A CRITICAL PATHWAY TO EVALUATE SUSPECTED DEEP-VEIN THROMBOSIS

Uncertainty regarding the optimal evaluation of suspected deep vein th rombosis (DVT) results in wide variations in practice, even within the same institution, To address variation in practice while maximizing t he efficiency and quality of care, our institution developed a critica l pathway guideline for the emergency department evaluation of patient s suspected of having DVT, We present the critical pathway and the cli nical rationale underlying its recommendations. The critical pathway w as developed by a multidisciplinary team using chart review of practic e at our institution, benchmarking at other institutions, and review a nd discussion of the medical literature, Consensus was achieved for th e selection of ultrasound as the primary imaging test for all patients and for recommending initial doses of heparin sodium that are higher than the current norm at our institution to reduce the length of time required to achieve therapeutic anticoagulation, A total time for pati ent evaluation of 5 hours or less was established as the target. Contr oversy arose in two key areas: (1) the treatment of patients with norm al ultrasound scans when high clinical suspicion for DVT exists and (2 ) the evaluation and treatment of suspected isolated calf-vein DVT, In its final form, the critical pathway recommendations seek to balance the benefits of standardization with the prerogatives of physicians to make decisions tailored to individual patients.