emergency vascular clinic...
TRANSCRIPT
Emergency Vascular
Clinic (EVC)
Grainne Killion
Vascular CNS
Guy’s and St Thomas’
NHS Foundation Trust
Meryl Green
Vascular CNS
Guy’s and St Thomas’
NHS Foundation Trust
Becky Sandford
Vascular Consultant
Guy’s and St Thomas’
NHS Foundation Trust
Aim:
1. To rapidly assess urgent vascular patients in a one-stop clinic with
same day imaging, diagnosis and treatment plan
2. To reduce pressure on the Emergency Department pathways and
avoid unnecessary admissions
3. Improve inpatient bed occupancy by reducing length of stay
Set up:
1. Run 5 days a week 08:30-17:30 with dedicated CNS, Registrar and
Consultant of the week
What is the EVC?
Inclusion Criteria:
• TIA (<14 since symptoms)
• CLI without sepsis
• Diabetic foot ulcer without sepsis
• Incidental finding AAA (non-tender)
at or above threshold (5.5cm>)
• Acute iliofemoral DVT (< 14 days
since symptoms)
• Possible digital ischaemia
• Deteriorating lower limb ulceration or
worsening wound infection
Exclusion criteria:
• SIRS (WCC >12, Temp >38, Pulse
>90, RR>20)
• Sepsis
• Any bleeding presentation
• Ruptured AAA
• Symptomatic dissection
• Gas gangrene / gas in tissues
• Any acute limb ischaemia WHICH
NEEDS TO BE SEEN IN <24 HOURS
REQURING URGENT TRANSFER
OR A+E ADMISSION
Any stable patient who requires an urgent opinion but is
systemically well with a non-life or limb threatening presentation.
Including (but not limited to):
EVC criteria
Definition:
“ Persistently recurring ischemic rest pain requiring regular analgesia for more
than two weeks”
Red flags:
• Discoloration of the leg or foot
• Unremitting rest pain
• Night pain, having to dangle the leg out of the bed or sleeping in the chair
• New ulceration/ tissue loss
Management:
• Aspirin, Statin
• Analgesia +/- PO ABX
• Refer to the EVC for assessment
Critical limb ischaemia
• 73 year old female
• Diabetic. BM 6.2mmols
• Rest pain
• Foot cool to touch, nil distal pulses
• Night pain, dangling the leg out of bed
• Small clean gaiter region ulcer and pressure
point changes over the 1st MTPJ
• Imaging- arterial duplex + CT Angiogram
performed on the same day + senior review
• Sent home with analgesia and planned
procedure date the following week. Pre
assessment done same day.
• Urgent elective admission 3/7 later for
successful revascularisation. Overall hospital
stay 36 hours.
Case study 1
• 75 year old female
• Referred from community with toe pain
having had treatment with Allopurinol +
antibiotics with no improvement
• Rest pain
• Night pain, sleeping on the sofa for 1 month
• Foot cold to touch, nil distal pulses
• Imaging- CT angiogram with contrast, pre
assessed with senior review
• Admitted urgently for fem-pop bypass +
Hallux amputation
• Follow up wound care in the EVC- VAC
therapy to hallux amputation site
Case study 2
Case study 3
6
• 30 year old male
• 6 day history of swollen + painful leg
• Unable to weight bear due to pain
• Imaging- Duplex scan + MR Venogram
• Admitted from EVC straight to IR for
venous thrombolysis the same day
• Overall hospital stay- 4 days
2 weeks of VAC
therapy with twice
weekly dressing
changes
(EVC GSTT- Google)
Vascular registrar on 07717513348
Attach a full medical history
• 73% increase in patient caseload over the past year
• 80% admission avoidance (16% brought back as a TCI for
planned surgery within 2 weeks)
• 63% reduction in vascular admissions via A+E
• 55% reduction in length of stay on the ward
• 20% reduction in bed occupancy
EVC outcomes
• Discharging wounds to the community- VAC, PICO, compression
bandaging.
• First clinic to be doing ambulatory vascular care. Plan to roll out around
the network- Patient demographics
• Limited information on the referral forms- triage priority
• Outdated referral system- missing vital information
• Unknown how much information is getting back to GPs/ PNs in a timely
manner
How would you like to be
contacted?
Challenges
• The EVC provides a quicker, more efficient pathway for vascular patients
requiring urgent review
• All patients had their investigations and decisions made on the same day
• There was a 80% admission avoidance among patients seen in the EVC
• Successful expedited discharge from the ward by discharging with VAC
therapy and reviewing in the EVC- reduced in LOS and bed occupancy
Conclusions