Nurses now take only four minutes, instead of 10, to put on anti-embolism stockings with a plastic bag.

PATIENTS who have open heart surgery are given strict advice – wear anti-embolism stockings after surgery for four to six weeks, to prevent serious, sometimes fatal, complications. But previously, despite warnings, only 17 per cent of patients complied after discharge. 

All this has changed, thanks to a small improvement made by a team at the National Heart Centre Singapore (NHCS), on how the stockings are worn. Now, 70 per cent of patients – a whopping 53 percentage point increase – are using them. 

Retiree Madam Ivy Jayamoni, 75, who had a heart bypass and valve replacement surgery, is one of them. 

In the hospital, she did not flinch when nurses slipped the stockings up from her feet to her upper thighs. And this was despite a long wound running down one leg where doctors had harvested leg veins to use as graft in her bypass surgery. 

Once home, she intends to continue using them, and is confident her caregiver can handle it, she said. 

The secret – it glides, not tugs 

The improvement is simple yet effective, and was the work of a seven-member multidisciplinary NHCS team. 

It involves placing a transparent plastic bag – the type you get at supermarkets when buying fruits – over the patient’s foot before the stockings are worn. The plastic bag prevents toes from getting caught in the stocking’s opening and provides better glide, especially around the difficult spot – the heel. Once over the heel, the stocking can be slowly slipped over the rest of the leg, even over the wounds (see sidebar). 

The team tried other solutions such as using powder and creams to get the stockings to slide better, but these were found to be too messy and unsuitable for heart bypass patients with leg wounds. 

The fuss-free plastic bag solution helps both patients and staff. It used to take nurses 10 minutes to do the task. Now it takes four, freeing them up for other duties. 

For their contribution, the NHCS team was placed ninth in the Team Excellence Best Team Competition 2013 in July. The award recognises the contributions of teams and individuals to continuous improvement and innovation. 

The seven-member multi-disciplinary NHCS team who came up with the idea included Patient Care Assistant Chia Li Sen (seated), Nurse Clinician Chang Choong Kek and Senior Nurse Manager Lee Chin Hian (right). 

Wear them to prevent complications 
Team member, Dr Loh Yee Jim, Vising Consultant, Department of Cardiothoracic Surgery, NHCS, said patients who have had open heart surgery need to wear the stockings all day, for four to six weeks after surgery. Other patients who must wear them are those who are less active for a long period, such as those with cancer or who have undergone orthopaedic surgery. 

When the stocking is in place, the plastic bag is removed and the process is repeated for the other leg. The same plastic bag can be re-used for the other leg. 

Over 1,000 patients undergo open heart or thoracic surgery at NHCS each year and are required to wear anti-embolism stockings. Dr Loh said if they stop wearing them, there can be swelling of the leg, oozing from leg wounds, and the complication of blood clots travelling from the leg to the lungs resulting in serious damage or death (see sidebar). 

The stockings reduce the risk of blood clots forming in the leg veins of patients who are less active than normal. It does this by exerting pressure on veins in the legs, resulting in better blood flow through the legs. The stockings also help to reduce swelling in the leg. 

Dr Loh said while complications can be severe, they can be easily prevented. “It’s the cheapest and most effective way to prevent venous thromboembolism (blood clots in veins of the leg).” 

Wearing anti-embolism stockings helps prevent oozing from leg wounds in patients who have had leg veins removed for use in their heart bypass surgeries. 

Better education and involvement 

While implementing the new method, the team also beefed up on educating patients and caregivers about why it is important to continue wearing the stockings, and showing them how to do so. Subsequently, they saw compliance rise. 

Ms Lee Chin Hian, Senior Nurse Manager, Ward 56, NHCS, and the team’s facilitator, said some patients had stopped because it was tedious and time consuming, or found it too hot for this weather. Some men found it too feminine and others stopped once they felt better. 

The team’s leader, Mr Chang Choong Kek, Nurse Clinician, Ward 56, NHCS, said the team also carefully monitored patients after discharge, making regular phone calls to ask if they were still wearing the stockings at home. 

“If they stopped, we would urge them to resume and explain why it was important to do so. This was also why compliance rose,” said Mr Chang. 

Possible complications if patients do not wear anti-embolism stockings: 

Leg oedema (swelling) – Prolonged periods of inactivity can lead to fluid retention which causes swelling in the affected tissues. This brings discomfort to patients trying to regain mobility after a long period of inactivity. 

Oozing from leg wounds – Heart bypass surgery usually involves patients having leg incisions to remove the great saphenous vein, which runs down both legs from the groin to the foot, for use as graft in the operation. The stockings help to reduce swelling and oozing from leg wounds by improving blood flow. 

Pulmonary embolism – it is the sudden blockage of a lung artery or one of its branches by a substance, usually a blood clot, which has travelled from elsewhere in the body. It is a serious condition that can result in permanent damage to the affected lung as well as damage to other organs due to the lack of oxygen. If the clot is large or if there are many clots, it can also cause death. 

Step-by-step procedure on how plastic bags are used to help patients wear the stockings 

Step 1: 
The nurse helps the patient slip her foot into a transparent plastic bag. The plastic bag should ideally be big enough to cover the ankle.

Step 2:
The nurse then rolls up the stocking from top to bottom before slipping it over the patient’s foot. The plastic bag prevents the toes from getting caught in the stocking’s opening (where the toes are) and provides better glide over the most difficult spot to navigate – the heel. 

Step 3:
The nurse then pulls and adjusts the stocking further up the leg, taking extra care to ensure that it is wrinkle-free.

Step 4: 
The nurse further adjusts the stocking until it extends all the way up to the upper thigh.

Step 5:
When the stocking is in place, the plastic bag is removed and the process if repeated for the other leg. The same plastic bag can be re-used for the other leg.

Source: Singapore Health © Singapore Press Holdings Limited. Permission required for reproduction.