Comparing ‘clinical hunch’ against clinical decision support systems (PERC rule, wells score, revised Geneva score and YEARS criteria) in the diagnosis of acute pulmonary embolism

Abstract

BackgroundPulmonary embolism (PE) is a common and potentially life-threatening condition. Since it is considered a ‘do not miss’ diagnosis, PE tends to be over-investigated beyond the evidence-based clinical decision support systems (CDSS), which in turn subjects patients to unnecessary radiation and contrast agent exposure with no apparent benefits in terms of outcome.The purpose of this study was to evaluate the yield of ‘clinical hunch’ (gestalt) and four CDSS: the PERC Rule, Wells score, revised Geneva score, and Years criteria.MethodsA review was conducted on the Electronic Medical Records (EMR) of 1566 patients from the Emergency Department at a tertiary teaching hospital who underwent CTPA from the 1st of January 2018 to the 31st of December 2019. The scores for the four CDSS were calculated retrospectively from the EMR data. We considered that a CTPA had been ordered on a clinical hunch when there was no mention of CDSS in the EMR, and no D-dimer test. A bypass of CDSS was confirmed when any step of the diagnostic algorithms was not followed.ResultsOf the total 1566 patients who underwent CTPA, 265 (17%) were positive for PE. The diagnosis yield from the five decision groups (clinical hunch and four CDSS) was as follows—clinical hunch, 15%; PERC rule, 18% (6% when bypassed); Wells score, 19% (11% when bypassed); revised Geneva score, 26% (13% when bypassed); and YEARS criteria, 18% (6% when bypassed).ConclusionClinicians should trust the evidence-based clinical decision support systems in line with the international guidelines to diagnose PE.