Clinical question: How useful is compression ultrasound (CUS) for diagnosing distal DVT?
Background: CUS can reliably evaluate proximal DVT, but its accuracy for distal DVT is controversial. Because of the risk of extension of distal DVT (up to 25%), guidelines recommend that some patients undergo serial proximal CUS after an initial negative result. As an alternative, recent studies have evaluated one-time, whole-leg CUS.
Study design: Systematic review and meta-analysis.
Setting: Review of randomized controlled trials and prospective cohort studies.
Synopsis: The study pooled data from seven studies and more than 4,700 patients with suspected DVT for whom anticoagulation was withheld after a single, negative, whole-leg CUS. At the three-month followup, the combined symptomatic VTE event rate was 0.57%, and the authors concluded that withholding anticoagulation was associated with a low VTE risk.
Although encouraging, this study had several limitations. First, whole-leg CUS is not widely performed or standardized, and the CUS technique varied slightly across the studies. Second, any attempt to generalize the results of this study might be limited, as the proportion of pregnant patients and those with malignancy was low. Furthermore, only one of the seven studies included inpatients that might be at higher VTE risk. Third, pre-test probability was assessed for only a subset of patients, limiting assessment of VTE by risk level. For example, the overall finding of the study—an event rate of 0.57%—appears low but is difficult to apply clinically when subset analyses for high-risk patients yielded a VTE rate of 2.5% with wide confidence intervals ranging from 0% to 7%.
Bottom line: Whole-leg CUS might be a practical alternative to serial proximal CUS, but more data incorporating pre-test probabilities and involving more inpatients are needed. Hospitalists should be cautious in applying pooled summary estimates.
Citation: Johnson SA, Stevens SM, Woller SC, et al. Risk of deep vein thrombosis following a single negative whole-leg compression ultrasound: a systematic review and meta-analysis. JAMA. 2010;303(5):438-445.
Localization of Inpatient Physicians on Hospital Units Increases Provider Communication Frequency
Clinical question: Does localization of inpatient physicians on hospital units improve communication with nursing staff?
Background: While nurses are typically localized on a hospital unit, inpatient physicians often care for patients on multiple units. This lack of regionalization makes it difficult for physicians and nurses to discuss care plans directly. No prior research has evaluated the effect of physician localization on nurse-physician communication.
Study design: Cross-sectional, pre- and postintervention study.
Setting: Tertiary-care teaching hospital, general medical service.
Synopsis: The study was a cross-sectional survey of nurses and physicians prelocalization (n=342 patients) and postlocalization (n=294 patients) of physicians on hospital units. Localization was associated with increased frequency of communication; however, it did not improve the consistency of nurse-physician agreement on the care plan. Nurse-physician agreement was improved on two aspects of the care plan—planned tests and anticipated length of stay—but not on primary diagnosis, planned procedures, medication changes, or consultations.
Limitations of the study were that it was conducted at a single teaching hospital, communication patterns might have changed during the year between pre- and postlocalization, and physicians were not completely localized to specific units (73% localization).
Despite the limitations, this study is the first to evaluate staff localization and communication on a general medical service. The findings suggest that localization is a first step toward interdisciplinary communication. It also shows that quality and content of communication require further assessment.
Future studies must assess the impact of communication on the quality of patient care.
Bottom line: Physician localization improved the frequency of nurse-physician dialogue but did not consistently facilitate a shared understanding of the care plan. Although not assessed in this study, the implication is that the quality of communication between providers needs improvement.