Dear Simon,
This seems a very sensible approach.
The other key point to get across is that D-dimer has a positive likelihood
ratio for VTED of 1. In other words a positive result is just as likely to
be a false positive as a true positive and therefore a positive result has
no value: I usually describe this as "non-contributory" to incredulous
medical SHOs who refuse to believe that a positive D-dimer doesn't increase
the likelihood of VTED one jot. A D-dimer can be useful in selected patients
if negative. A positive test is of no value whatsoever.
Regards,
Jonathan.
-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of McCormick Simon Dr,
Consultant, A&E
Sent: 27 January 2012 08:55
To: [log in to unmask]
Subject: Re: d dimers
Can relate to that Sue. We had the same problem here a few years ago across
the Trust (it isn't usually just ED docs doing them inappropriately) and it
was the Lab Consultants that eventually snapped! After discussion with us
and the MAU the guidelines were clarified (only D-Dimer in low risk DVT/PE)
and then NO D-Dimer sample was processed without one of those diagnoses
queried on the form and a Wells Score written on the form too. If a sample
went up without both of these it was put to one side and not put in the
analyzer.
Clearly the option to fake the diagnosis/scoring on the lab form is there
but that has to be an active decision, the test can't just be added as a
scatter gun approach and there is a bit more personal accountability.
Coincidentally, it makes the juniors look up the Wells Score more often as
well, rather than just guessing it, because there is far more chance that
they are going to get asked by a senior about it!
Hasn't been perfect but the drop off happened very quickly and has been more
or less sustained.
Unsurprisingly, a joint approach between the clinicians and the laboratories
worked!
Simon
"Hospitals with overcrowded Emergency Departments are overcrowded hospitals
that have chosen to manifest the overcrowding in a single location"
Full Capacity protocol: an end to double standards in acute hospital care
provision Emerg Med J 2011;28:547-549
-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Suzanne M Mason
Sent: 26 January 2012 09:39
To: [log in to unmask]
Subject: d dimers
Dear List
I wonder if any of you would be prepared to share thoughts / departmental
guidelines you have about the use of D-Dimers? We seem to have some issues
in our ED that this test is used indisciminately by staff and wonder how
other EDs have managed this problem?
Best Wishes
Suzanne Mason
Professor of Emergency Medicine
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