Patients over 70 years
To rule out deep vein thrombosis
Clinical practice problem
From the clinical practice issue and PICO components that have been established, the EBP questions are:
Is the d?dimer assay more accurate at ruling out deep vein thrombosis compared to ultrasound in patients more than 70 years?
Older individuals can encounter DVT assuming they have specific ailments that sway how their blood coagulations. As we said above, blood clumps can frame in the legs because of fixed status, for example, when an individual is on bed rest in hospice or because of mishap or medical procedure. Delayed bed rest is the most well-known reason for DVT in the old, yet there are positively other gamble elements to know about also.
1. Evidence appraisal of a research article
2. Introduction or background
Deep Vein Thrombosis Is a Condition When The Blood Coagulation Structure In At Least One Profound Veins In Body Particularly In Legs It Is Caused Because Of Leg Expanding or torment and may happen with any side effects (Marcianò and Franchini, 2021). The old populace experience DVT in the event that they experience the ill effects of a specific ailment that affects the method of blood coagulating. The blood might clump due to stability when the individual is at bed rest in hospice or because of a medical procedure or mishap. In geriatric consideration, DVT is typically analyzed utilizing harmless strategies. It tends to be expressed that pressure ultrasound is the indicative best quality level that includes an authoritative analysis of the issue. The aim was to administering intense DVT in the lower appendages of indicative inpatients and to survey the adequacy of D-dimer cut-off values over tolerates age of 70 years.
From the article conducted by Marcianò and Franchini (2021), it can be found that it was a prospective study that has been conducted with two aims. The study period was 10 months and it involve studying inpatients who were suspected with lower limb DVT and had simultaneously undergone ultrasound and ELSIA plasma D-dimer assay. The respondents were chosen on the basis of certain criteria as it can be seen that a large number of inpatients who were suspected with lower limb DVT were found. From the understanding of the study, the non-inclusive criteria that were applied in this research were comorbid conditions that have an impact on the modification of D-dimer. In this case, a total of 150 respondents were selected out of which 125 were women and 25 men.
The John Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals Model is considered to be a powerful problem-solving approach that allows clinicians decision-making with the aid of user-friendly tools thus, guiding individual or group use (Dang et al., 2021). There are three evidence levels based on which the quality is judged. From the article, it can be the evidence level is II as it is a prospective study.
The data analysis was done using receiver operating characteristic (ROC) curve analysis. ROC curve is a graphical plot that has been used for demonstrating the diagnostic ability of the binary classifier system as it allows in discrimination threshold to be verified (Obuchowski & Bullen, 2018).
As it can be seen that human respondents were included in this study, thus, ethical consideration was one of the most important aspects of the study. An informed consent where the respondents were asked for consent after understanding the details of the research was taken prior to data collection. The privacy and confidentiality of each respondent need to be protected and disclosure of any personal data was prohibited (Arifin, 2018). This ensure that each respondent was anonymous.
From the article, the quality of the article is of good quality. This is because it has a reasonably consistent result, a sufficient sample was chosen, and a definitive conclusion and consistent recommendation that was based on a comprehensive literature review were included in the scientific study.
The normal age of the example was 86.3 years and a finding of lower appendage DVT was directed upon 53% of the example. Utilizing 500 ng/mL D-dimer cut-off customary worth, DVT was precluded in 5 patients and 750 ng/mL precluded in 19 patients where the responsiveness was 98.1% and the negative prescient worth was 95% The bogus negative included patients with 15 mm clots in the distal calf (Marcianò and Franchini, 2021). In this way, it was inferred that ELISA plasma D-dimer where the worth was less than 750 ng/mL is a quick and dependable harmless method that aids in precluding lower appendage DVT in the event that shading stream Doppler ultrasound is not accessible.
According to the review, it was expressed that venous thromboembolism is an issue that has two normal appearances, apoplexy in the veins of the leg and aspiratory embolism. On account of DVT, the blood clot structures in the veins of the leg and later, it travels through the venous framework to the lungs and influences the aspiratory supply routes (Philbrick, 2009). Subsequently, it is essential to survey the presence of DVT in patients giving indications and side effects of DVT. This is on the grounds that it might prompt aspiratory embolism that can be deadly and treatment require the utilization of quick anticoagulants. On account of geriatric patients, the issue turns out to be more serious as there are different inconveniences related. The point of the review includes considering to assess the viability of d-dimer to preclude profound vein apoplexy as far as highest quality levels and predisposition concerning negative prescient worth.
The study that has been conducted is stated to be a quality improvement project that has been focused on the EBP question formulated in this case.
On the basis of the JHNEBP model, this is a level II evidence because it involves a systematic review where a total of 6 studies were studied in order to understand the use of lower-extremity venography in the gold standard. It also involves assessing whether it is capable of imaging calf and thigh veins by verifying the sensitivity and negative predictive values that were false.
The quality rating of the non-research based articles as per the JHNEBP model is good. As per the study, the result was consistent and helped in answering the research question.
Identification of the level of evidence
As per the study by Rinaldi et al. (2021), it was stated that d-dimer could be easily performed using a blood test that has several advantages with respect to diagnostic rest in the lower extremity DVT. As required required any skill technique for conducting the test or analysis as in the case of venography and ultrasonography. In addition, there is no risk of radiological contrast such as allergic reaction or renal damage that can be an issue in the case of venography. However, it is important to take care while interpreting the result of the studies where ultrasound was used as the gold standard.
A practice change that can be used for addressing the EBP question with the help of both research and non-research articles is to assess the D-dimer advantage and disadvantage over other non-invasive techniques that can be helpful in detecting DVT in lower-extremity on a regular basis.
The three key stakeholders that can be involved in supporting practice change recommendations include patients above 70 years, healthcare professionals and health care organisations. These stakeholders are important because this will help in early diagnosis of DVT among then patients as a result of which, it would lessen the complications that may occur in due course of time. Moreover, the patient satisfaction level will improve that have a direct implication on the reputation of the organisation. The healthcare professionals will ensure that the results are accurate as per the predictive value thus; there will be less chance of error.
The barrier that may be encountered while implementing the practice change recommendation is many healthcare professionals will oppose using D-dimer because it is not a gold standard as a result, there can be issues in terms of result and affecting the treatment course to some extent.
The strategy that can be used for overcoming the barrier stated above is to educate the healthcare professionals about the advantages of using d-dimer among geriatric patients as it can be stated that these patients have comorbid conditions that may have an effect if not immediately detected. Thus, the rapidity and reliability are two main factors that need to be highlighted about d-dimer over ultrasound among these staff to adopt the technique in the testing process.
The outcome from the EBP question that can be used for measuring the recommended practice change is to rule out the possibility of DVT among the target population. As it can be stated that DVT is a progressive medical issue that occurs in the deep vein of the blood that develops in the low extremity such as the leg, thigh, pelvis and some cases arm. The condition that is caused due to DVT is pulmonary embolism, which can be fatal especially among geriatric patients in case they suffer from other lung diseases (Gao, Liu & Li, 2018). Therefore, the use of d-dimer to rule out DVT need to be implemented in geriatric care in order to help these patients from undergoing the severe treatment process.
Arifin, S. R. M. (2018). Ethical considerations in qualitative study. International Journal of Care Scholars, 1(2), 30-33. DOI: https://doi.org/10.31436/ijcs.v1i2.82
Dang, D., Dearholt, S. L., Bissett, K., Ascenzi, J., & Whalen, M. (2021). Johns Hopkins evidence-based practice for nurses and healthcare professionals: Model and guidelines. Sigma Theta Tau.
Gao, H., Liu, H., & Li, Y. (2018). Value of Ddimer levels for the diagnosis of pulmonary embolism: An analysis of 32 cases with computed tomography pulmonary angiography. Experimental and therapeutic medicine, 16(2), 1554-1560.
Marcianò, T., & Franchini, S. (2021). Could a D-dimer/fibrinogen ratio have a role in ruling-out venous thromboembolism?. Emergency Medicine Journal.
Obuchowski, N. A., & Bullen, J. A. (2018). Receiver operating characteristic (ROC) curves: review of methods with applications in diagnostic medicine. Physics in Medicine & Biology, 63(7), 07TR01.
Philbrick, J. T. (2009). D-dimer as a rule-out test for deep venous thrombosis: Gold standards and bias in negative predictive value.
Rinaldi, I., Hamonangan, R., Azizi, M. S., Cahyanur, R., Wirawan, F., Fatya, A. I., ... & Winston, K. (2021). Diagnostic Value of Neutrophil Lymphocyte Ratio and D-Dimer as Biological Markers of Deep Vein Thrombosis in Patients Presenting with Unilateral Limb Edema. Journal of Blood Medicine, 12, 313.
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