Australasian Emergency Nursing Journal (2011) 14, 232239

Available online at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/aenj

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
Clinical nursing practice guideline; DVT prevention; Critically trauma patient

Summary Deep vein thrombosis (DVT) is the third leading cause of morbidity in critically ill trauma patients but it can be prevented by performing appropriate risk assessment and preventive strategies. The purpose of this study was to evaluate of implementing a clinical nursing practice guideline (CNPG) for preventing DVT in critically trauma patients at Songklanagarind Hospital. The CNPG content with 37 items initially developed from evidence-based knowledge 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 difculty of using the CNPG, (2) nurses satisfaction in implementation of CNPG, and (3) the patients femoral blood ow 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 satisfaction at high (M = 8.06, SD = 0.96). There were no differences in femoral venous blood ow velocity before and after 7 days and without signs of DVT. The ndings 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 ow velocity in those patients who are at risk. Further study could be explored to conrm its effectiveness with the large sample size. 2011 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.

a b

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). Tel.: +66 081 898 8400. 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

233

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 difcult 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, particularly 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 incidence 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 Hospital, Bangkok showed that 10.15% of patients admitted to the surgical intensive care unit (ICU) developed DVT at 6-month follow up.6 Virchows 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 effective 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 patients risk for DVT.8 Although evidence based consensus guidelines for prevention of DVT have been available, guidelines for DVT prevention remain underused in nursing. The use of a protocol 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 hospitalized high risk patients.24 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 modication based on variations in organizational resources such as facilities and treatment offered in the local context, and design for a specic group of patients, such as postoperative patients.11 A clinical nursing practice 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 nursing 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 critically 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.

Conceptual framework
The Australian National Health and Medical Research Councils Guide to the development, implementation, and evaluation of clinical practice guidelines14 was modied and used as a framework for this study. The simple process of developing, implementing and evaluating the evidencebased 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 implementation 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 difculty in using the CNPG, (2) the nurses satisfaction with CNPG, and (3) the patients femoral blood ow 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 evidence from the literature and from expert review and was designed as a ow 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 19982009 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 initially 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 categories and (2) nursing interventions for preventing DVT. The instruments used in the study consisted of (1) the evidencebased DVT prevention guideline (CNPG for prevention of DVTThai 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 consisting 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 surgical 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 further 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 ow chart and divided into three groups depending on the patients risk (see Fig. 1). As risk categories were identied for patients, Combined interventions were given such as (i) passive exercise, (ii) elastic stocking or intermittent pneumatic cuff pressure (IPC), and (iii) anticoagulants.

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 ow 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 suffered 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.

Guideline implementation (short term)

The nal 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 practice 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 ow velocity to evaluate as the primary outcome in 11 patients. Nurse opinion and satisfaction were measured using open-ended questions and group discussions. The satisfaction score was assessed using a numeric scale (010), with 10 indicating the highest level of satisfaction. A total satisfaction score of 13 was interpreted as low, 47 was interpreted as moderate, and 810 was interpreted as high. In terms of blood ow velocity, a twice daily assessment using a vascular Doppler detector was conducted to determine the mean value of normal (1520 cm/s) or slow rate of blood ow velocity (<10 cm/s), which may pose a risk for DVT development.15

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 overall activities reported as possible to implement are shown in Table 2. Promoting foot exercise was identied by most nurses (97.62%) as having the greatest possibility of implementation. 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 interventions 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

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 difculty of using the CNPG, (2) nurse satisfaction with CNPG, and (3) the patients femoral blood ow 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

CNPG in preventing DVT

Patient with Trauma Autar DVT Assessment risk categories 10 = low risk 11-14 =moderate risk >15 = high risk

235

Initial risk assessment using DVT screening tool within 24 hours of admission

Give intervention as risk categories

Low risk (score 10)

Moderate risk (score =11 14)

High risk (score 15)

1. give advice of DVT prevention 2. motivate exercise or activity either passive or active as tolerate 3. ankle exercise each site 5 min, 75 times rate 15 times/min (level 3.1) Ankle rotation 20 time 15 times/min 4. ambulate and walking (level 1) **exercise at least twice a day** (level 3.1)

1. give advice 2. do exercise as Table 1 3. on IPC or GCS (level 1) 4. Release IPC or GCS twice a day for 30 (level 1) 5. consult for medication prophylaxis (level 1)

1. consult for medication prophylaxis (level 1) 2. give intervention as Table 2 (1-4)

Reassessment every 24 hours (level 3.3) Notify if there is any sign of DVT

Figure 1

A ow 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 satised at a moderate level. Each patients outcome as measured by femoral venous blood ow 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 ow velocity was monitored in 8 patients who received continuous DVT prevention activities following the CPNG and revealed little increase in blood ow 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). Level of opinion Moderate agree number (%) Highly agree number (%) 41 (97.62) 40 (95.24) 39 (92.86) 38 (90.48) 29 (69.05) 24 (57.14) 38 (90.48) 39 (92.86) 41 (97.62)

Assessment to screen each risk

1. 2. 3. 4. 5. 6. 7. 8. 9.

Age specic group Mobility Trauma risk category Surgical intervention Body mass index Special risk category High risk diseases Scoring and dividing into three risk groups Evaluation of signs of DVT

1 (2.38) 2 (4.76) 3 (7.14) 4 (9.52) 13 (30.95) 18 (42.86) 4 (9.52) 3 (7.14) 1 (2.38)

236
Table 2

P. Songwathana et al.
Nurses opinions regarding the item guideline in the nursing interventions to prevent DVT (N = 42). Level of opinion Moderate agree number (%) Highly agree number (%) 40 (95.24) 40 (95.24)

Nursing intervention in each risk group

Nursing interventions in low risk groups 1. Providing information to patients and/or relatives about prevention of DVT 2. Encouraging patients to do foot exercise by themselves or having staff and relatives help if patients are unable to do so 3. Motivating patients to do foot exercise 4. Encouraging early ambulation when the patient is ready 5. Doing foot exercise 2 times per day Nursing intervention in moderate risk groups 1. Providing information to patients and/or relatives about prevention of DVT 2. Motivating patients to do foot exercise 3. Encouraging early ambulation when the patient is ready 4. Doing foot exercise 2 times each day 5. On IPC all the time until patient can ambulate except some restrictions on using of GCS 6. Remove the sleeve for approximately 30 min to check the skin (2 times a day) 7. Consult doctor for pharmacological use Nursing intervention in high risk groups 1. Consult doctor for pharmacological use 2 Encouraging early ambulation when the patient is ready 3. On IPC all the time until patient can ambulate except some restrictions on using of GCS 4. Remove the sleeve about 30 min to check the skin (2 times a day) 5. Doing foot exercise 2 times per day 6. Encouraging patients doing foot exercise by themselves or with staff or relatives if patients are unable to do 7. Reassess the risk of DVT every day 8. Report to doctor when clinical sign of DVT exist

2 (4.76) 2 (4.76)

1 (2.38) 6 (14.29) 2 (4.76) 2 (4.76) 2 (4.76) 4 (9.52) 2 (4.76) 5 (11.90) 3 (7.14) 9 (21.43) 10 (23.81) 3 (7.14) 4 (9.52) 3 (7.14) 2 (4.76) 7 (16.67) 4 (9.52) 2 (4.76)

41 (97.62) 36 (85.71) 40 (95.24) 40 (95.24) 40 (95.24) 38 (90.48) 40 (95.24) 37 (88.10) 39 (92.86) 33 (78.57) 32 (76.19) 39 (92.86) 38 (90.48) 39 (92.86) 40 (95.24) 35 (83.33) 38 (90.48) 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 condition of DVT, and history of contraceptive pill use were

not accessible, approximately half the nurses were of the opinion assessment was difcult (52.38%, N = 22). Some nursing interventions to prevent DVT were limited: 71.42% of nurses reported limitations in applying the graduated compression stockings and 61.90% of nurses reported limitations in applying IPC.

Table 3 (N = 42).

Nurses opinion towards the item recording of the risk assessment screening and nursing interventions to prevent DVT Level of opinion Moderate agree number (%) Highly agree number (%) 38 (90.48) 40 (95.24) 39 (92.86) 39 (92.86) 39 (92.86)

Recording assessment for risk screening and nursing intervention

1. 2. 3. 4. 5.

Risk assessment scale Record clinical sign and site of DVT Sign up screening risk patients. Record activity done for patients Record problems and obstacles that cannot be performed as specied in the guidelines

4 (9.52) 2 (4.76) 3 (7.14) 3 (7.14) 3 (7.14)

CNPG in preventing DVT

Table 4 Day Patients femoral blood ow velocity before (day 1) and after (day 7) using CNPG (N = 8). Case 1 2 3 99.40 11.60 4 11.20 11.40 5 11.20 11.80 6 11.60 11.80 7 11.80 11.80 8

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Femoral blood ow velocity (cm/s) Day 1 99.40 11.60 Day 7 10.20 11.70

10.30 11.70

Table 5

Nurses comments on problems and difculties in CNPG implementation. Number 15 14 10 4 22 21 17 1 30 26 16 18 12 7 7 % 35.71 33.33 23.81 9.52 52.38 50.00 40.48 2.38 71.42 61.90 38.10 42.86 28.57 16.67 16.67

Problems in CNPG implementation CNPG handbook 1. Contents in some items was unnecessary to evaluate 2. CNPG has too much content 3. No time to use the CNPG 4. Contents of CNPG are difcult to understand Risk assessment as a screening tool 1. Assessing records for congenital conditions, i.e. DVT is difcult 2. Assessing history of using contraceptive pills is difcult 3. Assessing the patients body mass index is difcult. 4. Assessing for signs of neonatal DVT is difcult Nursing interventions 1. Using graduated compression stockings is difcult 2. Using IPC is difcult to encourage 3. Consulting a doctor for pharmacological use is difcult 4. Staff assistance of patients with passive exercise is very difcult 5. Motivating patients to exercise is difcult 6. Providing advise relative to passive exercise is difcult 7. Encouraging patients to do foot exercises 2 times each day is difcult
Note: More than 1 item was identied.

Discussion
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 ow 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 ow 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 difcult to assess. Body mass index (BMI) was one item with less feasibility as it cannot be measured by weight alone. Difculty 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 patients 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 classication to some degree. However, the literature review results indicate that body mass index

is one factor in high risk patients that should be measured 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 ow velocity.20,21 Although nurses made comments about problems and difculty in performing foot exercises for patients who were unable to do them by themselves, foot exercises were often performed by relatives under the nurses 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 moderate 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 signicantly limited use of this equipment. Prevention 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 rst 24 h of hospital admission.21 However, anticoagulant medication was less likely to be prescribed by a physician unless a nurse made the request. Skills in effective 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 satisfaction. 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 nursing 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 relationships 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 ow velocity in the rst 7 days after SICU admission was a positive nding. This is similar to previous studies of foot exercise in critically patients and healthy adults, where the results showed that femoral blood ow 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 ow velocity in critically trauma patients. In this study, 72.72% of the patients received analgesics such as morphine and fentanyl for surgical pain and blunt injury. Analgesic drugs may affect vasodilatation of the vessels and decrease blood ow. For example, with a 0.5 mg/kg morphine dose, resistance to blood ow in peripheral arteries dropped 46% 23 min after treatment and returned to normal within 9 min.23 Other drugs, such as dopamine, noradrenaline, and dobutamine, which increase blood ow velocity, may have effects on the cardiovascular system. However, blood ow velocity on average changed little by day 7 after being admitted to the SICU. This may have limitations in terms of factors affecting venous ow velocity often found in critically ill trauma patients. A nding was that venous blood ow velocity was maintained during immobilization.

P. Songwathana et al. of blood ow velocity may also be inuenced by other factors.

Conclusions
The ndings of the study indicated that the use of evidencebased clinical practice guidelines for prevention of deep vein thrombosis could be benecial for nursing risk assessments and maintenance of venous blood ow 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 majority of nurses felt satised 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 ow velocity was maintained during immobilization. Further studies could explore or conrm the effectiveness of the CNPG with a large sample size. In addition, implementation of CNPG must be supported at the policy 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 conict of interest

The authors conrm 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 Practice 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. Marguerite J. Purnell for editing the English in this manuscript.

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Limitations
Because this was a pilot study with a small sample size, the generalisability of results is limited. The measurement

CNPG in preventing DVT

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