Variation in the management of deep vein thrombosis: implications for the potential impact of a critical pathway

To evaluate the potential impact of a practice guideline in the form of a critical pathway on variation and quality of care in patients with deep vein thrombosis (DVT).

Goals were identified for key steps and processes that were believed to be important for meeting a length-of-stay (LOS) goal of 5.5 days, and for improving quality of care for patients with DVT. Data collected via chart review were used to determine the percentage o patients with uncomplicated DVT admitted in the year after October 1, 1992, whose management would have met these goals.

Only 11 (12%) of 92 eligible patients with a primary discharge diagnosis of DVT met the LOS goal. In 30%, the activated partial thromboplastin time (aPTT) was >60 seconds within a target of 12 hours after admission. The goals for the initiation of warfarin (within 12 hours after aPTT >60 seconds) and the achievement of a therapeutic international normalized ratio (INR) level (within 120 hours) were met in 51% and 58% of patients, respectively. The target duration of intravenous heparin therapy was achieved in 78% of patients. Only 18% of patients, however, were discharged within 12 hours after 96 hours of heparin therapy had been given and a therapeutic INR had been achieved.

These data demonstrate considerable variation in management of uncomplicated DVT at a single hospital, suggesting that a critical pathway could have impact on both LOS and quality of care.