Anti-Embolism Stockings Clinical Guideline V3
Anti-Embolism StockingsClinical GuidelineV4.0November 2021
1. Aim/Purpose of this Guideline1.1. Each year 25,000 people in the UK die from venous thromboembolism.This figure includes both patients admitted for medical care of seriousillnesses, as well as those admitted for surgery. Deep vein thrombosis(DVT), once developed, is a cause of substantial morbidity and maylead to the development of post thrombotic syndrome (PTS) with clinicalfeatures of chronic swelling and ulceration of the legs. Graduated Antiembolism compression stockings (AES) are used as a prophylacticmeasure to prevent deep vein thrombosis and pulmonary emboli in atrisk patients. Correctly applied, they are a safe, non-invasive therapythat works by exerting graded circumferential pressure from distal toproximal regions of the leg.1.2. AES have two potential actions in preventing DVT in the immobilepatient; graduated compression increases blood flow velocity andpromotes venous return whilst the prevention of passive venousdistension is thought to prevent sub- endothelial tears and the activationof clotting factors. Application of AES is not without risk, therefore it isimportant that patients are fully assessed and their legs measuredbefore stockings are fitted and that stocking use is closely monitored.1.3. Anti-embolism stockings can be used either as a therapy on their ownor as an adjunct to anti-coagulant therapy in patients who have beenclinically assessed as having a moderate to high thrombotic risk.Prophylactic treatment should be started pre-operatively or as soon asthe patient becomes immobile. Evidence supports the use of belowknee stockings in the majority of cases (1,2). Thigh length stockingsmay be required for individual patients and these should be specificallyprescribed.1.4. The purpose of this guideline is to set the standard for clinical staff whoapply anti-embolism stockings to patients as prescribed.1.5. This version supersedes any previous versions of this document.Data Protection Act 2018 (General Data Protection Regulation – GDPR) LegislationThe Trust has a duty under the Data Protection Act 2018 and General Data ProtectionRegulations 2016/679 to ensure that there is a valid legal basis to process personal andsensitive data. The legal basis for processing must be identified and documented beforethe processing begins. In many cases we may need consent; this must be explicit,informed, and documented. We cannot rely on opt out, it must be opt in.Data Protection Act 2018 and General Data Protection Regulations 2016/679 is applicableto all staff; this includes those working as contractors and providers of services.For more information about your obligations under the Data Protection Act 2018 andGeneral Data Protection Regulations 2016/679 please see the Information UseFramework Policy or contact the Information Governance Teamrch-tr.infogov@nhs.netAnti-Embolism Stockings Clinical Guideline V4.0Page 2 of 15
2. The Guidance2.1. ResponsibilitiesIt is the responsibility of clinical managers to ensure healthcare workersundertaking this clinical skill have received sufficient and appropriatetraining. Clinical competency must be assessed and achieved beforeundertaking this task. The individual practitioner is responsible forensuring that knowledge and skills are maintained through regularupdate and practice.2.2. Use of Anti-embolic stockingsAnti-embolic stockings must be prescribed on the patient's electronicprescription chart (EPMA) following medical assessment of risk ofthrombosis.2.3. Cautions / Contra-indications2.3.1.Patients must be assessed for any pre-disposing conditionswhere anti-embolism stockings are contra-indicated. Anycontra-indications to AES should be clearly recorded in thepatient’s medical notes or EPMA system.2.3.2.Do not offer anti-embolism stockings to patients who have.2.3.2.1. Suspected or proven peripheral arterial diseaseincluding arterial bypass grafting External pressurefrom the stocking will further decrease the flow of bloodto the lower limb causing ischaemia and/or necrosis oftissue. The colour of the patient’s feet should be notedand felt for warmth and palpable pedal pulses. If pedalpulses are not palpable by hand then a Dopplerassessment may be required. Clinicians should listencarefully to arterial signals, and where monophasic orbiphasic sounds are detected senior advice must besought.2.3.2.2. Stroke. Patients with confirmed acute stroke should notbe prescribed compression stockings. Clinicians shouldrefer to the RCHT stroke guidelines. In patients with nonhaemorrhagic stroke at high risk of VTE pharmacologicalprophylaxis with LMWH should be considered. NB aprevious history of minor stroke with minimal residualhemi- paresis is not an automatic contra-indication toAES use. Patients should be assessed for their suitabilityfor AES in line with patients who have peripheralneuropathy (see below).2.3.2.3. Peripheral neuropathy or other causes of sensoryimpairment. Patients with diabetes may have peripheralneuropathy and/or have a reduced peripheral bloodsupply. Without accurate assessment of sensation orAnti-Embolism Stockings Clinical Guideline V4.0Page 3 of 15
peripheral blood flow then the patient’s skin integrity maybe affected if anti-embolic stockings are applied. Checkfeet for appearance, sensation, warmth and colour. If footdeformity, cracked skin or loss of sensation is identifiedpatients will not detect undue pressure caused by antiembolism stockings and must be monitored very closely.2.3.2.4. Any local conditions in which stockings may causedamage e.g. fragile ‘tissue paper’ skin, dermatitis,gangrene or recent skin graft. Arterial blood flow to thefoot may already be reduced/occluded if pressuredamage is present. Any previous history of pressuresores should be identified as anti-embolism stockingscan further compound the situation. The patient’s heelsmust be observed for signs of pressure damage.2.3.2.5. Known allergy to material of manufacture. Thepatient’s allergy status must be checked prior toapplication.2.3.2.6. Acute Cardiac failure with severe leg oedemaCompression stockings may further increase thepressure within the circulatory system if the pulmonarycirculation is already overloaded. Note known andcontrolled heart failure without significant oedema is nota contra-indication to use of AES.2.3.2.7. Unusual leg size or shape or Major limb deformitypreventing correct fit.2.3.3.Caution and clinical judgement should be exercised when applyinganti-embolism stockings over venous ulcers or wounds.2.3.4.Due to their potential employment as a ligature caution should beexercised when deciding to provide stockings to patients who may beat risk of self-harm or who may present a risk of violence oraggression to hospital staff.2.4. Patient Assessment2.4.1. Patients who require anti-embolism stockings must have theirlegs measured to ensure the correct size of stocking isprovided. Anti-embolism stockings should be fitted and patientsshown how to use them by staff trained in their use.2.4.2. Patients who develop oedema or postoperative swelling musthave their legs re-measured and anti-embolism stockingsrefitted.2.4.3. If arterial disease is suspected, seek expert opinion beforefitting anti-embolism stockings.Anti-Embolism Stockings Clinical Guideline V4.0Page 4 of 15
2.4.4. Anti-embolism stockings that provide graduated compressionand produce a calf pressure of 14-15mmHg should be used.2.5. Documenting the AssessmentThere should be evidence in the nursing records that a patientassessment has been undertaken prior to stocking application. If anycriteria are identified which prevent stocking application the medicalstaff must be informed, the reasons documented and alternativeprophylaxis considered. A record of the measurement and the size ofstockings selected must be entered in the patient’s record by thepractitioner undertaking the procedure. The appliance label sticker /LOT number (where available) can be affixed to the patient’s nursingnotes or VTE prevention care plan and signed accordingly.2.6. Measurement and Application of anti-embolism stockings2.6.1. Accurate measurements of the patient's calf are required toprovide effective prophylaxis.2.6.2. To obtain accurate measurements the patient should be eithersat on a chair, the edge of the bed or if immobile ensure theirleg is not resting on the bed by bending the knee. Legs restingon the bed will give an inaccurate calf measurement resultingin insufficient pressure application if the stocking is too big ortourniquet effect if the stocking is too small.Measure the circumference of the calf at thegreatest point on both legs. The legcircumference will determine the size.Below Knee:Measure at Point CAbove Knee:Measure at Point TFor calf length stockings you will also need tomeasure the length from behind the knee to theheel of the foot2.6.2.1.Choose the correct size according to the manufacturer'sguide. Re- assessment must be made following aprocedure where the stockings have been removed andneed to be re-applied, eg, in the recovery room after asurgery as the patient’s leg may have developedoedema during surgery.2.7. Application of StockingsAnti-Embolism Stockings Clinical Guideline V4.0Page 5 of 15
1.Put hand inside thestocking and grab theheel.Pull the stocking inside out.2.Place the foot inside theopening you havemade.3.Ease the stocking up theleg making sure there areno wrinkles. Ensure heelis fitted correctly4.Ensure stocking top sits inline with the base of thepatella.Ensure thestocking feelscomfortable forthe patient.Nb. All the images contained in this guideline are produced by RCHT and areTrust owned images.2.8. Care of the Patient following Application of Stockings2.8.1. Patients should be encouraged to wear their anti-embolismstockings day and night until they no longer have significantlyreduced mobility.Anti-Embolism Stockings Clinical Guideline V4.0Page 6 of 15
2.8.2. Anti-embolism stockings should be removed daily for hygienepurposes and to inspect skin condition. In patients with asignificant reduction in mobility, poor skin integrity or anysensory loss, inspect the skin two or three times per day,particularly over the heels and bony prominences.2.8.3. Discontinue the use of anti-embolism stockings if there ismarking, blistering or discolouration of the skin, particularly overthe heels and bony prominences, or if the patient experiencespain or discomfort. If suitable, offer an intermittent pneumaticcompression device as an alternative.2.8.4. Show patients how to use anti-embolism stockings correctlyand ensure they understand that this will reduce their risk ofdeveloping VTE.2.8.5. Monitor the use of anti-embolism stockings and offer assistanceif they are not being worn correctly.2.9. Intermittent pneumatic compression devices2.9.1. Intermittent pneumatic compression devices should beconsidered in instances where the wearing of AES is contraindicated (i.e. in stroke) or where the patient is experiencingproblems with daily wearing of AES. Intermittent pneumaticcompression devices should not be offered to patients with aknown allergy to the material of manufacture.2.9.2. Patients who have intermittent pneumatic compression devices fittedshould be encouraged to use them for as much of the time as is possibleand practical, both when in bed and when sitting in a chair.2.10. Maintaining Safe Practice2.10.1. Once Anti-embolism stockings have been applied it is importantto monitor the patient's skin in order to identify early signs of skinbreakdown.ComplicationsPossible CauseRed marks on feet or Poor fitting hosiery.legs.Patient complainsPoor fitting hosiery.stockings are too tight.Poor fitting hosiery.Top of stockings tootight or rolled down.ManagementRe-measure limbs andcheck application.Re-measure limbs andcheck application.Re-measure limbs andcheck application. Ifthigh length stockings inuse, consider the use ofbelow knee.Anti-Embolism Stockings Clinical Guideline V4.0Page 7 of 15
ComplicationsPossible CauseDusky heels, pressure Unrelieved pressure on heels.damage.Stockings too tight.Rash on legs.Reaction to stockingcomponents.Stockings not removedfrequently enough. Patientsusceptible to dry skin.Dry skin.ManagementAssess arterial bloodflow. Relieve heelpressure. Discuss withdoctor's alternativeprophylaxis.Discuss with doctorsalternative prophylaxisWash legs inemollient/water daily toremove dry skin.2.10.2. Should complications arise following application that results inremoval of the stockings then approval must be sought frommedical staff and alternative prophylaxis considered andclinical decision must be documented in the patient'smedical/nursing records.2.11. Discharge of Patients with Stockings2.11.1. Assessment of the need to wear stockings following dischargeshould be made by the medical staff. Patients should be informed about the wearing andwashing of their stockings, and the length of time tocontinue wearing. Patients should receive a Trust Patient Information Sheetprior to discharge (RCHT063). A supply should be kepton the ward for inpatient use and further copies can beordered from design and publications dept. RCHT Patients should receive two pairs of stockings ondischarge because of the need to wear them at all times.They are not available on FP10.2.11.2. Orthopaedic patients who have had a total knee or hipreplacement and are taking Rivaroxaban do not need to wearstockings on discharge.2.11.3. Ensure that people who are discharged with anti-embolismstockings: understand the benefits of wearing them understand the importance of wearing them correctly understand the need to remove them daily for hygienepurposes are able to remove and replace them, or have someoneavailable who will be able to do this for them know what to look for if there is a problem – for example,skin marking, blistering or discolouration, particularly overAnti-Embolism Stockings Clinical Guideline V4.0Page 8 of 15
the heels and bony prominences. Know who to contact ifthere is a problem. know when to stop wearing them2.12. AuditWard / departmental managers are responsible for monitoring practice.Review of practice may result from any adverse incidents highlighted onthe Trust’s risk reporting system. In such circumstances the managerwill assess whether practice complied with RCHT guidelines andimplement and provide evidence of remedial action where appropriatebefore closing the incidence on the system.3. Monitoring compliance and effectivenessElement to bemonitoredNumber of patients with no prescription for AES when clinicallyindicatedNumber of patients with prescription for AES when not clinicallyindicatedEvidence of initial patient assessment for suitability of application ofAnti embolism stockingsEvidence that stockings have been applied according toprescriptionEvidence that patients have received written or verbal informationregarding their stockingsLeadAndrew McSorley – Lead Anticoagulant/Thrombosis NurseToolMonthly data harvest from EPMA, via reporting/investigation ofadverse incidents to DATIX system and systematic investigationinto hospital associated thrombosis eventsFrequencyOngoingReportingarrangementsThe outcomes of any incident investigations will be reported via theSenior Nursing Committee and actions planned according to theissues identifiedActing onThe Lead Anti Coagulant Nurse will work with the Divisional Nursingrecommendations team to develop and implement the action plan.and Lead(s)Change inpractice andlessons to besharedRequired changes to practice will be identified and actioned within 3months. A lead member of the team will be identified to take eachchange forward where appropriate. Lessons will be shared with allthe relevant stakeholdersAnti-Embolism Stockings Clinical Guideline V4.0Page 9 of 15
4. Equality and Diversity4.1. This document complies with the Royal Cornwall Hospitals NHS Trustservice Equality and Diversity statement which can be found in the 'Equality,Inclusion & Human Rights Policy' or the Equality and Diversity website.4.2. Equality Impact AssessmentThe Initial Equality Impact Assessment Screening Form is at Appendix 2.Anti-Embolism Stockings Clinical Guideline V4.0Page 10 of 15
Appendix 1. Governance InformationDocument TitleAnti-Embolism Stockings Clinical Guideline V4.0This document replaces (exacttitle of previous version):Anti-Embolism Stockings Clinical Guideline V3.0Date Issued/Approved:16th November 2021Date Valid From:November 2021Date Valid To:November 2024Directorate / Departmentresponsible (author/owner):Andrew McSorley, Lead Anticoagulation/ Thrombosis NurseContact details:01872-253827Brief summary of contentsThe purpose of this guideline is to set the standardfor clinical staff who apply anti- embolism stockingsto patients as prescribed.Suggested Keywords:antiembolism, compression stockings, venousthrombo-embolism, TEDs, AES, prophylaxis,mechanical prophylaxisRCHT Target AudienceCFTKCCGExecutive Director responsiblefor Policy:Medical DirectorApproval route for consultationand ratification:RCHT Thrombo-embolic group Tissue Viabilityteam RCHTGeneral Manager confirmingapproval processesIan McGowanName of Governance Leadconfirming approval byspecialty and care groupmanagement meetingsSuzanne Atkinson NICE CG92 (2010) – Venousthromboembolism: Reducing the risk ofvenous thromboembolism (deep veinthrombosis and pulmonary embolism) inpatient.Links to key external standards NICE CG 89 (2018) Venous thromboembolism in over 16s: reducing the risk ofhospital-acquired deep vein thrombosis orpulmonary embolism NHSLA Risk Management StandardsRelated Documents: RCHT Standards of Record-KeepingAnti-Embolism Stockings Clinical Guideline V4.0Page 11 of 15
RCHT Patient Identification Policy RCHT Consent Policy RCHT Infection Control Policy RCHT Clinical Guideline for Acute strokeManagement RCHT Clinical Guideline for secondaryprevention after stroke or TIA RCHT / PCT multi-disciplinary care pathwayfor stroke and TIA RCHT Thrombosis prevention andanticoagulation policy RCHT Thrombosis prevention, Investigationand management guidelines SIGN 122 (2010) – Prevention andmanagement of venous thrombo- embolismA national clinical guidelineTraining Need Identified?NoPublication Location (refer toPolicy on Policies – Approvalsand Ratification):Internet & IntranetDocument Library Folder/SubFolderClinical / Anticoagulation and Thrombosis Intranet OnlyVersion Control TableDateVersionNoChanges Made by(Name and Job Title)Summary of ChangesPrevious version history not known.1 Jun 13V1.0Changes to wording to reflect nationalguidance NICE 92 CGInclusion of up-to date photographsreflecting stockings currently in use atRCHT1 Aug 16V2.0Content reviewed – Minor wordingchange and change to corporateheaderAndrew McSorley, LeadAnticoagulation/ThrombosisNurseV3.0Content review and wording changesto ensure compliance with NICE 89Addendum Appendix 3 decisionalgorithm for AES useAndrew McSorley, LeadAnticoagulation/ThrombosisNurse1 Sep 18Heather Newton, ConsultantNurse Tissue Viability.Andrew McSorley, LeadAnticoagulation/ThrombosisNurseAnti-Embolism Stockings Clinical Guideline V4.0Page 12 of 15
1 Nov 21V4.0No change to context of documentsupporting information updated.Andrew McSorley, LeadAnticoagulation/ThrombosisNurseAll or part of this document can be released under the Freedom of InformationAct 2000This document is to be retained for 10 years from the date of expiry.This document is only valid on the day of printingControlled DocumentThis document has been created following the Royal Cornwall Hospitals NHS TrustPolicy for the Development and Management of Knowledge, Procedural and WebDocuments (The Policy on Policies). It should not be altered in any way without theexpress permission of the author or their Line Manager.Anti-Embolism Stockings Clinical Guideline V4.0Page 13 of 15
Appendix 2. Equality Impact AssessmentSection 1: Equality Impact Assessment FormName of the strategy / policy /proposal / service function to be assessedAnti-Embolism Stockings Clinical Guideline V4.0Directorate and service area: Covering allareas of the TrustIs this a new or existing Policy?Existing PolicyName of individual/group completing EIAContact details:Andrew McSorley, Lead Anticoagulation /01872 253597Thrombosis Nurse1. Policy AimWho is theTo promote best practice in the care of patients requiring antistrategy / policy /embolic stockingsproposal / servicefunction aimed at?2. Policy ObjectivesTo ensure all staff are aware of their responsibilities in relation toassessment, application, monitoring and discharge of patients withanti-embolism stockings3. Policy IntendedOutcomesPatient safety and reduction of risk4. How willyou measurethe outcome?5. Who is intendedto benefit from thepolicy?6a). Who did youconsult with?Audit of assessment of patients for DVT risk and OutcomesAll patients admitted to RCHT who are assessed at being at risk ofdeep vein thrombosis will be supplied with anti-embolism stockings.Assessment and application will be according to best practiceInformed workforce through education and organisationsXPlease record specific names of groups:b). Please list anygroups who haveRCHT Thrombo-embolic group – Thrombosis prevention andbeen consultedabout this procedure. anticoagulation steering group (TPAS)c). What was theoutcome of theconsultation?Agreement to proposed updates to guideline following consultationAnti-Embolism Stockings Clinical Guideline V4.0Page 14 of 15
7. The ImpactPlease complete the following table. If you are unsure/don’t know if there is a negative impactyou need to repeat the consultation step.Are there concerns that the policy could have a positive/negative impact on:ProtectedYes NoUnsureRationale for Assessment / Existing EvidenceCharacteristicAgeOlder person’s skin is at greater risk of skindamage from stocking application.XOlder people have an increased risk of vasculardisease which is a contraindication to the applicationof the stockingsSex (male, femalenon-binary, ties/groupsXDisability(learning disability,physical disability,sensory impairment,mental healthproblems and somelong term healthconditions)Religion/other beliefsSome patients with significant sensory impairmentwill be contra-indicated to Anti-embolism stockingsXPatient leaflets will be available in alternative formatse.g. easy read.XMarriage and civilpartnershipXPregnancy andmaternityXSexual orientation(bisexual, gay,Xheterosexual, lesbian)If all characteristics are ticked ‘no’, and this is not a major working or servicechange, you can end the assessment here as long as you have a robust rationalein place.I am confident that section 2 of this EIA does not need completing as there are no highlightedrisks of negative impact occurring because of this policy.Name of person confirming result of initialimpact assessment:Andrew McSorley, Lead Anticoagulation /Thrombosis NurseIf you have ticked ‘yes’ to any characteristic above OR this is a major working orservice change, you will need to complete section 2 of the EIA form available here:Section 2. Full Equality AnalysisFor guidance please refer to the Equality Impact Assessments Policy (available fromthe document library) or contact the Human Rights, Equality and Inclusion Leadindia.bundock@nhs.netAnti-Embolism Stockings Clinical Guideline V4.0Page 15 of 15
2.2. Use of Anti-embolic stockings Anti-embolic stockings must be prescribed on the patient's electronic prescription chart (EPMA) following medical assessment of risk of thrombosis. 2.3. Cautions / Contra-indications 2.3.1. Patients must be assessed for any pre-disposing conditions where anti-embolism stockings are contra-indicated.
Anti oxidation, Anti aging Anti oxidation, Anti aging Anti oxidation, Anti aging Skin regeneration, Nutrition, Anti wrinkle Anti oxidation, Anti aging Anti oxidation Whitening Whitening Effects Skin Whitening, Anti oxidant Anti inflammatory, Acne Anti oxidant, Anti inflammatory Skin smooth and glowing Anti oxidant, Anti inflammatory Anti ageing .
designed to facilitate the fitting of anti-embolism stockings in day-to-day hospital care and in the operating theatre. The device diameter can be adjusted to allow a non-touch fitting. Inspection Opening The inspection opening allows constant monitoring of potential neurovascular changes of the toes, without having to remove the stocking.
The Scarlet Stockings Spy Directions: Skim and search for the following words in The Scarlet Stockings Spy. Read the content in which each word is used, then choose the word from the box that best matches the definition. Write
DO use a measuring tape. DO remeasure with decrease or increase of weight. (i.e., edema). C. Apply stockings DO “walk” the stockings up the legs and use powder sparingly, if necessary, to assist with easy application. D. Maintain stockings properly DO check for proper heel and gusset placement.
Below Knee and Thigh Length Below Knee and Thigh Length Stockings Stockings . on the leg to provide active and comfortable preventative care against these problems, . The Unisex Compression Sock should be fitted using the instructions for Below Knee (BK) Stockings (see p4). p6 Var
cauda equina is usually located below L3 (Picture: Dr K Laubscher) Fat embolism syndrome Definition: Fat embolism is a rare, non- thrombotic embolism that is potentially fatal and has a mortality rate of 15%. It is a systemic dysfunction caused by the entry of fat into
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