Assessing the Knowledge Base and Comfort Level of Urgent Care Providers in Performing Risk Stratification of Deep Vein Thrombosis in the Urgent Care Setting

One of the most common complaints listed by patients who visit acute care providers in the emergency department and urgent care settings is concern for possible deep vein thrombosis (DVT). The current literature indicates that only 20-30% of patients that are presenting to the UC setting to be evaluated for possible DVT will have a confirmed DVT and require treatment (Boren, 2016). The traditional work-up for exclusion of DVT has been done primarily by emergency departments. With the expansion of more sophisticated urgent care centers (UCC) over the past 40 years, it may be possible for patients to be evaluated in UCC for exclusion of DVT. In order to proceed with a possible change in clinical pathway regarding DVT exclusion in UCC, research needs to be done regarding the comfort level and current practices of urgent care providers in evaluating risk for DVT in their practice. To evaluate this question, UCC providers in the Salt Lake valley were given a questionnaire assessing their current comfort level in assessing a patient for risk of a DVT as well as current clinical practice and policy for patients presenting with concern for possible DVT. Thirty nine respondents completed the pre-education module questionnaire. The same urgent care providers were presented with an educational intervention via an education module including instruction on assessing risk of DVT and how to safely exclude DVT in an acute care setting. After the education module was given the participants were given a questionnaire to assess for any changes in comfort level of assessing for risk of DVT in the urgent care patient and to evaluate whether the education would affect current practice in regards to excluding DVT without an emergency department referral. Twenty five of the respondents completed both the pre education and post education questionnaires and thus our analysis was performed using this number. The findings of the post-education questionnaire showed a statistically relevant change in knowledge and comfort level in performing risk assessment for DVT in the UCC setting. The hypothesis set forth in this study is this: If urgent care providers were comfortable, and had the knowledge base needed, they could craft policies allowing for exclusion of DVT in the UCC setting. Effectively performing risk stratification for DVT in the UCC could provide a safe and effective avenue to assess and manage DVT outside of the emergency department.

Risk Stratification of DVT in Urgent Care 1 Assessing the Knowledge Base and Comfort Level of Urgent Care Providers in Performing Risk Stratification of Deep Vein Thrombosis in the Urgent Care Setting Rebecca Kline Burt, APRN, FNP-BC, DNP-S Project Chair: Julie Balk, DNP, FNP-BC Content Expert: Pam Nielsen, PA-C Westminster College In Partial Fulfillment of the Requirements for the Doctor of Nursing Practice Risk Stratification of DVT in Urgent Care 2 Abstract One of the most common complaints listed by patients who visit acute care providers in the emergency department and urgent care settings is concern for possible deep vein thrombosis (DVT). The current literature indicates that only 20-30% of patients that are presenting to the UC setting to be evaluated for possible DVT will have a confirmed DVT and require treatment (Boren, 2016). The traditional work-up for exclusion of DVT has been done primarily by emergency departments. With the expansion of more sophisticated urgent care centers (UCC) over the past 40 years, it may be possible for patients to be evaluated in UCC for exclusion of DVT. In order to proceed with a possible change in clinical pathway regarding DVT exclusion in UCC, research needs to be done regarding the comfort level and current practices of urgent care providers in evaluating risk for DVT in their practice. To evaluate this question, UCC providers in the Salt Lake valley were given a questionnaire assessing their current comfort level in assessing a patient for risk of a DVT as well as current clinical practice and policy for patients presenting with concern for possible DVT. Thirty nine respondents completed the pre-education module questionnaire. The same urgent care providers were presented with an educational intervention via an education module including instruction on assessing risk of DVT and how to safely exclude DVT in an acute care setting. After the education module was given the participants were given a questionnaire to assess for any changes in comfort level of assessing for risk of DVT in the urgent care patient and to evaluate whether the education would affect current practice in regards to excluding DVT without an emergency department referral. Twenty five of the respondents completed both the pre education and post education questionnaires and thus our analysis was performed using this number. The findings of the post-education questionnaire showed a statistically relevant change in knowledge and comfort level in performing risk assessment for DVT in the UCC setting. The hypothesis set forth in this study is this: If urgent care providers were comfortable, and had the knowledge base needed, they could Risk Stratification of DVT in Urgent Care 3 craft policies allowing for exclusion of DVT in the UCC setting. Effectively performing risk stratification for DVT in the UCC could provide a safe and effective avenue to assess and manage DVT outside of the emergency department. Keywords: Urgent Care, Deep Vein Thrombosis, D-Dimer, Wells Score, Adult Learning Theory. Risk Stratification of DVT in Urgent Care 4 Introduction Background The CDC estimates 1 in 1000 Americans will be diagnosed with a deep vein thrombosis (DVT) in their lifetime. Of these patients, up to 6% could die due to complications from DVT, including pulmonary embolism, stroke and heart attack. (Wilbur, 2012). These deaths are largely preventable if DVT is recognized and treated early. A DVT is a medical condition that occurs when a blood clot(s) form in a deep vein. (Chappel et al., 2016). These most often form in the lower limbs and pelvis. If a DVT goes untreated it can grow larger and fully occlude the vessel, causing tissue death of the affected limb. A DVT can also fracture and cause small pieces to spread throughout the body and possibly to the heart and/or lungs, causing stroke, heart attack or death. The increased risk of mortality and morbidity associated with DVT is a primary reason why early identification and treatment of DVT is imperative. According to Virchow's Triad, the formation of the clots is caused by at least one of these etiologic factors: damage to the vessel wall, alterations in flow, or hypercoagulability. (Michaels et al., 2015). Risk factors for formation of DVT reflect the pathophysiologic mechanisms postulated by Virchow's Triad. Some of the risk factors are identified as hereditary risks such as Factor V leiden mutation and other clotting disorders, major surgery, trauma, malignancy, prolonged immobility, pregnancy, estrogen therapy, smoking, chronic kidney disease, and obesity. (Chappell et al., 2016). Patients who develop a DVT often have at least 1 of the stated risk factors. (Pyzocah, 2019). Unprovoked DVT is less likely and is often a sign of malignancy. Clinical features of patients presenting to acute care settings for concern of possible DVT include unilateral leg pain, unilateral leg swelling, redness, and warmth of the affected limb. (Demarais, 2021). These clinical symptoms occur without known injury and are often sudden onset. The clinical symptoms can be vague and require that acute care providers consider other Risk Stratification of DVT in Urgent Care 5 differential diagnoses such as calf strain, cellulitis, lymphedema, Baker’s cyst or other causes of unilateral leg pain. The medical provider can formulate a pretest probability for DVT by using clinical judgment of presenting symptoms in combination with risk factors for DVT. The literature recommends use of a validated clinical prediction rule, such as the Wells Score, to formulate a pretest probability for DVT (Wilbur, 2012). The Wells Score evaluates risk of DVT by assigning points for each positive risk factor and then removes points if a differential diagnosis is more likely than DVT (Cornuz, 2002). If the Wells Score total is 3 or more points then the patient has a high probability of DVT. If the score is 2 then the patient has moderate probability for DVT. If the score is 0-1 then the patient is at low risk for DVT. Using the Wells Score is industry standard in many acute care settings for the initial evaluation of possible DVT. This score is used widely in emergency departments, but may be less well known in other acute care settings such as urgent care. Research has shown that a Wells Score of 0-1 alone is not enough to safely exclude DVT in a symptomatic patient. (Velde, 2011). The literature recommends that risk stratification for DVT include a Wells Score of 1 or lower AND a negative d-dimer test in order to safely exclude DVT in the presenting patient. (Pulivarthi, 2014). D-dimer is a soluble fibrin degradation product present in the blood due to activation of coagulation and fibrinolysis as seen in DVT formation. (Favresse, 2018). The d-dimer test is very sensitive, but it is not specific. An elevated d-dimer can be related to inflammation, advanced age, recent illness such as COVID 19, and malignancy. (Bhatt, 2020). Because a d-dimer must be done in combination with a low Wells Score in order to safely exclude DVT, many patients are triaged to the nearest emergency department from other acute care settings. This can cause patients to experience longer wait times, delay in care and increased costs than they would in another acute care setting such as an Urgent Care Center (UCC). Risk Stratification of DVT in Urgent Care 6 Beginning in 1980 UCCs began to open in large urban areas to combat the need for more access to acute and after hours care. (Lee, 2013). The Urgent Care Association of America defines UCCs as “organizations that are not emergency departments but typically are walk in basis, open extended hours and weekends, and provide acute care such as suturing and onsite fracture care.” (Weinick 2009). These UCCs have grown to more than 9000 in the US as of 2020, with more anticipated to open in the coming years. (Micahs, 2020). UCCs serve as less expensive options to the ED for patients and usually provide patients quicker access to acute care. One study estimates that on average a UCC visit costs around $168 while a visit to an ED averages around $2200. (Dolan, 2022). Factors such as cost and convenience have led more patients to choose UCCs for their acute health care needs. As more patients choose UCCs as their first point of contact with the health care system, more urgent care providers may find themselves in situations calling for the assessment of risk for DVT. These situations may force the UCC provider to decide when a referral to the ED is warranted, and may lead providers to re-evaluate current practice policy and include risk stratification to safely rule out DVT as part of their practice in the UCC. In order for UCC providers to consider and create policy for risk stratification and safe exclusion for DVT in the acute care setting, we must first evaluate what the current practice and climate are for assessing DVT outside of the ED. Many factors contribute to UCC providers' ability to safely stratify risk for DVT outside the ED. Some of these factors include the UCC clinician’s knowledge and comfort level of using the Wells Score and the UCC clinician’s knowledge about interpreting a d-dimer result. In addition, the ability to perform risk stratification of possible DVT in the UCC depends on the current clinical practice guidelines being used in the UCC provider’s place of employment. All of these variables need to be assessed in order to determine if stratifying risk for the patient with suspected DVT is possible in the UCC setting. Risk Stratification of DVT in Urgent Care 7 Literature Review UCCs are becoming more common in urban and suburban areas across the United States. It is estimated that there will be more than 10,000 UCCs in the United States by 2023 (Micahs, 2020). According to the Urgent Care Association UCCs handle about 112 million patient visits a year (Stoimenoff, 2019). The literature indicates that up to 35% of ED visits are non-emergent and the use of UCCs for these visits would be a better use of resources. The expansion of services at UCCs could further help decrease the strain on EDs. Literature supports the importance of ruling out DVT in order to prevent mortality and morbidity associated with the condition. Literature suggests that risk factors for DVT are generally accepted and suggests the need to stratify assessment of DVT risk using a validated clinical tool such as the Wells Score. The accepted exclusion criteria for DVT is a low Wells Score and a negative d-dimer (Fancher et al., 2004). If the patient has both a negative d-dimer and Wells Score of 0-1, DVT can be safely excluded without using diagnostic imaging. (Corunna 2002). It is unknown if current urgent care medical providers in the Salt Lake Valley are knowledgeable about, or comfortable with, assessing risk of DVT. Literature shows that Likert scales are useful in gauging attitudes, such as comfort levels, in adults and other participants. (Sullivan 2013). Furthermore, literature supports the effectiveness of a Likert scale to gauge post intervention attitudes. Adult learning is often self-directed. This is especially true in regards to adult learning done online (Beach, 2017). According to Merriam’s andrology learning theory, adult learning characteristics tend to include: independent self-concept, experience-centered, professional outcome, problem-centered, self-motivated and goal-oriented. These characteristics would be referenced when designing the online education module regarding risk stratification of DVT in the urgent care setting. The online module was designed to be available to participants on Risk Stratification of DVT in Urgent Care 8 demand and to be accessed on participants’ own time, as this would support the idea of self-directed learning for adult learners. (Abedini et al., 2021). Purpose and Rationale Prompt evaluation of possible DVT is critical for decreasing risk of morbidity and mortality associated with DVT. Due to this need for prompt exclusion of DVT, many patients presenting to UCCs are triaged directly to an ED for a further work up. Literature supports an accepted process for safe exclusion of DVT in the outpatient setting using the Wells Score in combination with the use of a d-dimer result. If the patient has a Wells Score of 0-1 and a negative d-dimer then there is no need for diagnostic imaging and DVT can be safely excluded. One hypothesis is that a lack of knowledge and comfort in risk stratification of DVT is prevalent in the outpatient or UCC setting. I hypothesize that education regarding risk stratification including risk factors for DVT, clinical signs and symptoms of DVT, use of the Wells Score, and how to interpret a d-dimer value, will improve the knowledge base for UCC providers and make them more likely to advance policy allowing for UCCs to exclude DVT on site and avoid triages to the ED. Theoretical Framework The theoretical framework utilized for this study is the ACE Star Model for evidence-based practice. The ACE Star Model was developed in order to translate knowledge into improved evidence-based practice in the health care setting (Stevens, 2013). The ACE Star Model provides a framework for converting knowledge generated by research to clinical expertise in order to achieve a change in evidence based practice. The model follows five steps for quality improvement. These steps include: discovery research, evidence summary, translation into guidelines, practice integration, and process outcome evaluation (Indra, 2018). This project will primarily utilize discovery research and evidence summary in order to influence guidelines and practices in the future. A comprehensive literature review will be Risk Stratification of DVT in Urgent Care 9 completed on current guidelines for evaluation of DVT, DVT exclusion criteria, Wells Score and risk stratification. Discovery research will be gathered via questionnaires to participants of the research study. Evidence summary including questionnaire responses and possible use for development of practice guidelines in the future will be presented at the conclusion of the study. Objectives 1. Gain an understanding of the current comfort levels of UCC providers in the Salt Lake Valley in evaluating risk for DVT onsite. 2. Gain an understanding of the current practices and knowledge base of UCC providers in the Salt Lake Valley in evaluating patients for DVT on site. 3. Determine if UCC providers in the Salt Lake Valley are more comfortable and knowledgeable in completing risk stratification for possible DVT after an educational module regarding risk stratification of DVT in the urgent care setting. 4. Inform UCCs of potential policy change in the future to allow for DVT exclusion onsite for low risk urgent care populations. Implementation Study Design The project was approved by Westminster College Internal Research Board. There are no known conflicts of interest in this study design. There are no known costs, foreseeable monetary benefits, or other ethical concerns regarding this study design. This research project assessed clinician comfort level and knowledge base in performing risk stratification for a patient presenting with concerns of deep vein thrombosis in an urgent care setting. Data was obtained through questionnaires that clinicians completed before and after reviewing an education module. The education module sought to enhance clinician comfort level and knowledge base regarding risk stratification for assessment of deep vein thrombosis in the urgent care as an alternative to referral to the emergency department by providing education Risk Stratification of DVT in Urgent Care 10 regarding any gaps in knowledge identified on the pre questionnaire. The module focused on risk factors for DVTs, use of Wells Score and interpretation of d-dimer results. The inclusion criteria included urgent care clinicians (APRN, MD, PA, DO), 18 years of age and older, licensed to practice medicine in Utah, currently working in a UCC or acute care setting other than the ED. A convenience sample of clinicians currently practicing in the Salt Lake Valley and appropriately credentialed clinicians who consented to participate were used in this study. Recruitment methods included communication via phone, text message, email or in person. Clinicians were asked to participate in a questionnaire before reviewing an education module, and then a different questionnaire afterward. The questionnaires were structured using a Likert scale to ascertain comfort level and knowledge base in performing risk assessment of DVT in the urgent care setting. No advertisements for this study were created. Clinicians were contacted via email to participate in this research study. They received an email that included a link to the initial questionnaire, and to the education module (which included informed consent), and then a link to the post-education questionnaire at the end of the module. The education module was constructed using Google Slides with a voiceover component included on each slide . The education module was peer reviewed for accuracy in content. The education module was completed before the clinician could complete the post education module questionnaire. The education module was approximately 20 minutes in length. Completion of the initial questionnaire, then the education module, and then the post education module questionnaire, took the clinicians no longer than 30 minutes to complete. Data collection was completed by obtaining the questionnaire results. Each questionnaire response is identifiable using the clinician’s first initial and last 4 digits of their cell phone number. (Example: R6196) The participant’s data was de-identified and aggregated. The results and data are stored on a secure HIPAA compliant device. Descriptive statistics were used to analyze the data from the questionnaires. The study gauges current provider comfort level and Risk Stratification of DVT in Urgent Care 11 knowledge base for performing risk stratification of DVT in clinic before reviewing the education module. The intervention is an education module that will include instruction on performing risk stratification for DVT in the urgent care setting. After participants completed the education module they completed a separate questionnaire regarding comfort level and knowledge base of performing risk stratification of DVT in the urgent care setting. The questionnaires are compared using descriptive statistics to see if a statistically significant change in comfort level and knowledge base after the intervention has occurred. The only data used will be data provided by respondents that completed both the pre and post education module questionnaires. Questionnaire Design The pre and post-education questionnaires were designed using a Likert scale to obtain data. The pre-education questionnaire consisted of eleven questions. Six of these questions used a Likert scale to assess respondent comfort level and knowledge base in assessing risk of DVT prior to viewing the education module. Five questions were used to obtain background demographic information including a unique respondent identified, number of years in practice, credentials and current place of employment. The post-education module questionnaire consisted of ten questions. Five of these questions use a Likert scale to assess comfort level and knowledge base in assessing risk of DVT after viewing the education module. The additional five questions obtain background demographic information including a unique respondent identifier, number of years in practice, credentials and current place of employment. The pre and post education questionnaires were matched for consistency by using the unique respondent identifier. Unmatched identifiers or identifiers only found on one questionnaire were excluded. Both questionnaires can be found in Appendix A. Risk Stratification of DVT in Urgent Care 12 Questionnaire Administration Urgent Care clinicians were identified by contacting practice group administrators at Community Physicians Group, Intermountain HealthCare and via Westminster College FNP alumni. The questionnaires and education module were emailed to various Urgent Care clinicians in the Salt Lake Valley using contact information provided by practice group administrative assistants. The pre-education questionnaire provides that by completing the questionnaire the participant is giving informed consent to be included in the study by completing the questionnaire. The pre-education questionnaire was provided via a hyperlink connecting the respondent to a Google Form. This link is found on the second slide of the slide deck containing the education module. The post-education questionnaire was provided via a hyperlink on the 17th slide of the education module connecting the respondent to a Google Form. Questionnaire data was analyzed using excel statistical software using descriptive statistics to analyze the effectiveness of the education module. The goal was to ascertain the current clinician comfort level and knowledge base in performing risk stratification of DVT in the urgent care setting and to increase clinician comfort level and knowledge base via the provided education module. Results Descriptive statistics were used to analyze demographics of respondents. The questionnaires and education module were emailed to one hundred and thirteen urgent care clinicians. Thirty-nine urgent care clinicians completed the pre education questionnaire and twenty-five urgent care clinicians completed the post-education questionnaire. A Likert scale was used to create quantitative data for the analysis. A quantitative assessment was conducted via the use of the Likert scale for both a pre-education module questionnaire and post-education module questionnaire. The data was sorted into respondents that completed both questionnaires using the unique respondent identifier. The total number of Risk Stratification of DVT in Urgent Care 13 respondents who completed the education module and both questionnaires was 25. This data was analyzed using a paired t-test approach due to the number of respondents that met all criteria for the study. The number of respondents to the pre-education questionnaire totaled thirty nine. The number of respondents to the post-education questionnaire totaled twenty five. The number of unique respondent identifiers that identified in both the pre and post-education questionnaire was twenty-five. Questionnaire results that did not have both a pre and post test identifier were not included in the statistical analysis. There were a total of fifteen pre-education questionnaires that were not included in the analysis of the Likert scale data. The respondents were based in the greater Salt Lake City area. As shown in Figure 1, seventeen of the twenty-five respondents were APRNs, seven were PAs and 1 is an MD. Twelve of the respondents have been practicing for 6-10 years, ten of the respondents have been practicing for 0-5 years, two have been practicing for 11-15 years and one respondent has been practicing for greater than 15 years, as shown in Figure 2. The majority of the respondents work for University of Utah Health, seen in Figure 3. Figure 1 Figure 2 Risk Stratification of DVT in Urgent Care 14 Figure 3 Both questionnaires used a 5 point Likert scale to quantify data where 1 represents strongly disagree and 5 represents strongly agree. The pre-education questionnaire consisted of five Likert Scale questions assessing comfort level and knowledge base regarding risk stratification for DVT in the urgent care setting. The pre-education questionnaire showed that most participants were familiar with the Wells Criteria with a mean result of 4.16 where 1 equals strongly disagree and 5 equals strongly agree, as seen in Figure 4. Figure 4 The majority of the respondents were also familiar with the d-dimer laboratory test with an average answer of 4.66, as seen in figure 5. Risk Stratification of DVT in Urgent Care 15 Figure 5 On the pre-education assessment respondents were also moderately comfortable in using the Wells criteria with an average answer of 4.28 and interpreting a d-dimer result with an average answer of 4.24, as shown in figure 6. Figure 6 The pre-education questionnaire indicates that respondents are less comfortable in performing risk stratification for DVT in their current clinical setting with an average answer of 3.62, as seen in figure 7. Risk Stratification of DVT in Urgent Care 16 Figure 7 The respondents answered with an average of 3.75 when addressing if they feel competent in performing risk stratification for the DVT patient in their current clinical setting, as seen in figure 8. Figure 8 All of these results were analyzed using descriptive statistics with our 25 respondents. Of note, the pre-education questionnaire asked respondents if their current place of employment has a policy in place for evaluation of the patient presenting with concerns of DVT. The majority of the respondents answered “unsure” to this question, as seen in figure 9. Risk Stratification of DVT in Urgent Care 17 Figure 9 Upon analysis of the post-education questionnaire it appears that overall respondents did have an improved sense of comfort and knowledge base in performing risk stratification for deep vein thrombosis in the urgent care setting after viewing the education module. When assessing whether respondents felt comfortable and knowledgeable when calculating a Wells Score the mean improved from 4.28 before review of the education module to 4.76 after review of the education module. This suggests the education module did improve respondents’ comfort level and knowledge base in calculating a Wells Score. The data showed similar results for interpreting a d-dimer result with an average mean of 4.24 on the pre-education module compared to 4.68 on the post-education module. Most significantly, the education module appears to have improved respondents’ overall comfort level and knowledge base in performing risk stratification for the patient with suspected DVT as shown in figures 10 and 11. Risk Stratification of DVT in Urgent Care Figure 10 Figure 11 Additionally, most of the 25 respondents indicated they would consider performing risk stratification for DVT in the urgent care setting, as seen in figure 12. 18 Risk Stratification of DVT in Urgent Care 19 Figure 12 Note: Respondents that would consider performing risk stratification for evaluation of DVT using a Wells Score and d-dimer result in the urgent care setting, after participating in education module intervention where n=25. Discussion The results of this analysis show the specific aims of this study were met by obtaining a current overall level of comfort and knowledge in performing risk stratification for patients with possible DVT in the urgent care setting. The study was also able to identify that most respondents were familiar with the Wells criteria and d-dimer laboratory tests before review of the education module. Respondents were less comfortable and knowledgeable in calculating a Wells Score and/or interpreting a d-dimer result prior to viewing the education module. They were even less comfortable and knowledgeable in performing a full risk stratification for the patient presenting with DVT in the urgent care setting prior to completing the education module. An education module was presented to this same group of respondents that addressed performing risk stratification of DVT in the urgent care setting. This education module discussed risk factors for developing a DVT, clinical signs of DVT, the Wells criteria and how to calculate a Wells score, how to interpret a d-dimer result, and finally how to put it all together to perform risk stratification of DVT in the urgent care setting. After reviewing the education module the study respondents were given a post-education questionnaire to re-evaluate comfort level and knowledge base in performing risk stratification of the patient presenting with DVT. The results Risk Stratification of DVT in Urgent Care 20 of the post-education questionnaire showed an improvement in respondents’ comfort level and knowledge base in performing risk stratification of a possible DVT patient by using the Wells criteria and a d-dimer. The post-education questionnaire also showed that most respondents would be willing to perform risk stratification for possible DVT in their own clinical settings. Future Implications This post-education data is significant because as urgent care clinicians become more comfortable and knowledgeable in performing risk assessment of possible DVT in the outpatient setting policy may be changed to allow for the DVT assessment to be started, if not completed, in the outpatient setting in a safe way. This would allow free-standing clinics and urgent cares to triage fewer patients to the ED for further diagnostic workup of DVT. This could save the patient the cost and time of an ED visit while still safely ruling out a DVT. This would also benefit EDs as less than 10% of patients presenting with concern of DVT actually end up having a DVT. Overall, a future change in policy to provide appropriate screening for patients reporting to UCCs with potential DVTs would be beneficial to all involved. Limitations Over half of respondents are employed by the same health care system. However, respondents from many employers were given the opportunity to participate in this study. Additionally, geographic limitations of the population of Utah may interfere with the translation of these results beyond Utah as Utah tends to have a younger and healthier population when compared to other states (Utah Health Department, 2022). Lastly, the sample size of 25 is a fairly small sample size and consequently the improvement in knowledge and comfort level observed may not translate to the large population of urgent care clinicians in the greater Salt Lake Valley. Conclusion This project demonstrated that clinicians in the Salt Lake Valley that practice in the Urgent Care setting are generally comfortable and knowledgeable about d-dimers and the Wells Risk Stratification of DVT in Urgent Care 21 criteria, but they are less comfortable and knowledgeable in calculating a Wells score and interpreting a d-dimer. The clinicians were even less comfortable and knowledgeable in performing a full risk assessment for a patient presenting with a possible DVT. This study shows that with a short education module touching on topics of risk assessment of DVT including risk of developing DVT, clinical signs of DVT, calculating a Wells score and interpreting a d-dimer, clinicians’ comfort level and knowledge base for performing risk assessment of a patient presenting with a possible DVT in the urgent care setting could be improved. This study also suggests the possibility that a lack of knowledge about workplace policies may deter clinicians from performing this type of risk assessment. This study suggests it may be possible for more urgent care centers to perform accurate risk stratification for the patient presenting with possible DVT on site and thus avoid triages to the emergency department. This could lead to an improvement in standard of practice going forward. 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Risk Stratification of DVT in Urgent Care 27 Appendix A Pre-Education questionnaire Please select the degree to which you agree or disagree with these statements: Strongly Disagree Disagree Neutral Agree Strongly Agree I am familiar with the Wells criteria for deep vein thrombosis assessment. 1 2 3 4 5 I feel comfortable calculating a Wells Score. 1 2 3 4 5 I am familiar with a d-dimer laboratory test. 1 2 3 4 5 I feel comfortable interpreting a d-dimer result. 1 2 3 4 5 I feel comfortable performing risk stratification for possible deep vein thrombosis in my current clinical setting. 1 2 3 4 5 I feel competent in performing risk stratification for possible deep vein thrombosis in my current clinical setting. 1 2 3 4 5 Risk Stratification of DVT in Urgent Care Pre- Education Demographics 1. Please enter your Study ID (the first initial of your name + last four digits of your phone number). Example: B6196 Your Answer: 2. What is your professional credential? Example: DO, MD, APRN, PA Your Answer: 3. How many years have you been a practicing clinician? a. 0-5 years b. 6-10 years c. 11-15 years d. 16+ years 4. What health care organization do you currently practice with? a. IHC b. University of Utah c. Iasis d. Mountain Star e. Other__________________________ 5. Do you currently have a policy in place at your clinical site for evaluation of the patient presenting with concerns of deep vein thrombosis? a. Yes b. No 28 Risk Stratification of DVT in Urgent Care 29 Appendix B Post-Education Module questionnaire Please select the degree to which you agree or disagree with these statements: Strongly Disagree Disagree Neutral Agree Strongly Agree I feel comfortable and knowledgeable when calculating a Wells Score for assessment of deep vein thrombosis. 1 2 3 4 5 I feel comfortable interpreting a d-dimer result. 1 2 3 4 5 I feel more comfortable performing risk stratification for possible deep vein thrombosis in the clinical setting after reviewing the education module. 1 2 3 4 5 I feel more competent in performing risk stratification for possible deep vein thrombosis in the urgent care patient after reviewing the education module. 1 2 3 4 5 I would consider performing risk stratification for evaluation of deep vein thrombosis using a wells score and d-dimer result in the urgent care setting. 1 2 3 4 5 Risk Stratification of DVT in Urgent Care Post- Education Demographics Please enter your Study ID (the first initial of your name + last four digits of your phone number). Example: B6196 Your Answer: 1. What is your professional credential? Example: DO, MD, APRN, PA Your Answer: 2. How many years have you been a practicing clinician? a. 0-5 years b. 6-10 years c. 11-15 years d. 16+ years 3. What health care organization do you currently practice with? a. IHC b. University of Utah c. Iasis d. Mountain Star e. Other__________________________ 4. Do you currently have a policy in place at your clinical site for evaluation of the patient presenting with concerns of deep vein thrombosis? a. Yes b. No 30 APPROVAL of a thesis/project submitted by Author(s): Rebecca Burt, APRN, FNP-C, DNP School Department: DNP Title of Thesis: Assessing the Knowledge Base and Comfort Level of Urgent Care Providers in Performing Risk Stratification of Deep Vein Thrombosis in the Urgent Care Setting The above named master's thesis/project has been read by each member of the supervisory committee and has been found to be satisfactory regarding content, English usage, format, citations, bibliographic style, and consistency, and is ready to be deposited and displayed in the Westminster College—Institutional Repository. Chairperson, Supervisory Committee: Julie Balk, DNP Approved On 8/2/2022 6:01:32 PM Dean, School: Sheryl Steadman Ph.D Approved On 8/3/2022 8:46:05 AM STATEMENT OF PERMISSION TO DEPOSIT & DISPLAY THESIS IN THE INSTITUTIONAL REPOSITORY Name of Author(s): Rebecca Burt, APRN, FNP-C, DNP School Department: DNP Title of Thesis: Assessing the Knowledge Base and Comfort Level of Urgent Care Providers in Performing Risk Stratification of Deep Vein Thrombosis in the Urgent Care Setting With permission from the author(s), the staff of the Giovale Library of Westminster College has the right to deposit and display an electronic copy of the above named thesis in its Institutional Repository for educational purposes only. I hereby give my permission to the staff of the Giovale Library of Westminster College to deposit and display as described the above named thesis. I retain ownership rights to my work, including the right to use it in future works such as articles or a book. Submitted by the Author(s) on 7/30/2022 11:23:03 PM The above duplication and deposit rights may be terminated by the author(s) at any time by notifying the Director of the Giovale Library in writing that permission is withdrawn.