When an FP suspects a case of deep
vein thrombosis (DVT), the usual protocol is to send
the patient straight to the local emerg for tests. But
a novel pilot project launched at the QEII Hospital
in Halifax in late March teams MDs and paramedics to
tackle so-called "economy class syndrome" differently
— and free up much-needed ED beds in the bargain.
"FPs identified DVT as something
that they knew how to treat, but they couldn't access
the tools to do it," says Dr Sam Campbell, an emerg
doc who's part of the scheme, which launched in late
March. "As a result, they were forced to send all patients
to the ED, where they sat waiting for hours." To help
them make the initial diagnosis, QEII hematologist Dr
David Anderson adapted the Wells criteria, a checklist
for diagnosing pulmonary embolism, for assessing DVT
risk. "If the patient's scores signal DVT, the doctor
then decides the best path to take with a given patient,"
explains Mike MacDonald, administrative coordinator
of the project.
If the patient is deemed high-risk,
the FP immediately books an ultrasound at the hospital.
For cases that are less urgent,
the doctor calls the results in to the ED before sending
the patient over. When they arrive, they're met by an
advanced care paramedic who takes care of any blood
work and, in the case of a confirmed diagnosis, sets
up a consult with a hematologist. In both cases, the
patient bypasses the ED completely. (See "How
QEII's DVT process works" below.)
WHY
DVT?
Prior to the project, the hospital didn't have a coordinated
process for managing DVT patients once they arrived
in the ED, explains Dr Campbell. DVT was a great condition
to pilot, he adds, because it's common enough to be
able to show improvement, but not so overwhelming as
to be difficult to manage. "It represents an opportunity
for managing patients who don't need ED beds, without
making them wait for a bed (that they don't need),"
he says.
Around 80 of 400 FPs in the Capital
Health Authority district (which includes Halifax) are
participating in the study. "We started developing the
method last fall," explains Mr MacDonald, "and we're
going to be doing a statistical analysis on whether
the system is better for the patient or not."
SO
FAR, SO GOOD
Only a handful of patients have been pushed through
the new system so far, but response from physicians
has been very positive, according to Dr Campbell. "So
far the emerg docs are happy. They have these patients
managed for them and not blocking up their beds," he
says. A few nurses have, however, expressed concern
about the paramedics' increased responsibility. "[Paramedics]
are doing a job that they feel should be a nursing role,"
says Dr Campbell. He explains the main reason for enlisting
paramedics was that they're are available 24 hours a
day and don't have a dedicated patient roster that these
added responsibilities would pull them away from —
advanced care paramedics are also occasionally asked
to resuscitate or transfer patients.
One of the key goals of the project
is to close the gap between primary and secondary care.
"Before this, the FP got as far as he could, and then
had to send the patient to the ED, where someone else
had to start the whole process again," says Dr Campbell.
"Now the patient moves smoothly through the system to
diagnosis and treatment or reassurance."
COMING
SOON
Meanwhile, the QEII is considering expanding the approach
to include other conditions, depending on the success
of the DVT pilot. "We have a 'tool' for cellulitis,
although the process to facilitate their ED visit is
undeveloped," notes Dr Campbell. "We're also working
on one for patients with excessive anticoagulation,
which guides the FP on what to do, and where to send
the patient in each possible circumstance."
Flow Chart: Courtesy of the Primary
Secondary Care Quality Initiative Committee
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