Diagnosing venous thromboembolism – protocols and problems, the Salford experience Kerstin Hogg Clinical Lecturer, University of Manchester

Problems with diagnosing PE Paradigm shift in approach to diagnosis with Wells, Canada, 1998 Structured clinical probability scoring Dislike for D-dimer Evolution of CT scanning

Problems with diagnosing DVT Doctors cannot diagnose DVT by looking at a leg Structured clinical probability scoring Dislike for D-dimer Many hospitals only scan the thigh Lack of consistent approach to 1. Below knee DVTs 2. Chronic thrombosis

Approach in Salford Royal Hospital Emergency Department centralised DVT service Hospital working group Hospital wide electronic protocols Education, education, education

Population 929 approached for the study 448 consented and investigated for DVT 358 consented and investigated for PE 98 lacked capacity 25 declined to participate

Demographics 60% female mean age 60 13% inpatients 14% had had a recent hospital admission 6% post-op orthopaedics 14% anticoagulated 18% past history VTE 10% cancer 2% pregnant 4% IVDAs

448 investigated for DVT 98 low / moderate Wells score and negative D-dimer 69 had DVT diagnosed on first thigh USS 16 had DVT diagnosed on second thigh USS 28 failed to have two USS 350 patients had USS ordered No DVTs or PE diagnosed during three month follow up

DVT PROBLEMS Recognising a chronic DVT IVDAs Below knee DVTs

358 investigated for PE 76 low Wells score and negative D-dimer 18 had VQ scanning 254 had CTPA 12 failed to have imaging 282 patients had imaging ordered Two patients with a negative CTPA were diagnosed with PE during the 3 month follow up 62 patients diagnosed with PE

PE PROBLEMS 2 false negative CTPAs Lack of use Wells score/D-dimer Differentiating acute from chronic PE

Questions?