG) for the trauma nursing assessment
and management of DVT prevention was developed in 2009
and then tested for its consistency, predictive validity
and practical utility. In Thailand, although previous studies
have shown that the use of practice guidelines in nurs-
ing could improve the quality of nursing care and patient
outcomes,12,13 a guideline for prevention of DVT has not
been well developed and has not been used in nursing crit-
ically ill trauma patients. As a result, this present study
was conducted in order to develop a CNPG with critically
ill trauma patients at Songklanagarind Hospital, Hat Yai,
Thailand.
233
Conceptual framework
The Australian National Health and Medical Research Coun-
cil’s Guide to the development, implementation, and
evaluation of clinical practice guidelines14 was modified and
used as a framework for this study. The simple process
of developing, implementing and evaluating the evidence-
based DVT prevention CNPG consisted of 4 main steps: (1)
determining the need for and scope of guideline including
purpose and target population, (2) review of the evidence
and guideline development, (3) guideline assessment by a
panel of experts and pilot testing, and (4) guideline imple-
mentation and evaluation.
Objectives
The objective of the study was to evaluate the CNPG for
prevention of DVT after its practical application in terms of
(1) feasibility and difficulty in using the CNPG, (2) the nurse’s
satisfaction with CNPG, and (3) the patient’s femoral blood
flow velocity before and after 7 days.
Methods
Ethical Review Board approval
This study was approved by both the Ethical Review Board
of the Faculty of Nursing, Prince of Songkla University and
the Songklanagarind Hospital Ethics Committee.
Research design
This study employed a research and development design and
included two phases: guideline development and guideline
implementation. The CNPG was developed based on evi-
dence from the literature and from expert review and was
designed as a flow chart or diagram for nurses to implement
in a pilot study in surgical intensive care unit (SICU). The
guideline was intended to accompany usual nursing practice
and guide initial risk assessment and on-going nursing care.
The study site was a 10-bed adult SICU in Songklanagarind
Hospital. The participants were SICU nurses who provided
care for patients in SICU in the two months before and after
the implementation phase (January to February 2010).
Guideline development
Research articles and reviews (N = 59) published from
1998—2009 were reviewed and analyzed in order to develop
the CNPG for preventing DVT in critically ill trauma patients.
The CNPG was then developed from the evidence-based
knowledge related to DVT and to DVT prevention and ini-
tially contained 37 items. Instruments were created in the
Thai language. The CNPG was initially divided into two parts:
(1) the DVT screening tool using Autar assessment risk cate-
gories and (2) nursing interventions for preventing DVT. The
instruments used in the study consisted of (1) the evidence-
based DVT prevention guideline (CNPG for prevention of
DVT—–Thai version) and (2) the DVT prevention data form,
234
assessed by a panel of experts and critiqued by nurses and
doctors in SICU.
The CNPG content was validated by an expert panel con-
sisting of a clinical nurse specialist with expertise in nursing
critically ill surgical patients, a trauma surgeon, a medical
doctor with expertise in developing CNPGs, and two sur-
gical care nurse educators. The CNPG was revised by the
expert panel to include a total of 30 items which were
tested for inter-rater reliability, yielding values of 0.90 and
1.00 respectively. The DVT prevention guideline was fur-
ther reviewed by two nursing and medical representatives
from SICU, Songklanagarind Hospital: one additional part for
reassessment and evaluation was also included in the CNPG
content. The guideline was then designed as a flow chart
and divided into three groups depending on the patient’s risk
(see Fig. 1). As risk categories were identified for patients,
Combined interventions were given such as (i) passive exer-
cise, (ii) elastic stocking or intermittent pneumatic cuff
pressure (IPC), and (iii) anticoagulants.
Guideline implementation (short term)
The final 30-item draft guideline was implemented in SICU.
Immediate in-service education sessions were conducted
that included a summary of the literature review, feedback
of the audit data related to DVT prevention in routine prac-
tice without guideline, and an explanation of the CNPG. The
manual accompanying the CNPG was available in the Thai
language both in electronic and hard copy in the unit. The
CNPG implementation was evaluated in terms of process and
outcome, namely; nurse satisfaction, and measurement of
femoral venous blood flow velocity to evaluate as the pri-
mary outcome in 11 patients. Nurse opinion and satisfaction
were measured using open-ended questions and group dis-
cussions. The satisfaction score was assessed using a numeric
scale (0—10), with 10 indicating the highest level of satis-
faction. A total satisfaction score of 1—3 was interpreted as
low, 4—7 was interpreted as moderate, and 8—10 was inter-
preted as high. In terms of blood flow velocity, a twice daily
assessment using a vascular Doppler detector was conducted
to determine the mean value of normal (15—20 cm/s) or slow
rate of blood flow velocity (<10 cm/s), which may pose a risk
for DVT development.15
Data collection and data analysis
Forty-two nurses and 11 patients participated in this study.
The initial evaluation of this CNPG was described in terms of
(1) feasibility and difficulty of using the CNPG, (2) nurse sat-
isfaction with CNPG, and (3) the patient’s femoral blood flow
velocity before the implementation of the CNPG and 7 days
after implementation. Data were analyzed using frequency
and percentages.
Results
The results showed that 23 items of the CNPG were
described as being feasible for implementation in practice
by more than 90% of nurse participants in the study. The
other 7 items of the CNPG were reported as feasible by less
P. Songwathana et al.
than 90% of nurse participants. Satisfaction was rated as
high by 78.5% of nurses (M = 8.06, SD = 0.96). Femoral venous
blood flow velocity assessed as a primary patient outcome
was unchanged before and after 7 days and no patients had
clinical signs of DVT.
Nurses’ and patients’ characteristics
Of the 42 nurses who participated in the study, all except one
were female. The mean age was 30 years (SD = 6.41 years),
and length of work experience was 7.5 years (SD = 6.45
years). Most participants had a Bachelors degree (N = 38,
90.48%). Fifteen nurses had experience in medical intensive
care units (35.71%), while only 3 nurses (7.14%) had training
or had attended a seminar on DVT. Twelve nurses (28.57%)
were involved in the development or use of guidelines.
The patient group consisted of 11 critically ill trauma
patients admitted to the SICU during the study period. Most
patients were males (81.82%), with a median age of 39
years (SD = 15.91 years). The majority of participants suf-
fered from head injuries (63.64%), followed by abdominal
trauma (54.55%), and chest and lower limb injuries (45.45%).
Patients in this study had injuries of two organ systems or
more, accounting for injury severity scores (ISS) greater than
25. The risk of DVT in low, moderate and high level was
36.6%, 27.28%, and 36.6% respectively.
Process of implementing a nursing practice
guideline
In the process of the CNPG implementation, nurses were
asked about opinions towards the items in the guideline
after their actual patient care was performed. The results
showed that almost all nurses (97.5%) reported it essential
and feasible to include the CNPG in their routine practice
of nursing. More than 90% of nurses described 23 items of
the CNPG as feasible for implementation in practice; the
remaining 7 items were reported as feasible by less than
90% of nurses. Implementation was agreed as acceptable for
ward policy if responses for particular activities performed
were higher than 90%. For DVT risk screening, more than
90% of risk assessments were found possible to implement
at a high level, except in an assessment of body mass index
(69.05%), and with the special risks of DVT (57.14%) as shown
in Table 1.
Regarding nursing interventions to prevent DVT, the over-
all activities reported as possible to implement are shown
in Table 2. Promoting foot exercise was identified by most
nurses (97.62%) as having the greatest possibility of imple-
mentation. However, several activities reported with less
than 90% of implementation included motivating patients
to ambulate (get out of bed), applying IPC, and consulting
the doctor when medications were needed. For their actual
recording of the risk assessment screening and nursing inter-
ventions to prevent DVT, overall activities were found to
be most frequently recorded by nurses (>90%) as shown in
Table 3.
In terms of nurse satisfaction, 78.57% of nurses rated
their satisfaction as high (M = 8.06, SD = 0.96). This indicates
that the CNPG was useful in preventing the risk of DVT and
CNPG in preventing DVT 235

Patient with Trauma

Autar DVT
Assessment risk categories
≤10 = low risk
Initial risk assessment using DVT 11-14 =moderate risk
screening tool within 24 hours of >15 = high risk
admission

Give intervention as risk categories

Low risk Moderate risk High risk

(score ≤10) (score =11 – 14) (score ≥ 15)

1. give advice of DVT 1. give advice 1. consult for

prevention 2. do exercise as medication
2. motivate exercise or Table 1 prophylaxis
activity either passive or 3. on IPC or GCS (level 1)
active as tolerate (level 1) 2. give
3. ankle exercise each site 4. Release IPC or intervention as
5 min, 75 times rate 15 GCS twice a day for Table 2 (1-4)
times/min (level 3.1) 30 (level 1)
Ankle rotation 20 time 15 5. consult for
times/min medication
4. ambulate and walking prophylaxis (level 1)
(level 1)
**exercise at least twice a
day** (level 3.1)

Reassessment every 24 hours (level 3.3)

Notify if there is any sign of DVT

Figure 1 A flow chart of DVT prevention guideline for nursing care of the critically ill trauma patient.

enhancing the quality of care. The other 9 nurses (21.43%)
were satisfied at a moderate level.
Each patient’s outcome as measured by femoral venous
blood flow velocity was unchanged before implementation
and after 7 days and none of patients had signs of DVT. The
critically ill trauma patients were assessed for DVT risk and
risk management at least once a day until the patient moved
out of the SICU. Blood flow velocity was monitored in 8
patients who received continuous DVT prevention activities
following the CPNG and revealed little increase in blood flow
velocity (Table 4). There were only 3 patients in whom CNPG
was discontinued because of worsening conditions such as

Table 1 Nurses’ opinions regarding the item guideline in the risk assessment of deep vein thrombosis (N = 42).

Assessment to screen each risk Level of opinion

Moderate agree number (%) Highly agree number (%)

1. Age specific group 1 (2.38) 41 (97.62)

2. Mobility 2 (4.76) 40 (95.24)
3. Trauma risk category 3 (7.14) 39 (92.86)
4. Surgical intervention 4 (9.52) 38 (90.48)
5. Body mass index 13 (30.95) 29 (69.05)
6. Special risk category 18 (42.86) 24 (57.14)
7. High risk diseases 4 (9.52) 38 (90.48)
8. Scoring and dividing into three risk groups 3 (7.14) 39 (92.86)
9. Evaluation of signs of DVT 1 (2.38) 41 (97.62)
236 P. Songwathana et al.

Table 2 Nurses’ opinions regarding the item guideline in the nursing interventions to prevent DVT (N = 42).

Nursing intervention in each risk group Level of opinion

Moderate agree number (%) Highly agree number (%)

Nursing interventions in low risk groups

1. Providing information to patients and/or relatives 2 (4.76) 40 (95.24)
about prevention of DVT
2. Encouraging patients to do foot exercise by themselves 2 (4.76) 40 (95.24)
or having staff and relatives help if patients are unable
to do so
3. Motivating patients to do foot exercise 1 (2.38) 41 (97.62)
4. Encouraging early ambulation when the patient is ready 6 (14.29) 36 (85.71)
5. Doing foot exercise 2 times per day 2 (4.76) 40 (95.24)
Nursing intervention in moderate risk groups
1. Providing information to patients and/or relatives 2 (4.76) 40 (95.24)
about prevention of DVT
2. Motivating patients to do foot exercise 2 (4.76) 40 (95.24)
3. Encouraging early ambulation when the patient is ready 4 (9.52) 38 (90.48)
4. Doing foot exercise 2 times each day 2 (4.76) 40 (95.24)
5. On IPC all the time until patient can ambulate except 5 (11.90) 37 (88.10)
some restrictions on using of GCS
6. Remove the sleeve for approximately 30 min to check 3 (7.14) 39 (92.86)
the skin (2 times a day)
7. Consult doctor for pharmacological use 9 (21.43) 33 (78.57)
Nursing intervention in high risk groups
1. Consult doctor for pharmacological use 10 (23.81) 32 (76.19)
2 Encouraging early ambulation when the patient is ready 3 (7.14) 39 (92.86)
3. On IPC all the time until patient can ambulate except 4 (9.52) 38 (90.48)
some restrictions on using of GCS
4. Remove the sleeve about 30 min to check the skin (2 3 (7.14) 39 (92.86)
times a day)
5. Doing foot exercise 2 times per day 2 (4.76) 40 (95.24)
6. Encouraging patients doing foot exercise by themselves 7 (16.67) 35 (83.33)
or with staff or relatives if patients are unable to do
7. Reassess the risk of DVT every day 4 (9.52) 38 (90.48)
8. Report to doctor when clinical sign of DVT exist 2 (4.76) 40 (95.24)

circulatory failure and one of them was transferred to the
general ward.
The problems related to implementation of the CNPG
are shown in Table 5. Assessment of some items in risk
assessment for DVT, particularly a genetic history or con-
dition of DVT, and history of contraceptive pill use were
not accessible, approximately half the nurses were of the
opinion assessment was difficult (52.38%, N = 22). Some nurs-
ing interventions to prevent DVT were limited: 71.42% of
nurses reported limitations in applying the graduated com-
pression stockings and 61.90% of nurses reported limitations
in applying IPC.

Table 3 Nurses’ opinion towards the item recording of the risk assessment screening and nursing interventions to prevent DVT
(N = 42).

Recording assessment for risk screening and nursing Level of opinion

intervention
Moderate agree number (%) Highly agree number (%)

1. Risk assessment scale 4 (9.52) 38 (90.48)

2. Record clinical sign and site of DVT 2 (4.76) 40 (95.24)
3. Sign up screening risk patients. 3 (7.14) 39 (92.86)
4. Record activity done for patients 3 (7.14) 39 (92.86)
5. Record problems and obstacles that cannot be 3 (7.14) 39 (92.86)
performed as specified in the guidelines
CNPG in preventing DVT 237

Table 4 Patient’s femoral blood flow velocity before (day 1) and after (day 7) using CNPG (N = 8).

Day Case

1 2 3 4 5 6 7 8

Femoral blood flow velocity (cm/s)

Day 1 99.40 11.60 99.40 11.20 11.20 11.60 11.80 10.30
Day 7 10.20 11.70 11.60 11.40 11.80 11.80 11.80 11.70

Table 5 Nurses’ comments on problems and difficulties in CNPG implementation.

Problems in CNPG implementation Number %

CNPG handbook
1. Contents in some items was unnecessary to evaluate 15 35.71
2. CNPG has too much content 14 33.33
3. No time to use the CNPG 10 23.81
4. Contents of CNPG are difficult to understand 4 9.52
Risk assessment as a screening tool
1. Assessing records for congenital conditions, i.e. DVT is difficult 22 52.38
2. Assessing history of using contraceptive pills is difficult 21 50.00
3. Assessing the patient’s body mass index is difficult. 17 40.48
4. Assessing for signs of neonatal DVT is difficult 1 2.38
Nursing interventions
1. Using graduated compression stockings is difficult 30 71.42
2. Using IPC is difficult to encourage 26 61.90
3. Consulting a doctor for pharmacological use is difficult 16 38.10
4. Staff assistance of patients with passive exercise is very difficult 18 42.86
5. Motivating patients to exercise is difficult 12 28.57
6. Providing advise relative to passive exercise is difficult 7 16.67
7. Encouraging patients to do foot exercises 2 times each day is difficult 7 16.67
Note: More than 1 item was identified.

Discussion is one factor in high risk patients that should be measured

This study evaluated the feasibility of using CNPG for DVT
prevention in major trauma patients, nurse satisfaction in
the use of the CNPG, and assessing femoral blood flow of
patients in SICU. It was conducted during a time when ward
policy was promoting the use of evidence-based practice
by nurses, which may be a cause of study bias. Overall,
implementation of CNPG for DVT prevention has resulted
in improvements of blood flow velocity in patients receiving
both mechanical and medical prophylaxis, particularly those
who were at high risk for DVT as shown in Table 4. This is
an important change in practice as DVT in trauma patients
is often overlooked and not regarded as an initial priority.1
Furthermore, although DVT risk screening tools are often
used, some contents of the tool are difficult to assess.
Body mass index (BMI) was one item with less feasibility
as it cannot be measured by weight alone. Difficulty
assessing BMI was reported by 41% of nurses because the
majority of patients were unconscious, and some patients
had no relative to contact, or the relatives did not know
about the patient’s health history. In addition, nurses often
estimated body weight to calculate BMI. The score may
therefore vary depending on individual experience and this
may affect the risk classification to some degree. However,
the literature review results indicate that body mass index
with an indirect method.16,17 Calculation of the weight
could be estimated by height using the formula: height
[cm] − 152.4 in male patients and 0.9 (height [cm]) − 152.4
in female patients.18,19
Foot exercise was an item with high levels of reported
feasibility. Previous studies showed that all patients who
received foot exercise, either by others and self, had
increased blood flow velocity.20,21 Although nurses made
comments about problems and difficulty in performing foot
exercises for patients who were unable to do them by them-
selves, foot exercises were often performed by relatives
under the nurse’s supervision. In addition, most activities
were regarded as independent functions which could be
managed by nurses.
The use of IPC and graduated compression stockings
remained problematic, especially in patients with moder-
ate risk and high risk for DVT due to limited resources and
inappropriate stocking size. The sleeve of the IPC was unable
to be cleaned when it was dirty or contaminated with blood
or faeces and single use costs approximately 1630 Thai Baht
($55 AUD) per pair. There was also no IPC machine available
if the patient had been moved out to the general ward: it
was only available in SICU. In addition, almost half (45.5%)
of patients had intravenous lines inserted in lower limbs or
had splints and casts due to fractures or leg ulcers; these
238
factors significantly limited use of this equipment. Preven-
tion by other equipment to replace the IPC and graduated
compression stockings is necessary.21
Anticoagulants decrease the incidence of obstructive
vein thrombosis from 7% to 58%5 especially if administered
within the first 24 h of hospital admission.21 However, anti-
coagulant medication was less likely to be prescribed by a
physician unless a nurse made the request. Skills in effec-
tive communication and advocacy are required particularly
by novice nurses when consulting medical staff regarding
DVT prophylaxis. The increased risk of bleeding in critically
ill trauma patients combined with high numbers of novice
nurses with little experience in consultation, were obstacles
in the use of the anticoagulant element of the CNPG.
The researchers felt that it was acceptable to have over
90% of nurses agree that the CNPG was both feasible and
satisfactory, and indicated a high level of nurse satisfac-
tion. There were several major reasons for high levels of
satisfaction with the CNPG. First, all nurses took part in the
CNPG development process so they were therefore happy
to use the CNPG. Second, nursing interventions included
in the CNPG were evidence-based which made it possible
to implement for critically ill trauma patients. Finally, the
development of a feasible and practical CNPG handbook
that was easily accessible acted as a guide for nurses and
included detailed explanations of risk assessments and nurs-
ing interventions.
Although there were constraints of time and workload
among nurses, updated content in the CNPG was necessary.
In order to reduce the workload of nurses and staff, the rela-
tionships between patients and relatives were established
through nursing activities. These also promoted continuing
care when patients were moved to general wards.
In terms of patient outcomes, increases in femoral
blood flow velocity in the first 7 days after SICU admission
was a positive finding. This is similar to previous studies
of foot exercise in critically patients and healthy adults,
where the results showed that femoral blood flow velocity
was increased up to 2 h after foot exercise for 5 min.21,22
However, other factors such as analgesic drugs, muscle
relaxants, and inotropic drugs, may affect the blood flow
velocity in critically trauma patients. In this study, 72.72% of
the patients received analgesics such as morphine and fen-
tanyl for surgical pain and blunt injury. Analgesic drugs may
affect vasodilatation of the vessels and decrease blood flow.
For example, with a 0.5 mg/kg morphine dose, resistance to
blood flow in peripheral arteries dropped 46% 2—3 min after
treatment and returned to normal within 9 min.23 Other
drugs, such as dopamine, noradrenaline, and dobutamine,
which increase blood flow velocity, may have effects on
the cardiovascular system. However, blood flow velocity on
average changed little by day 7 after being admitted to the
SICU. This may have limitations in terms of factors affect-
ing venous flow velocity often found in critically ill trauma
patients. A finding was that venous blood flow velocity was
maintained during immobilization.
Limitations
Because this was a pilot study with a small sample size,
the generalisability of results is limited. The measurement
P. Songwathana et al.
of blood flow velocity may also be influenced by other
factors.
Conclusions
The findings of the study indicated that the use of evidence-
based clinical practice guidelines for prevention of deep vein
thrombosis could be beneficial for nursing risk assessments
and maintenance of venous blood flow velocity in critically
ill trauma patients who are at high risk. Almost all nurses
(97.5%) reported that this CNPG was essential and feasible
to practice in the trauma care setting. Although the major-
ity of nurses felt satisfied on a high level, some content
needs to be further revised for appropriate use. Patients
also received better care as a standard to prevent DVT and
gained more safety as a part of quality of care indicators
in trauma and ICU. Hence, venous blood flow velocity was
maintained during immobilization.
Further studies could explore or confirm the effective-
ness of the CNPG with a large sample size. In addition,
implementation of CNPG must be supported at the pol-
icy level with physician involvement being required for
proper management. To ensure compliance with the CNPG
guideline, a multidisciplinary team approach is necessary,
including providing the staff with audit results.
Provenance and conflict of interest
The authors confirm that there are no competing interests
involved in this paper. This paper was not commissioned.
Funding
The research was funded by the Graduate school, Prince
of Songkla University and some support from the Prac-
tice Guideline and Innovative Caring for Trauma patients
Research Unit, Faculty of Nursing, Prince of Songkla
University.
Acknowledgements
The authors wish to thank Dr. Julie Considine and Dr. Mar-
guerite J. Purnell for editing the English in this manuscript.
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