The Haemostasis Service at Christchurch Hospital was established to provide outpatient care for adults with bleeding and clotting disorders, principally those with haemophilia or venous thrombosis. It consists of a haemostasis nurse (full time) and a haemostasis physician/haematologist (part time). Most patients with DVT were seen initially in the Emergency Department, diagnosed by ultrasound, and then assessed by the Internal Medicine Acute Team. If they had no other significant illness requiring admission they were referred to the Haemostasis service for further management. Patients arriving during normal working hours were often referred immediately. Those arriving out of hours received an initial dose of low molecular weight heparin and were referred to the clinic the following morning. Some patients with extensive superficial thrombophlebitis or with non-massive PE were also referred to the clinic.

The patients were seen daily by the haemostasis nurse and at least once by the haemostasis physician. They received daily subcutaneous injections of dalteparin (Fragmin) on a weight-based schedule (Table 1) with a maximum dose of 20000iu. Warfarin therapy was commenced the same day as the heparin or the following day and was administered according to a nomogram (Table 1) modified from one devised by Fennerty and colleagues.5 The Fennerty protocol was modified (a) to have a weight-determined dose on day 1, (b) to have a lower dose day 2, (c) to have a zero dose if INR >3 and (d) to have fewer steps. Patients who had commenced warfarin off protocol prior to referral or whose initial INR was elevated were dosed empirically. Patients with superficial thrombophlebitis were treated with therapeutic doses of dalteparin for two weeks without the addition of warfarin.
Patient history and examination were recorded on a standard form and the following tests were routinely performed: prothrombin time (PT), APTT, blood count, ESR, creatinine, liver function tests, D-dimers (SimpliRED screening test or IL D-dimer assay), thrombophilia screen (antithrombin, protein S, protein C, activated protein C (APC) resistance, plasminogen, lupus anticoagulant–genetic tests for Factor V Leiden and the G20210A prothrombin mutation were performed if the APC resistance test was positive), chest X-ray and ECG. Prostate specific antigen (PSA) was performed in males aged over 40 years and pelvic ultrasound in females.
The patients were monitored daily with clinical assessment of legs and pulse oximetry. Low molecular weight heparin was given for at least five days and until the INR was ≥2.0 on two consecutive days. Blood was taken for INR testing, warfarin tablets were provided and the patient was phoned later that day with warfarin dose advice. The patients were discharged to their general practitioner once oral anticoagulation was stable with a recommendation for the duration of therapy and DVT patients were offered a review at the clinic in one year’s time. Those who attended that clinic were assessed for history of clinical recurrence of venous thromboembolism (VTE) and for development of the post-phlebitic syndrome. The patient data were collected in the hospital notes and on a Microsoft Access database and statistical analysis was performed using Microsoft Excel software.