Poor adherence to the recommended pulmonary embolism diagnostic pathway in the emergency department: A retrospective cohort study
1Department of Emergency Medicine, Tawam Hospital, Al Ain, UAE
2Department of Emergency Medicine, Tawam Hospital; Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, UAE
Keywords: Clinical decision rules, computed tomography pulmonary angiograms, D‑dimer, diagnosis, emergency department, pulmonary emboli rule‑out criteria, pulmonary embolism, wells
OBJECTIVES: Pulmonary embolus (PE) is a form of venous thromboembolism associated with increased morbidity and mortality if not diagnosed and treated early. Variations in clinical presentation make the diagnosis challenging. The gold standard for diagnosing PE is a computed tomography pulmonary angiogram (CTPA). Physicians show a low threshold for over-investigating PE. The evaluation of patients with suspected PE should be efficient, including but not limited to the use of risk stratification methods. This study aims to assess the adherence to the recommended diagnostic pathways of ordering CTPAs in patients with suspected PE.
METHODS: This retrospective cohort study included patients above 18 years of age who received a CTPA for a suspected PE in the emergency department (ED) of a hospital between 2015 and 2019. Patient demographic data, chief complaint, variables of the Wells and pulmonary emboli rule out criteria scores, pregnancy status, investigations, and the patient’s final PE diagnosis were extracted from the hospital electronic medical records. Diagnostic pathways that took place were compared to the internationally recommended pathway.
RESULTS: Four hundred and eighty six patients were included in this study. The mean age was 51.01 (±19.5) years, and 377 (69.3%) patients were female. The recommended PE diagnostic pathway to order CTPA was incorrectly followed in 288 patients (59.3%). Seventy five (15.4%) patients received an unnecessary CTPA. D-dimer test was ordered unnecessarily in 144 patients (29.6%). The overall prevalence of PE in our population was 9.47% (n: 46). Out of the 75 unnecessarily ordered CTPAs, 2 (2.7%) showed PE, while CTPAs ordered using the correct pathway showed 31 (10.9%) PEs.
CONCLUSION: Our study revealed that approximately two-thirds of all CTPA requests did not adhere to the recommended PE clinical decision pathway. There was a significant improper and unnecessary utilization of CTPA imaging and D-dimer testing. Improvements seem imperative to enhance physicians’ clinical approach to PE diagnosis.
How to cite this article: Hadid AM, Jalabi A, Anka M, Cevik AA. Poor adherence to the recommended pulmonary embolism diagnostic pathway in the emergency department: A retrospective cohort study. Turk J Emerg Med 2023;23:44-51.
The Tawam‑Office of Research Governance and Research Ethics Committee approved this study on December 20th, 2020 (#MF2058‑2020‑760).
AH: Project administration; conceptualization; methodology; investigation; formal analysis; writing‑ original draft, review, and editing; visualization. AJ: Conceptualization; methodology; investigation; formal analysis; writing‑ original draft, review, and editing. MA: Conceptualization; investigation; supervision; writing‑review and editing. AAC: Conceptualization; formal analysis; supervision; writing‑ review and editing; visualization.