scholarly journals P115: Improving the diagnosis of pulmonary embolism in the emergency department

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S106-S106
Author(s):  
K. de Wit ◽  
S. Zarabi ◽  
T. Chan ◽  
F. Germini ◽  
S. Mondoux ◽  
...  
Keyword(s):  
Emergency Department ◽  
Pulmonary Embolism ◽  
Qualitative Interviews ◽  
Theoretical Domains Framework ◽  
Ct Scanning ◽  
Evidence Based ◽  
Novel Approach ◽  
Wells Score ◽  
And Function ◽  
D Dimer

Background: Emergency physicians (EPs) can choose from several evidence-based pathways to diagnose pulmonary embolism (PE), however literature suggests that EPs frequently use computer tomography (CT) scanning as a stand-alone test for PE. This is a program of research to improve adherence to evidence-based PE diagnosis in the emergency department (ED). Aim Statement: To create a novel approach to PE diagnosis in the ED based on a framework explaining EP diagnostic PE behaviour and barriers to using evidence-based PE testing. Measures & Design: We conducted two types of qualitative interviews: 1). EPs in 5 Canadian cities watched videos of 2 simulated cases and then explained how they would test the patient. 2). Semi-structured EP interviews using the theoretical domains framework (TDF). The results of our analyses informed the construction of an explanatory framework for common EP diagnostic PE behaviours. Barriers to evidence-based behaviour were classified into domains. A Canadian EP expert group reviewed these results along with the existing evidence on ED PE diagnostic implementation. We developed a new approach to diagnosis of PE in the ED which addresses each of our domains. Evaluation/Results: We conducted 71 interviews. We identified 4 domains, each addressed in our pathway. ‘PE in a mythical and deadly beast’ PE kills and can masquerade so EPs look for PE in places where it does not exist and are rewarded for ‘over-testing’. Response: Creating a departmental conversation about missing PE, talking about the facts, busting the myths. EP feedback on PE testing including positive rate. ‘The end goal is CTPE’ PE creates anxiety for EPs and ordering a CTPE hands over responsibility to the radiologist. Response: A departmental protocol for PE testing which starts with D-dimer for every patient. Shifting focus to ruling out PE with D-dimer. Protocol is automated once initiated by EP. ‘PERC eases anxiety’ PERC is documented when it is negative and allows EP to stop. Response: EPs can choose to use and document PERC. ‘No-one has been fighting for the Wells score’ Poor understanding of purpose and function. Often at odds to Gestalt. Response: Protocol does not use Wells score. Discussion/Impact: We have developed a new diagnostic PE pathway which addresses current barriers to evidence-based practice which we will evaluate further.

scholarly journals LO81: Optimizing the use of CT scanning for pulmonary embolism in the emergency department

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S56
Author(s):  
S. Sharif ◽  
C. Kearon ◽  
M. Li ◽  
M. Eventov ◽  
P.E. Sneath ◽  
...  
Keyword(s):  
Emergency Department ◽  
Pulmonary Embolism ◽  
False Negative ◽  
False Negative Rate ◽  
Ct Scanning ◽  
Negative Rate ◽  
Wells Score ◽  
Wells Rule ◽  
Acute Pe ◽  
D Dimer

Introduction: Diagnosing pulmonary embolism (PE) can be challenging because the signs and symptoms are often non-specific. Studies have shown that evidence-based diagnostic algorithms are not always adhered to in the Emergency Department (ED), which leads to unnecessary CT scanning. In 2013, the American College of Chest Physicians identified CT pulmonary angiography as one of the top five avoidable tests. One solution is to use a clinical prediction rule combined with the D-dimer, which safely reduces the use of CT scanning. The objective of this study was to compare the proportion of patients tested for PE in two emergency departments, who 1) had a CT-PE and 2) whose diagnosis of PE was missed. We compared these rates to those if the Wells rule and D-dimer had been applied as standard. Methods: This was a retrospective chart review of ED patients investigated for PE at two hospitals from April 2013 to March 2015 (24 months). Inclusion criteria were the ED physician ordered CT-PE, Ventilation-Perfusion (VQ) scan or D-dimer for investigation of PE. Patients under the age of 18 were excluded. PE was defined as CT/VQ diagnosis of acute PE or acute PE/DVT in 30-day follow-up. Trained researchers extracted anonymized data. The rate of CT/VQ imaging and the false-negative rates were calculated. The false-negative rate was calculated as the number of patients diagnosed with PE within 30 days as a proportion of those patients who did not have a CT/VQ scan at initial presentation. Results: There were 1,189 patients included in this study. 55/1,189 patients (4.6%; 95%CI 3.6-6.0%) were ultimately diagnosed with PE within 30 days. 397/1,189 patients (33.4%; 95%CI 30.8-36.1%) had CT/VQ scans for PE. 3 out of 792 who were not scanned had a missed PE resulting in a false-negative rate of 0.4% (95% CI 0.1-1.1%). 80 patients had an elevated D-dimer or high Wells score but were not imaged. Furthermore, 75 patients who did not have an elevated D-dimer nor a high Wells score were imaged. Had Wells rule/D-dimer been adhered to, 402/1,189 patients (33.8%; 95%CI 31.9-36.6%) would have undergone imaging and the false negative rate would be 0/727, 0% (95%CI 0.0-0.5%). Conclusion: If the Wells rule and D-dimer was used in all patients tested for PE, a similar proportion would have a CT scan but fewer PEs would be missed.

scholarly journals P113: Comparison of age-adjusted and clinical probability-adjusted D-dimer for diagnosing pulmonary embolism

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S116
Author(s):  
S. Sharif ◽  
C. Kearon ◽  
M. Li ◽  
M. Eventov ◽  
R. Jiang ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
False Negative ◽  
False Negative Rate ◽  
Retrospective Chart Review ◽  
Ct Scanning ◽  
Clinical Probability ◽  
Negative Rate ◽  
Wells Score ◽  
Acute Pe ◽  
D Dimer

Introduction: Diagnosing pulmonary embolism (PE) in the emergency department can be challenging due to non-specific signs and symptoms; this often results in the over-utilization of CT pulmonary angiography (CT-PA). In 2013, the American College of Chest Physicians identified CT-PA as one of the top five avoidable tests. Age-adjusted D-dimer has been shown to decrease CT utilization rates. Recently, clinical-probability adjusted D-dimer has been promoted as an alternative strategy to reduce CT scanning. The aim of this study is to compare the safety and efficacy of the age-adjusted D-dimer rule and the clinical probability-adjusted D-dimer rule in Canadian ED patients tested for PE. Methods: This was a retrospective chart review of ED patients investigated for PE at two hospitals from April 2013 to March 2015 (24 months). Inclusion criteria were the ED physician ordered CT-PA, Ventilation-Perfusion (VQ) scan or D-dimer for investigation of PE. Patients under the age of 18 were excluded. PE was defined as CT/VQ diagnosis of acute PE or acute PE/DVT in 30-day follow-up. Trained researchers extracted anonymized data. The age-adjusted D-dimer and the clinical probability-adjusted D-dimer rules were applied retrospectively. The rate of CT/VQ imaging and the false negative rates were calculated. Results: In total, 1,189 patients were tested for PE. 1,129 patients had a D-dimer test and a Wells score less than 4.0. 364/1,129 (32.3%, 95%CI 29.6-35.0%) would have undergone imaging for PE if the age-adjusted D-dimer rule was used. 1,120 patients had a D-dimer test and a Wells score less than 6.0. 217/1,120 patients (19.4%, 95%CI 17.2-21.2%) would have undergone imaging for PE if the clinical probability-adjusted D-dimer rule was used. The false-negative rate for the age-adjusted D-dimer rule was 0.3% (95%CI 0.1-0.9%). The false-negative rate of the clinical probability-adjusted D-dimer was 1.0% (95%CI 0.5-1.9%). Conclusion: The false-negative rates for both the age-adjusted D-dimer and clinical probability-adjusted D-dimer are low. The clinical probability-adjusted D-dimer results in a 13% absolute reduction in CT scanning compared to age-adjusted D-dimer.

scholarly journals P104: Evaluating the use of the pulmonary embolism rule-out criteria in the emergency department

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S93-S94
Author(s):  
S. Sharif ◽  
C. Kearon ◽  
M. Eventov ◽  
M. Li ◽  
P. Sneath ◽  
...  
Keyword(s):  
Emergency Department ◽  
Pulmonary Embolism ◽  
False Negative ◽  
False Negative Rate ◽  
Signs And Symptoms ◽  
Ct Scanning ◽  
Pulmonary Angiogram ◽  
Ct Angiogram ◽  
D Dimer ◽  
Rule Out

Introduction: Diagnosing pulmonary embolism (PE) can be challenging because the signs and symptoms are often non-specific. Studies have shown that evidence-based algorithms are not always adhered to in the Emergency Department (ED), which leads to unnecessary CT scanning. The pulmonary embolism rule-out criteria (PERC) can identify patients who can be safely discharged from the ED without further investigation for PE. The purpose of this study is to evaluate the use of the PERC rule in the ED and to compare the rates of testing for PE if the PERC rule was used. Methods: This was a health records review of ED patients investigated for PE at two emergency departments over a two-year period (April 2013-March 2015). Inclusion criteria were ED physician ordered CT pulmonary angiogram, ventilation-perfusion scan, or D-dimer for investigation of PE. Patients under the age of 18 were excluded. PE was considered to be present during the emergency department visit if PE was diagnosed on CT or VQ (subsegmental level or above), or if the patient was subsequently found to have PE or deep vein thrombosis during the next 30 days. Trained researchers extracted anonymized data. The rate of CT/VQ imaging and the negative predictive value was calculated. Results: There were 1,163 patients that were tested for PE and 1,097 patients were eligible for our analysis. Of the total, 330/1,097 (30.1%; 95%CI 27.4-32.3%) had CT/VQ imaging for PE, and 48/1,097 (4.4%; 95%CI 3.3-5.8%) patients were diagnosed with PE. 806/1,097 (73.5%; 95%CI 70.8-76.0%) were PERC positive, and of these, 44 patients had a PE (5.5%; 95%CI 4.1-7.3%). Conversely, 291/1,097 (26.5%; 95%CI 24.0-29.2%) patients were PERC negative, and of these, 4 patients had a PE (1.4%; 95%CI 0.5-3.5%). Of the PERC negative patients, 291/291 (100.0%; 95%CI 98.7-100.0%) had a D-dimer test done, and 33/291 (11.3%; 95%CI 8.2-15.5%) had a CT angiogram. If PERC was used, CT/VQ imaging would have been avoided in 33/1,097 (3%; 95%CI 2.2-4.2%) patients and the D-dimer would have been avoided in 291/1,097 (26.5%; 95%CI 24.0-29.2%) patients. Conclusion: If the PERC rule was used in all patients with suspected PE, fewer patients would have further testing. The false negative rate for the PERC rule was low.

scholarly journals Physician and Patient Beliefs and Preferences in Pulmonary Embolism and Deep Vein Thrombosis Testing in People with Cancer

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 4265-4265
Author(s):  
Anna Tran ◽  
Kerstin De Wit ◽  
Darshana Seeburruth
Keyword(s):  
Pulmonary Embolism ◽  
Diagnostic Imaging ◽  
Cancer Patients ◽  
Evidence Based ◽  
Vein Thrombosis ◽  
Clinical Probability ◽  
Wells Score ◽  
Low Threshold ◽  
Deep Vein ◽  
D Dimer

Abstract Introduction It is unclear whether evidence-based diagnostic protocols are followed when cancer patients are tested for venous thromboembolism (VTE). Evidence-based protocols reduce unnecessary diagnostic imaging, offer a patient-centered approach, and have the potential to standardize practice across medical specialties and settings. However, anecdote suggests that specialists who test people with cancer for VTE may prefer diagnostic imaging over clinical probability scoring and D-dimer testing. The aim of this study was to identify physician and patient knowledge, beliefs, values and preferences for VTE testing in cancer. This study was part of a program of research to set International Society of Thrombosis and Haemostasis standards for VTE testing in people with cancer. Methods This was an international qualitative interview study following COREQ guidelines. Semi-structured interviews with physicians and cancer patients were conducted via Zoom. We used purposive sampling to ensure inclusion of physicians from all specialties who test people with cancer for VTE, practicing across all continents. We invited people treated for cancer who had and did not have experience of VTE testing. We used grounded theory to create a conceptual framework which explains physician and patient values and preferences for VTE testing. Transcripts were coded by three researchers independently, who met to discuss their findings and agree on common codes. Researchers were a Thrombosis physician and two undergraduate students who ensured reflexivity was incorporated into their analysis. Results A total of 32 physicians and 6 cancer patients were invited to interview. Of those invited, 23 physicians and 6 patients across 6 continents completed an interview. Interviews lasted between 21 and 86 minutes. Our derived conceptual model can be seen in the attached Figure. Physicians reported a low threshold to test for VTE in people with cancer compared to those without cancer, because VTE was considered a fatal disease and highly prevalent in this patient population. Imaging was generally the only test used for VTE testing in cancer patients. Many participants relied on their Gestalt estimation of VTE probability when deciding whether to order imaging for pulmonary embolism or deep vein thrombosis. Most thought that low Wells score in combination with a negative D-dimer was not sufficiently sensitive to exclude VTE and anticipated the Wells score and D-dimer to be elevated. The Wells scores had poor face validity because they do not include cancer-specific variables and participants hoped to see a more nuanced formal score for VTE testing in cancer patients. Participants believed that their colleagues would support their diagnostic approach. Patients reported they were used to having tests and CT scans. Patients felt it was important for their physicians to prioritize testing for VTE. Patients had full trust and confidence in their physicians' testing decisions, particularly in decisions made by their oncologists. Conclusion Physicians have a low threshold to test people with cancer for VTE and tend not to use clinical probability assessment and D-dimer. Patients are comfortable having diagnostic imaging, feel VTE testing is important and have full trust in their physicians. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

scholarly journals LO01: Prevalence of pulmonary embolism among Canadian emergency department patients with syncope: a multicenter prospective cohort study

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S27
Author(s):  
V. Thiruganasambandamoorthy ◽  
M. Sivilotti ◽  
A. McRae ◽  
M.A. Mukarram ◽  
S. Kim ◽  
...  
Keyword(s):  
Emergency Department ◽  
Pulmonary Embolism ◽  
Cross Sectional Study ◽  
Study Cohort ◽  
Cross Sectional ◽  
Wells Score ◽  
Emergency Department Patients ◽  
Multicenter Prospective Cohort Study ◽  
Work Up ◽  
D Dimer

Introduction: A recent cross-sectional study reported a 17.3% prevalence of pulmonary embolism (PE) among patients with syncope. However, the study had several flaws including spectrum and work-up bias with over-diagnosis due to excessive investigations. We sought to evaluate the prevalence of PE among Canadian emergency department (ED) patients presenting with syncope. Methods: We enrolled adults with syncope at 5 EDs and collected demographics, proportion of patients evaluated for suspected PE, their Wells PE score values and results of investigations [d-dimer, computed angiography (CT) of chest or ventilation-perfusion (VQ) scan]. 30-day adjudicated outcome included diagnosis of PE requiring treatment. We used descriptive statistics to report the results. Results: 4,739 patients [mean age 54.3 years, 54.4% females, and 587 (12.4%) hospitalized] were enrolled. 323 patients (6.8%) had further evaluation and investigations performed for suspected PE: 255 patients had D-dimer performed, 140 had CT chest and 17 had VQ performed. Of the 323 patients, 300 patients were low risk (Wells score ≤4) and 23 were high-risk (score >4). A total of 16 patients (0.3%) in the study cohort were diagnosed with PE: 10 patients were diagnosed in the ED, 5 patients were diagnosed while hospitalized as inpatient, and 1 patient was diagnosed on a return ED visit. Overall the prevalence of PE was 0.3% among all ED patients with syncope; and a 0.9% among those hospitalized for syncope. Conclusion: Our study shows that the prevalence of PE is very low among all patients presenting to the ED with syncope. The prevalence is also very low among those hospitalized for syncope than previously reported. While PE should be suspected and further investigations performed among syncope patients if clinically appropriate, caution should also be taken against indiscriminate over-investigations for PE.

scholarly journals “What is the actual goal of the pathway?”: examining emergency department physician and nurse perspectives on the implementation of a pediatric concussion pathway using the theoretical domains framework

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Anh Ly ◽  
Roger Zemek ◽  
Bruce Wright ◽  
Jennifer Zwicker ◽  
Kathryn Schneider ◽  
...  
Keyword(s):  
Emergency Department ◽  
Health Care Providers ◽  
Clinical Pathways ◽  
Theoretical Domains Framework ◽  
Local Context ◽  
Emergency Department Physician ◽  
Evidence Based ◽  
Care Providers ◽  
Structured Interviews ◽  
Pediatric Concussion

Abstract Background Multiple evidence-based clinical practice guidelines (CPGs) exist to guide the management of concussion in children, but few have been translated into clinical pathways (CP), which operationalize guidelines into accessible and actionable algorithms that can be more readily implemented by health care providers. This study aimed to identify the clinical behaviours, attitudinal factors, and environmental contexts that potentially influence the implementation of a clinical pathway for pediatric concussion. Methods Semi-structured interviews were conducted from October 2017 to January 2018 with 42 emergency department clinicians (17 physicians, 25 nurses) at five urban emergency departments in Alberta, Canada. A Theoretical Domains Framework (TDF)-informed interview guide contained open-ended questions intended to gather feedback on the proposed pathway developed for the study, as well as factors that could potentially influence its implementation. Results The original 14 domains of the TDF were collapsed into 6 clusters based on significant overlap between domains in the issues discussed by clinicians: 1) knowledge, skills, and practice; 2) professional roles and identity; 3) attitudes, beliefs, and motivations; 4) goals and priorities; 5) local context and resources; and 6) engagement and collaboration. The 6 clusters identified in the interviews each reflect 2–4 predominant topics that can be condensed into six overarching themes regarding clinicians’ views on the implementation of a concussion CP: 1) standardization in the midst of evolving research; 2) clarifying and communicating goals; 3) knowledge dissemination and alignment of information; 4) a team-oriented approach; 5) site engagement; and 6) streamlining clinical processes. Conclusion Application of a comprehensive, evidence-based, and theory-driven framework in conjunction with an inductive thematic analysis approach enabled six themes to emerge as to how to successfullly implement a concussion CP.

scholarly journals Pulmonary Vessel Obstruction Does Not Correlate with Severity of Pulmonary Embolism

2019 ◽  
Vol 8 (5) ◽  
pp. 584 ◽  
Author(s):  
Marianne Lerche ◽  
Nikolaos Bailis ◽  
Mideia Akritidou ◽  
Hans Jonas Meyer ◽  
Alexey Surov
Keyword(s):  
Pulmonary Embolism ◽  
Statistical Significance ◽  
Pulmonary Arteries ◽  
Severity Index ◽  
Clinical Severity ◽  
Pulmonary Vessel ◽  
Wells Score ◽  
Clot Burden ◽  
Spearman’S Correlation ◽  
D Dimer

The aim of the present study was to analyze possible relationships between pulmonary vessel obstruction and clinically relevant parameters and scores in patients with pulmonary embolism (PE). Overall, 246 patients (48.8% women and 51.2% men) with a mean age of 64.0 ± 17.1 years were involved in the retrospective study. The following clinical scores were calculated in the patients: Wells score, Geneva score, and pulmonary embolism severity index (PESI) score. Levels of D-dimer (µg/mL), lactate, pH, troponin, and N-terminal natriuretic peptide (BNP, pg/mL) were acquired. Thrombotic obstruction of the pulmonary arteries was quantified according to Mastora score. The data collected were evaluated by means of descriptive statistics. Spearman’s correlation coefficient was used to analyze associations between the investigated parameters. P values < 0.05 were taken to indicate statistical significance. Mastora score correlated weakly with lactate level and tended to correlate with D-dimer and BNP levels. No other clinical or serological parameters correlated significantly with clot burden. Thrombotic obstruction of pulmonary vessels did not correlate with clinical severity of PE.

scholarly journals Wells’ Score in Diagnosis of Pulmonary Embolism in Patient with Thrombocytopenia: A Case Report

2019 ◽  
Vol 20 (3) ◽  
pp. 281-285
Author(s):  
Dragan Panic ◽  
Andreja Todorovic ◽  
Milica Stanojevic ◽  
Violeta Iric Cupic
Keyword(s):  
Pulmonary Embolism ◽  
Chest Pain ◽  
Acute Pulmonary Embolism ◽  
Pretest Probability ◽  
Clinical Prediction ◽  
Clinical Prediction Rules ◽  
Prediction Rules ◽  
Clinical Probability ◽  
Wells Score ◽  
D Dimer

Abstract Current diagnostic workup of patients with suspected acute pulmonary embolism (PE) usually starts with the assessment of clinical pretest probability, using clinical prediction rules and plasma D-dimer measurement. Although an accurate diagnosis of acute pulmonary embolism (PE) in patients is thus of crucial importance, the diagnostic management of suspected PE is still challenging. A 60-year-old man with chest pain and expectoration of blood was admitted to the Department of Cardiology, General Hospital in Cuprija, Serbia. After physical examination and laboratory analyses, the diagnosis of Right side pleuropne monia and acute pulmonary embolism was established. Clinically, patient was hemodynamically stable, auscultative slightly weaker respiratory sound right basal, without pretibial edema. Laboratory: C-reactive protein (CRP) 132.9 mg/L, Leukocytes (Le) 18.9x109/L, Erythrocytes (Er) 3.23x1012/L, Haemoglobin (Hgb) 113 g/L, Platelets (Plt) 79x109/L, D-dimer 35.2. On the third day after admission, D-dimer was increased and platelet count was decreased (Plt up to 62x109/L). According to Wells’ rules, score was 2.5 (without symptoms on admission), a normal clinical finding with clinical manifestation of hemoptysis and chest pain, which represents the intermediate level of clinical probability of PE. After the recidive of PE, Wells’ score was 6.5. In summary, this study suggests that Wells’ score, based on a patient’s risk for pulmonary embolism, is a valuable guidance for decision-making in combination with knowledge and experience of clinicians. Clinicians should use validated clinical prediction rules to estimate pretest probability in patients in whom acute PE is being consiered.

scholarly journals Investigation of Suspected Pulmonary Embolism at Hutt Valley Hospital with CT Pulmonary Angiography: Current Practice and Opportunities for Improvement

2015 ◽  
Vol 2015 ◽  
pp. 1-5 ◽  
Author(s):  
Nick Kennedy ◽  
Sisira Jayathissa ◽  
Paul Healy
Keyword(s):  
Pulmonary Embolism ◽  
Current Practice ◽  
Pulmonary Angiography ◽  
Pretest Probability ◽  
British Thoracic Society ◽  
Suspected Pulmonary Embolism ◽  
Ct Pulmonary Angiography ◽  
Wells Score ◽  
Positive Rate ◽  
D Dimer

Aims. To study the use of CT pulmonary angiography (CTPA) at Hutt Hospital and investigate the use of pretest probability scoring in the assessment of patients with suspected pulmonary embolism (PE).Methods. We studied patients with suspected PE that underwent CTPA between January and May 2012 and collected data on demographics, use of pretest probability scoring, and use of D Dimer and compared our practice with the British Thoracic Society (BTS) guideline.Results. 105 patients underwent CTPA and 15% of patients had PE. 13% of patients had a Wells score prior to their scan. Wells score calculated by researchers revealed 54%, 36%, and 8% patients had low, medium, and high risk pretest probabilities and 8%, 20%, and 50% of these patients had positive scans. D Dimer was performed in 58% of patients and no patients with a negative D Dimer had a PE.Conclusion. The CTPA positive rate was similar to other contemporary studies but lower than previous New Zealand studies and some international guidelines. Risk stratification of suspected PE using Wells score and D Dimer was underutilised. A number of scans could have been safely avoided by using accepted guidelines reducing resources use and improving patient safety.

Sign in / Sign up

Export Citation Format

Share Document