ambulatory care

Variability in Anticoagulation Duration and Follow-up for Deep Vein Thrombosis in Ambulatory Care

Research Audit and Clinical Practice, Volume 24, Issue 4, Pages 149 – 180 (2025)

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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Optimising Cardiology Ambulatory Care Pathways: A Comprehensive Approach to Admission Avoidance and Timely Intervention in a Post-Pandemic Healthcare Landscape

Original Articles, Volume 23, Issue 2, Pages 53 – 96 (2024)

Introduction: Cardiovascular diseases are a substantial burden on healthcare systems, contributing significantly to avoidable hospital admissions. We propose a Cardiology Ambulatory Care Pathway.
Methods: Conducted a 1 month study redirecting admission streams from primary and emergency care, into a Cardiology Ambulatory Care Hub providing triage in Hot Clinic, and access to a Multi-Modal Testing Platform.
Results: 98 patients were referred to the Ambulatory Care Hub, 91 of which avoided admission. 52 patients received care in the cardiology hub, 38 of which required further testing.
Conclusion: We successfully streamlined various service streams, reducing admissions, and improving patient outcomes. Outpatient CTCA, ambulatory ECG, and echocardiography proved instrumental. We project a cost saving of £53,379 per month in bed days (£640,556 annual saving).

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Clinical Reliability of point-of-care tests to support community based acute ambulatory care

Original Articles, Volume 19, Issue 1, Pages 1 - 60 (2020)

Objective: To ensure clinicians can rely on point-of-care testing results, we assessed agreement between point-of-care tests for creatinine, urea, sodium, potassium, calcium, Hb, INR, CRP and subsequent corresponding laboratory tests.

Participants: Community-dwelling adults referred to a community-based acute ambulatory care unit.

Interventions: The Abbott i-STATTM (Hb, clinical chemistry, INR) and the AfinionTM Analyser (CRP) and corresponding laboratory analyses.

Outcomes: Agreement (Bland-Altman) and bias (Passing-Bablok regression).

Results: Among 462 adults we found an absolute mean difference between point-of-care and central laboratory analyses of 6.4g/L (95%LOA -7.9 to +20.6) for haemoglobin, -0.5mmol/L (95%LOA -4.5 to +3.5) for sodium, 0.2mmol/L (95%LOA -0.6 to +0.9) for potassium, 0.0mmol/L (95%LOA -0.3 to +0.3) for calcium, 9.0 μmol/L (95%LOA -18.5 to +36.4) for creatinine, 0.0mmol/L (95%LOA -2.7 to +2.6) for urea, -0.2 (95%LOA -2.4 to +2.0) for INR, -5.0 mg/L (95%LOA -24.4 to +14.4) for CRP.

Conclusions: There was acceptable agreement and bias for these analytes, except for haemoglobin and creatinine.

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Non-Cardiac Chest Pain: management in the Ambulatory Clinic setting

Clinical Reviews, Volume 18, Issue 3, Pages 137 – 204 (2019)

Non-cardiac chest pain (NCCP) is a common presenting complaint which can be better managed. This requires the recognition of clinical sub-groups with investigation and treatment tailored accordingly. The aim of this paper is to encourage more accurate diagnoses and the better recognition of the source of chest pain. We discuss the appropriate investigations and management of each clinical sub-group.

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What is the evidence base for ambulatory care for acute medical illness?

Review Articles, Volume 17, Issue 3, Pages 117 – 172 (2018)

Acute ambulatory care is a critical component of the emergency care pathway with national policy support and a dedicated NHS Improvement network. The evidence base for treating acute medical illness outside hospital is a diverse mix of randomised and observational studies with varying inclusion criteria, prognostic stratification, interventions and healthcare setting which limits synthesis of all available evidence and translation to the UK context. There is little consensus on the level of risk for home-based treatment for acute medical illness. Selection tools for referral to acute ambulatory care have been developed but there is limited evidence for their use. There are still research questions concerning optimal staffing, referral mechanisms, point of care diagnostic portfolio and tools for shared decision making.

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Ambulatory Outpatient Management of patients with low risk febrile neutropaenia

Trainee Section, Volume 14, Issue 4, Pages 145 - 196 (2015)

Patients with febrile neutropenia are a heterogeneous group with only a minority developing significant medical complications. Scoring systems, such as the Multinational Association for Supportive Care in Cancer (MASCC) score, have been developed and validated to identify low risk patients. Caring for patients with low risk febrile neutropenia in an ambulatory setting is proven to be safe and effective. Benefits include admission avoidance, cost savings and reduced risk of nosocomial infections, as well as improved patient experience and satisfaction. Implementation of an ambulatory pathway for low risk febrile neutropenia provides an excellent opportunity for Acute Physicians and Oncologists to collaborate in delivering care for this group of patients.

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