Objectives: To describe an evidence-based algorithm formulated to overcome crowding in the emergency department (ED), whereby patients referred for suspected deep vein thrombosis (DVT) undergo investigation and initial treatment by an advanced care paramedic (ACP) without having to wait for an ED bed. 

Methods: Seventy-three patients referred to the ED for suspected DVT by their family physician were met in the waiting room by an ACP, who calculated the clinical probability of DVT using Wells' criteria and ordered tests and treatment according to a standard algorithm. Each case was reviewed by an emergency medicine physician at the time of discharge. Length of ED stay, tests performed, and outcome were compared with patients with similar signs and symptoms who presented before introduction of the process. Patients who consented were followed at 3 months. The satisfaction of patients, ACPs and emergency medicine physicians was evaluated. 

Results: Mean ED length of stay when the work-up included a D-dimer test decreased from 379.31 min. before, to 284.74 min. after introduction of the process, with no difference in the percentage of DVTpositive ultrasound scans (14.0% vs. 13.9%). Of the 52 patients who consented to follow-up, data was collected on 36. Eight (22.2%) were prescribed anticoagulation drugs and 26 (72.2%) rated the process as efficient. Thirty-two (88.9%) were very satisfied or satisfied with the process. A telephone survey of 30 family practitioners showed that 70% had used the process. Their average satisfaction rating on a 10-point scale was 8.99 (range 8.75-10). Of the 23 emergency medicine physicians surveyed, 22 (96%) had used the pathway and 21 (95%) felt it was worthwhile, as did 8 of the 9 ACPs (89%) interviewed. 

Conclusions: DVT investigation and management can safely be conducted by ACPs, resulting in decreased length of ED stay for patients and satisfaction of patients, ACPs, and family and emergency medicine physicians.

Authors: Campbell SG, MacKinley RP, Froese P, Etsell G , McDonald MA, Carr B, Anderson DR, Cairns SL , and the Advanced Care Paramedics of the QEII