Sequential compression devices, while effective at reducing the incidence of venous thromboembolism when properly used, often have poor rates of compliance. Overall compliance in our patient population of urologic postoperative inpatients was 78.6%. This was comparable to an intensive care unit compliance rate of 78% found by Comerota but was higher than the 48% compliance seen on routine nursing units in the same study . We found that hospital factors, including availability of SCDs and timely replacement of SCDs when a patient returns to bed, were the primary factors in non-compliance. Patient factors including demographics, knowledge, attitudes, and bother with SCDs did not play an important role in non-compliance.
Other studies have also suggested hospital related reasons for poor SCD compliance. Cornwell et al. identified that in 95% of instances of non-compliance, SCD devices were not in place . Comerota and colleagues identified a main reason for non-compliance in their study to be SCD device pumps not running despite appropriate sleeve placement . Failure to restart SCD devices after treatment was interrupted was identified as the most common cause of non-compliance in a third study .
Having medical devices readily available is the most basic requirement for safety device utilization [11, 12] but unfortunately was a major cause of non-compliance in our study. As a result of these findings, our facility has obtained additional SCD machines that are left at each patient bed, insuring that the devices will always be available. While necessary, availability alone may not always be sufficient for optimal utilization. For example, introduction of alcohol based hand rubs alone was not sufficient for improved hand hygiene in a study involving three hospital wards. Additional support by medical leadership and a behavioral modification program were also necessary for sustained success . In the case of SCDs, in addition to insuring availability, changing nursing behavior to encourage prompt replacement of devices after a patient’s return to bed may also be necessary in order to adequately address the problem of poor SCD compliance.
Improving medical device design to encourage and simplify use can be another approach to promote compliance [14, 15]. In our study, improving SCDs by making them “cordless” or “wireless” was the most common suggested design change to improve SCD compliance, with 49% of subjects listing this when asked about ways in which SCDs could be made easier to use. Such a device would also eliminate the need to remove and replace SCDs when a patient leaves the bed, which was an important cause of non-compliance in our study. Compact, portable, battery-powered pneumatic compression devices that do require constant attachment to a power source have been previously assessed in a study by Murakami et al.  In their study, overall compliance was greater in patients using the compact portable devices (78%) compared to patients using traditional SCD devices that required being plugged in at all times and which were bulkier (59%). The difference in compliance was primarily attributed to the ability of the portable devices to continue to operate during patient transport to radiologic procedures. However, the compact portable devices used in their study aren’t entirely self-contained in that they still have tubing connecting sleeves on the patients’ legs to the pump unit. Development of completely self-contained SCDs would likely further improve patient tolerability and compliance.
The acceptability of a therapy to a patient can play an important role in compliance. Easing use and reducing patient inconvenience has been shown to improve compliance with birth control regimens  and with continuous positive airway pressure for sleep apnea . Improving patient comfort with SCDs has been proposed as a way to improve compliance . However, our study suggested that patient related factors seemed to play only a minimal role in SCD non-compliance. Out of 12 categories of bother, the highest level of bother reported by subjects in this study was only 3.1 out of 10 for the category “The SCDs were confining.” Patients instead appeared to actually enjoy SCDs, with most reporting that “The SCDs felt like a massage” or “The SCDs were comfortable.” Consistent with these findings, our patients reported higher acceptability to using SCDs over the option of daily subcutaneous anticoagulation shots. Similarly, Cindolo and colleagues found an overall positive opinion about SCDs with 72% percent of patients regarding SCD sleeves as pleasant and 79% reporting that they did not feel oppressive .
Several limitations of the study should be noted. We did not use a validated questionnaire to assess patient response. Limited observation time points occurring only twice a day may have weakened the compliance data. Continuous patient monitoring would have been optimal but was not logistically feasible for this study. Interactions with subjects by research staff during observations for compliance may have elevated observed compliance rates. During observations, patients were sometimes asked why they were not wearing their SCDs in order to clarify the cause for non-compliance. This may have encouraged subjects to wear their SCDs more consistently. This study was conducted at one site and findings may not reflect the experience of other medical centers. Additionally, the patients in this study were all postoperative urology patients, and their experiences may not reflect that of other patient populations.