Annals of Long Term Care

We report three cases of Doppler ultrasound discrepancies between portable diagnostic unit and hospital-based units among skilled nursing facility residents.

Case 1
Mrs. HK is an 81-year-old female resident of a skilled nursing facility (SNF). Her medical history includes coronary artery disease (CAD), hypertension, and a right humeral neck fracture and left radial fracture 6 weeks earlier. She complained of pain and swelling of her right upper extremity (RUE). An order for an upper extremity portable Doppler ultrasound (US) was placed. This study, as well as all studies in the SNF, were done with portable equipment at the bedside. The study was read by a radiologist as compatible with a RUE deep vein thrombosis (DVT). The patient was transferred the same day to the closest acute care hospital, and a repeat US of RUE was read with no evidence for a DVT.

Case 2
Mrs. MJ, an 81-year-old female SNF resident with a history of hypertension, anemia, and congestive heart failure (CHF), was noted to have new onset of lower-extremity (LE) edema. A portable US was reported positive for a DVT in the right common femoral vein. The patient was transported to the hospital, where a Doppler US on the same found no evidence for a DVT in either extremity.

Case 3
Mrs. AM, a 91-year-old female SNF resident with a history of atrial fibrillation, CHF, right hip fracture (status post open reduction internal fixation) 1 month previously, taking enoxaparin, complained of pain and swelling of her right leg. A portable US was reported as consistent with a thrombus in the common femoral vein. When a repeat US was done the next day at the acute care hospital, there was no evidence for a DVT. At this point, the medical director was notified and an investigation started.

In each of the three cases, either the patient did not receive new anticoagulation or no change in present anticoagulation therapy was made (Table). No further clinical adverse reactions were noted.

Deep vein thromboses are very common in both acute care hospitals and SNFs, with prevalence from 5-20%.¹ Risk factors include malignancy, advanced age, history of thromboembolism, and post-surgical conditions that are common in a SNF population. For all these reasons, the medical staff must have a high index of suspicion for this common and potentially life-threatening disease.^2,3

The SNF in this vignette is a not-for-profit, religiously affiliated facility that is part of a Continuing Care Retirement Community in suburban Philadelphia. All of the patients were short-stay residents admitted to the facility for acute rehabilitation after a hospitalization for an acute illness. The mobile ultrasound company is a division of a larger mobile x-ray company that had been serving the SNF and multiple other nursing facilities in Philadelphia and the surrounding area for many years. The mobile studies were read and reported in writing by board-certified radiologists. It should be noted that the studies were performed by different technicians and were read by different radiologists in the portable ultrasound company and the acute care hospital.

The acute care hospital is an academic university-affiliated, 570-bed, not-for-profit hospital in suburban Philadelphia less than one mile from the nursing facility. The second ultrasound was ordered while the patients were in the emergency room and was read by board-certified radiologists.

Discussion
These cases present a potentially serious problem for patients and staff at long-term care facilities.