Pearson S D, Polak J L, Cartwright S, McCabe-Hassan S, Lee T H, Goldhaber S Z
Department of Medicine, Brigham and Women's Hospital, Boston, Mass., USA.
Arch Intern Med. 1995 Sep 11;155(16):1773-8.
Uncertainty regarding the optimal evaluation of suspected deep vein thrombosis (DVT) results in wide variations in practice, even within the same institution. To address variation in practice while maximizing the efficiency and quality of care, our institution developed a critical pathway guideline for the emergency department evaluation of patients suspected of having DVT. We present the critical pathway and the clinical rationale underlying its recommendations. The critical pathway was developed by a multidisciplinary team using chart review of practice at our institution, benchmarking at other institutions, and review and discussion of the medical literature. Consensus was achieved for the 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 patient evaluation of 5 hours or less was established as the target. Controversy arose in two key areas: (1) the treatment of patients with normal 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.
对于疑似深静脉血栓形成（DVT）的最佳评估存在不确定性，这导致了实践中的广泛差异，即使在同一机构内也是如此。为了解决实践中的差异，同时最大限度地提高护理效率和质量，我们机构制定了一项针对急诊科对疑似DVT患者进行评估的关键路径指南。我们展示了该关键路径及其建议背后的临床原理。该关键路径由一个多学科团队制定，采用了对我们机构实践的图表回顾、其他机构的标杆对照以及医学文献的回顾与讨论。对于选择超声作为所有患者的主要影像学检查，以及推荐高于我们机构当前标准的肝素钠初始剂量以缩短达到治疗性抗凝所需的时间，达成了共识。确定患者评估的总时间为5小时或更短作为目标。在两个关键领域出现了争议：（1）当对DVT有高度临床怀疑但超声扫描正常的患者的治疗，以及（2）疑似孤立性小腿静脉DVT的评估和治疗。在最终形式中，关键路径建议旨在平衡标准化的益处与医生根据个体患者情况做出决策的特权。
