The use of clinical decision rules for pulmonary embolism in the emergency department: a retrospective study

Omran Al Dandan,Mohammed Al Gadeeb,Malak Al Shammari,Afnan Alnasr,Hossain Abualola,Alaa Alzaki,Sarah Alshahwan,Ali Hassan

doi:10.1186/s12245-020-00281-1

Abstract

BackgroundPulmonary embolism (PE) is a common and life-threatening medical condition with non-specific clinical presentation. Computed tomography pulmonary angiography (CT-PA) has been the diagnostic modality of choice, but its use is not without risks. Clinical decision rules have been established for the use of diagnostic modalities for patients with suspected PE. This study aims to assess the adherence of physicians to the diagnostic algorithms and rules.MethodsA retrospective observational study examining the utilization of CT-PA in the Emergency Department of King Fahd Hospital of Imam Abdulrahman Bin Faisal University for patients with suspected PE from May 2016 to December 2019. The electronic health records were used to collect the data, including background demographic data, clinical presentation, triage vital signs, D-dimer level (if ordered), risk factors for PE, and the CT-PA findings. The Wells score and pulmonary embolism rule-out (PERC) criteria were calculated retrospectively without knowledge of the results of D-dimer and the CT-PA.ResultsThe study involved a total of 353 patients (125 men and 228 women) with a mean age of 46.7 ± 18.4 years. Overall, 200 patients (56.7%) were classified into the “PE unlikely” group and 153 patients (43.3%) in the “PE likely” group as per Wells criteria. Out of all the CT-PA, 119 CT-PA (33.7%) were requested without D-dimer assay (n = 114) or with normal D-dimer level (n = 5) despite being in the “PE unlikely” group. Only 49 patients had negative PERC criteria, of which three patients had PE.ConclusionsThe study revealed that approximately one-third of all CT-PA requests were not adhering to the clinical decision rules with a significant underutilization of D-dimer assay in such patients. To reduce overutilization of imaging, planned interventions to promote the adherence to the current guidelines seem imperative.

Highlights

Pulmonary embolism (PE) is a common and life-threatening medical condition with non-specific clinical presentation
Patients characteristics The study involved a total of 353 patients, including 125 men and 228 women, representing 35.4% and 64.6% of the study population, respectively
Decision rules Wells criteria Based on Wells criteria, 200 patients (56.7%) were classified into the “PE unlikely” group and 153 patients (43.3%) in the “PE likely” group (Fig. 1)

Summary

Introduction

Pulmonary embolism (PE) is a common and life-threatening medical condition with non-specific clinical presentation. Computed tomography pulmonary angiography (CT-PA) has been the diagnostic modality of choice, but its use is not without risks. Clinical decision rules have been established for the use of diagnostic modalities for patients with suspected PE. Pulmonary embolism (PE) is a common and potentially life-threatening medical condition. Due to its nonspecific signs and symptoms, the diagnosis of PE is often missed or delayed [2]. Diagnosis and management are crucial as the mortality rate reaches nearly 30% for untreated PE [3]. Computed tomography pulmonary angiography (CT-PA) has become the modality of choice in the evaluation of patients with suspected PE because of its high sensitivity and accuracy [4]. It has been reported that the USA spends approximately twice as much as other high-income countries on the healthcare and overutilization of diagnostic imaging was the main reason [8]

Objectives

Methods

Results

Conclusion