Compliance with The National Institute for Health and Care Excellence (NICE) Guideline (NG158) Venous Thromboembolic Diseases: Diagnosis, Management, and Thrombophilia Testing; Proximal Lower Limb Venous Ultrasound Time Standards at Wexford General Hospital

Abstract

Introduction:The consequences of missed lower-limb deep vein thromboses (DVT) can be life-threatening. Similarly, inappropriate treatment with anticoagulation in low-risk patients carries a significant risk of harm. Early diagnosis and appropriate treatment with anticoagulation rely on timely ultrasound access. The National Institute for Health and Care Excellence (NICE) recommends timeframes for ultrasound acquisition based on Well’s score and D-dimer value.If rapid ultrasound (Point of care Ultrasound POCUS in our context) demonstrates no features of DVT, it is safe to arrange follow-up scan within eight days without empiric anticoagulation. If, however, no bedside ultrasound is performed, anticoagulation is commenced until a formal scan excludes DVT. NG158 recommends this scan be performed within 24 hours. This audit investigated our compliance with NG158 time standards at Wexford General Hospital (WGH) emergency department (ED).Method:Electronic records for patients undergoing formal ultrasound for suspected DVT between 08/01/2022-10/13/2022 were reviewed using the hospital’s databases. Charts were reviewed to determine if POCUS was performed. In total, 42 records met selection criteria. Audit Committee governance review was obtained. Fisher’s exact test was used to compare compliance rates between those that underwent bedside ultrasound and those that did not.Results:Overall compliance with NG158 was 40.5%. Compliance rates for those offered bedside ultrasound were significantly higher than those that weren’t (58.3% vs. 16.7% p<0.0106). The mean waiting time for a radiology department ultrasound is six days, 12 hours, and 16 minutes.Conclusion:Overall compliance is low, and delays to obtaining formal ultrasound are long. We observed that compliance rates for those who underwent bedside ultrasound were significantly higher than for those who did not. This suggests that bedside ultrasound is under-utilized in our ED. Training more staff to perform bedside scans would alleviate current delays to ultrasound diagnosis and reduce risks associated with empiric anticoagulation.