Evidence Based Practice: Clinician assessment of DVT with Homans’ Sign

 

Ask the PICO Question

Question: In hospitalized patients, is Homans’ sign a reliable clinician tool for assessing the presence of deep venous thrombosis to prevent pulmonary embolisms?

Background

John Homans (1877-1954) was a surgeon who studied peripheral vascular disease in America. With his colleagues he found how a sign involving pain in the calf and popliteal region on dorsiflexion of the ankle when the knee is in a flexed position was present in 42% of 139 patients with suspected deep vein thrombosis (DVT). (Urbano, 2001) Since his discovery and contribution to medicine Homans sign is still a widely used clinical practice for physical examination of DVT in hospitalized patients.

Hospital-acquired DVT and pulmonary embolisms (PE) are preventable problems that can significantly increase mortality. (McCaffrey et al, 2007) Many high acuity patients are at increased risk for development of DVT and therefore the development of PE referred to as Virchow’s triad that includes: venous stasis (bed rest, severe illness, major surgery), hypercoagulability (cancer, contraceptives, sepsis) and venous injury (trauma, surgery infection and central venous catheters. (Wagner, Johnson and Kidd, 2006)

Each year DVT and PE conditions impact nearly 30 million Americans each year, with an estimated incidence of 0.1% that has a major burden on the health care system often extending into longer-term complications such as event recurrence and post thrombotic syndrome. (MacDougall, Feliu, Buccuzzi and Lin, 2006) The impact of DVT and PE’s is noted by the fact that 10% of hospital deaths can be attributed to PE and is a significant health care issue. (MacDougall, 2006) Many die within 1 hour of the onset of symptoms or before the diagnosis is suspected. (Ignatavicius and Workman, 2006) Mortality from a DVT when in the lower extremities is between 13% and 21% but increases to 48% when located in the upper extremities. (Crowther and McCourt, 2005)

Regular clinical assessment tools for the peripheral vascular system in nursing for detections of DVTs and impaired blood flow include the following: measurement of calf circumference and symmetry, presence of Homans’ sign, assessment of temperature, tenderness and color of extremities and palpitation peripheral pulses. (Jarvis, 2004)

Objective: To determine the reliability of Homans’ sign at the bedside as part of a nursing assessment for DVT in hospitalized patients.

Search for Evidence

Search Strategies Selection criteria included English, publications and research based articles within the past 10 years (levels I-IV) concerning DVT and Homan’s sign.

Databases Used EBSCOhost, CINAHL, emedicine, PubMed, Trip Database, ProQuest, Sigma Theta Tau International, All Nurses forums and scholarly nursing textbooks.

Critically Analyze the Evidence

The clinical diagnosis of DVT is difficult and full of uncertainty. The classic signs and symptoms of DVT that nurses assess at the bedside are those associated with obstruction to venous drainage which include pain, tenderness, warmth, erythema, positive Homan’s sign, palpable cord and unilateral leg swelling. Based on these clinical findings alone the chance that DVT is the correct diagnosis 50% of the time. (Feied, 2005) A positive Homan’s sign which is calf pain with dorsiflexion and plantar flexion of the foot occurs in about 35% of cases of deep vein thrombosis and is not specific to this condition. (Jarvis, 2004) Physical examination is only 30% accurate for DVT and while it can serve to increase clinical suspicion it cannot be used to eliminate the possibility to thromboembolic disease. (Kennedy, Setnik and Li, 2001) A double blind peer review study of 239 patients in the ICU with more than 72 hours of stay were analyzed for the reliability of clinical signs in the evaluation of DVT. The results showed with a 95% CI that history and physical examination for DVTs are not useful in detecting lower limb DVT in the ICU. (Crowther et al, 2005) Approximately 90% of DVT in the lower extremities detected by screening with techniques such as ultrasonography, duplex sonography and venography are clinically silent, indicating low sensitivity to diagnosis. (Crowther and McCourt, 2005) The authors McCourt and Crowther further state that Homans’ sign is neither sensitive nor specific for DVT. Autopsy results from a 30 year prospective study of men demonstrated that approximately 80% of all cases of DVT and PE remain undiagnosed, even in cases when they are the immediate cause of death. (Feied, 2005)

Apply the Evidence: Recommendations

The absence of signs and symptoms of Homans’ sign as part of a clinical assessment tool of the peripheral vascular system does not rule out DVT. Homans’ sign noted as a long taught clinical tool should be omitted from the examination and is of little value in the diagnosis of a DVT. (Ebell, 2001) However this technique is still widely used at the bedside in nursing, yet as research shows a diagnosis of a DVT solely based on the evaluation of clinical signs has proven unreliable. (Urbano, 2001)

Although research results show when properly treated for DVT, patients have good recovery and the rate of mortality drops to approximately 9%, traditional the clinical assessment tool, Homans’ sign, fall significantly short of finding DVT and prevention remains the best practice for prophylaxis of DVT and PE. (Crowther and McCourt, 2005) Nursing is in need of a valuable and reliable tool for assessing at the bedside for DVT. New studies are working on providing such tools to use at the bedside which include using the JFK Medical Center’s risk assessment tool. (McCaffrey et al, 2007)

References

McCaffrey, R; Bishop, M; Adonis-Rizzo, M; Williamson, E; McPherson, M; Cruikshank, A; Carrier, VJ; Sands, S; Pigano, D; Girard, P; Lauzon, C. (2007) Development and testing of a DVT risk assessment tool: providing evidence of validity and reliability. Worldviews on Evidence-Based Nursing. March 2007; 4(1): 14-20. Sigma Theta Tau International, Honor Society in Nursing.

Crowther, MA; Cook, DJ; Griffith, LE; Devereaux, PJ; Rabbat, CC; Clarke, FJ; Hoad, N; McDonald, E; Meade, MO; Guyatt, GH; Geerts, WH; Wells, PS. (2005) Deep vein thrombosis: clinically silent in the intensive care unit. Journal of Critical Care. 2005, Dec; 20(4); 334-40 (19 ref)

Crowther, Maryanne; McCourt, Kimberly. (2005) Venous thromboembolism: A guide to prevention and treatment. The Nurse Practitioner. August 2005; Vol.30 No.8

Ebell, Mark H. (2001) Evaluation of the patient with suspected deep vein thrombosis. The Journal of Family Practice. Feb 2001; Vol.50; No 2. Retrieved from on 6/18/07 http://allnurses.com/forums/f35/homans-sign-45871.html

Feied, Craig. Deep Venous Thrombosis. Emedicine from WebMD. Last updated 3/20/05; Retrieved from on 6/17/07 www.emedicine.com/med/topic2785.htm

Ignatavicius, Donna D; Workman, Linda M. (2006) Medical-Surgical Nursing: Critical Thinking for Collaborative Care. Elsevier Saunders, St. Louis, Mo.

Jarvis, Carolyn. (2004) Physical Examination and Health Assessment. (4 th Edition) Saunders, St. Louis, Mo

Kennedy, D; Setnik, G; Li, J. (2001) Physical examination findings in deep venous thrombosis. Emergency Medicine Clinics of North America. 2001 Nov; 19 (4): 869-76. PMID 11762276

MacDougall, DA; Feliu, AL; Boccuzzi, SJ; Lin, J. (2006) Economic burden of deep-vein thrombosis, pulmonary embolism and post-thrombotic syndrome. American Journal of Health System Pharmacy. 10/15/2006; 63

Urbano, Frank L. (2001) Homans’ sign in the diagnosis of deep venous thrombosis. Hospital Physician. March 2001; pp 22-24. Turner White Communications Inc., Wayne, PA

Wagner, Kathleen Dorman; Johnson, Karen; Kidd, Pamela Stinson. (2006) High Acuity Nursing. (4 th Edition) Prentice Hall, Upper Saddle NJ.