Background
We evaluated the impact of an after-hours policy regulating venous duplex ultrasound
(VDU) for deep vein thrombosis (DVT) diagnosis on resource utilization and patient
care.
Methods
On July 1, 2007, we altered the approach to emergent VDU of patients with potential
DVT during off-hours (defined as 5:00 p.m. to 7:00 a.m. weekdays, after 3:30 p.m. Saturdays and Sundays). Instead of 24 hr access, we permitted a venous duplex study in the noninvasive vascular laboratory
(NIVL) only after meeting set criteria developed collaboratively across services.
In the emergency department (ED), we based all VDU requests on a preset modified Wells
score (MWS) as determined by the ED physician. Those patients with MWS 0 or 1 and
those above 1 who could receive empiric single-dose low–molecular weight heparin (LMWH)
received next-morning imaging unless consultation with a vascular surgeon created
an emergent imaging plan. In parallel, inpatient emergent VDU was permitted only after
contact with an attending vascular surgeon and where empiric short-term anticoagulation
could not occur safely. We tracked NIVL utilization, patient morbidity, sonographer
retention, and satisfaction.
Results
The number of overall off-hours emergent VDUs decreased from 59 to 19/month after
implementation. Testing was deferred in 52 ED patients: 15 stayed in the ED for testing
in the morning and 37 were discharged to be tested the following day. Thirty-one of
37 patients returned for testing as outpatient follow-up. Twenty-eight received ED
LMWH while awaiting testing. No adverse events were noted with the delay. The mean
MWS for ED after-hours studies was 2.9±1.6 and that for deferred ER studies was 2.4±1.3 (p=0.005). Incidentally, overall off-hours inpatient and ED VDU requests decreased 64%
with no clinical adverse events in the first year. The rate of overall positive studies
done off-hours increased from 6.7% to 20% (p<0.0001). Sonographer satisfaction was maintained with regulation of call.
Conclusion
Our collaborative approach allowed off-hour VDU utilization to decrease without any
measurable negative care impact.
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Article info
Publication history
Published online: September 11, 2009
Identification
Copyright
© 2010 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.
