All Journals from Thomas Knight
Objective: To determine whether front-door discharge decision tools operate at different mortality thresholds.Methods: Three databases searched, for studies testing, deriving or validating front-door risk prediction tools or discharge decision aids, with defined discharge ‘cut-off’, reporting mortality or readmission rates. Studies supporting tools’ inclusion in national guidelines were also included.Results: Twenty-four studies were included, frequently for acute chest pain. Mortality rates among those discharged based on tools 0-1.7%. Eight studies reported readmission rates, 0-8% among those discharged early or deemed low-risk.Conclusion: Although mortality rates were lower for those deemed low-risk by decision aids than those admitted or control groups, readmission rates tended to be higher among low-risk or discharged patients, than among control group or admitted patients. Full Text File size: 372 KB Downloads: 396...
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We thank Dr Gyan and colleagues for their thoughtful critique of our paper and welcome the opportunity to clarify the intended interpretation of our findings.
We acknowledge that there are a number of limitations to this service evaluation highlighted in your letter, which are also addressed in the paper itself.
Subarachnoid haemorrhage (SAH) is a potentially life-threatening cause of acute severe headache. This service evaluation aimed to investigate the prevalence of SAH in patients referred to acute medicine with acute severe headache who underwent a lumbar puncture (LP) at a tertiary teaching hospital, over a four-year period. Of the 677 samples analysed for CSF bilirubin, 619 were negative (91.5%), 48 indeterminate (7%), and 10 classified as positive (1.5%). Only one patient (0.1%) was diagnosed with an aneurysmal SAH and underwent intervention. Therefore, the diagnostic yield of an LP to exclude SAH in this setting is extremely low. This service evaluation challenges the dogma that LP is necessary in all patients with acute severe headache.
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Background: Deep vein thrombosis (DVT) is commonly managed in ambulatory care. Guidelines recommend reassessment at three months to review anticoagulation duration, but no structured follow-up pathway exists within our Trust.
Aim: To evaluate anticoagulation duration, follow-up practices, and outcomes in patients with DVT diagnosed in ambulatory care.
Methods: Retrospective, observational service evaluation across two ambulatory care units in Manchester, UK. Patients with confirmed lower limb DVT were identified between January 2023 and June 2023. Data were collected from electronic patient records including complication rates over a 2-year period.
Results: Of 307 patients assessed for suspected DVT, 90 had confirmed DVT. Most cases were unprovoked (77.8%). At discharge, 39% were prescribed 3 months’ anticoagulation, 31% 6 months, 11% lifelong, 6% received a duration range of 3-6 months, and 13% had no specified duration. Discrepancies between recommendation at discharge and primary care prescribing were seen in 53%, with nearly half receiving longer treatment. 20% had secondary care follow-up. Recurrent DVT occurred in nine patients, none of whom had received follow-up; no recurrences were seen in the followed-up group, although this difference was not statistically significant (Fisher’s exact test, p = 0.195). Bleeding events were seen in 4.4% of cases and were minor.
Conclusions: There is substantial variability in anticoagulation management following DVT in ambulatory care. Although recurrence was not observed in the followed-up group, the study was not powered to detect differences, and this finding should be interpreted cautiously. Further work is needed to establish if a follow-up DVT clinic will improve patient outcomes.
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