Authors (including presenting author) :
Cheung HY(1), Lui CT(1), Fung HT(1), Lee LY(2), Chan KM(1), Lau CL(1)(2)
Affiliation :
(1)Accident and Emergency Department, Tuen Mun Hospital (2)Accident and Emergency Department, Tin Shui Wai Hospital
Introduction :
A standardized clinical protocol for workup and treatment of lower limb deep vein thrombosis (DVT) was established and implemented in the Accident and Emergency Department (AED) and Emergency Medicine Ward (EMW) of Tuen Mun Hospital (TMH) in 2016. This protocol integrated initial risk assessment, Modified Wells Score, point-of-care ultrasound (POC USG) by emergency physicians and formal Doppler USG by radiologists. There was standardized care for complication screening, workup of underlying causes and thrombosis treatment. The use of Direct Oral Anticoagulant (DOAC) facilitated timely discharge. Low risk patients fulfilling early discharge criteria would be treated with anticoagulants and referred to a dedicated fast-track medical clinic, with interim follow-up in EMW.
Objectives :
(1) To evaluate the effectiveness of protocol-driven management of patients with suspected lower limb DVT from AED to EMW
(2) To assess the treatment, complications and clinical outcome for the handled DVT patients
Methodology :
Suspected lower limb DVT patients admitted to TMH EMW from either TMH or Tin Shui Wai Hospital (TSWH) AED from the period of 1/10/2016 to 31/10/2019 were included. Efficacy was assessed by the length of stay (LOS) and the formal Doppler USG waiting time. A historical control group of lower-limb DVT patients managed in medical wards in the period 1/12/2012 – 30/11/2014 was recruited for comparison.
Result & Outcome :
201 patients were admitted to EMW during the audit period for suspected lower limb DVT. Mean age was 60.5. 43 were confirmed DVT (21.4%). Mean LOS in EMW was 1389 minutes (53 – 7758) overall, 1663 minutes for non-DVT and 2501 minutes for DVT patients. POC USG was performed in 52 patients (25.9%), with accuracy of 94.2% with reference to radiologist. Formal Doppler USG by radiologist was performed in 158 patients (78.6%), with mean waiting time of 27.2 hours (2-192). For those confirmed DVT, 2 developed pulmonary embolism (4.7%). 16 were transferred out (37.2%) for complication or high risk on stratification. For treatment, 72% were anticoagulated with direct oral anticoagulants (DOAC), and the rest with low-molecular-weight heparin and warfarin. Mean time from discharge to 1st medical follow-up in SOPC was 24 days (3-77). The historical data of DVT patients of same inclusion criteria and clinical complexity between 1/12/2012 – 30/11/2014 demonstrated a mean length-of-stay of 7 days while the pulmonary embolism rate was similar. Conclusion Implementation of protocol-driven management for lower limb DVT in AED and EMW could reduce hospital LOS. With enhancement to USG arrangement and DOAC usage, in the future we could further enhance ambulatory management.
