Abstract:Background: Pulmonary embolism (PE) is a common disease in the USA responsible for up to 10% of hospital mortality. Modified wells score (MWS) and D-dimer assay are used to categorize patients into high or low probability of PE. Patient with high probability need Computed tomography pulmonary angiography (CTPA), while patients with low probability and low D-dimer can safely forgo the CTPA. Objectives: The aim of this study was to investigate the rate of inappropriate CTPA use in the emergency department of a c… Show more
“…Research and quality improvement initiatives in guideline adherence have required labor‐intensive, manual retrospective chart review or prospective data collection . The current national emphasis on reducing inappropriate CTPA imaging in the ED will require widespread and frequent quality assessment and review.…”
Section: Components and Point Values For The Wells And Revised Genevamentioning
The Wells and revised Geneva score risk classifications can be approximated with high accuracy using automated extraction of structured EHR data elements in patients who received a CTPA. Combining these automated scores with D-dimer ordering data allows for the automated assessment of clinical guideline adherence for CTPA ordering in the ED, without the burden of manual chart review.
“…Research and quality improvement initiatives in guideline adherence have required labor‐intensive, manual retrospective chart review or prospective data collection . The current national emphasis on reducing inappropriate CTPA imaging in the ED will require widespread and frequent quality assessment and review.…”
Section: Components and Point Values For The Wells And Revised Genevamentioning
The Wells and revised Geneva score risk classifications can be approximated with high accuracy using automated extraction of structured EHR data elements in patients who received a CTPA. Combining these automated scores with D-dimer ordering data allows for the automated assessment of clinical guideline adherence for CTPA ordering in the ED, without the burden of manual chart review.
“…However, it carries the burden of radiation exposure and the need for using an iodine-based intravenous contrast agent. CTPA is being overused in many departments resulting in clinically non-significant incidental findings, unnecessary follow-ups or contrast-induced nephropathy [5][6][7][8][9][10][11][12][13] . This is why several clinical scoring systems have been developed to identify clinically stable outpatients who have an increased PE risk and may benefit from CTPA, such as the Geneva Score, the Wells Score, and the YEARS Algorithm 14 .…”
Background and Aim. Assessment of appropriateness of CT pulmonary angiograms (CTPA) in patients with suspected pulmonary embolism (PE) is based on risk stratification algorithms such as simplified the Geneva Score (sGS) in combination with D-dimer blood tests. The aim of this study was to validate the diagnostic yield and appropriateness of CTPA examinations in accordance with 2014 European Society of Cardiology (ESC) guidelines. Materials and Methods. Data from 155 outpatients who underwent CTPA for clinical suspicion of PE were gathered from the radiology information system (RIS) and the clinical information system (CIS). We assessed the presence of sGS items and D-dimer blood test results in RIS from CTPA request forms and from clinical documentation in CIS. Results. Based on the RIS, there were 2.6% patients with high (sGS≥3) and 97.4% patients with low pre-test PE probability (sGS<3), and CTPA indication was formally comprehendible in 75.5% using sGS and D-dimer blood tests. Based on RIS and CIS data in combination, there were 41.3% patients with high and 58.7% patients with low pre-test PE probability, and CTPA indication was formally comprehendible in 88.4%. Using RIS and CIS in combination, PE probability was upgraded from low to high probability in 39.7% compared with RIS alone. In 12.9%, there was a lack of data in RIS for CTPA justification. Conclusion. There is a high diagnostic yield when applying current diagnostic guidelines to our data. There was however a notable discrepancy between the data transferred to the CTPA request forms from the full clinical documentation, therefore not readily available for clinical decision making.
“…Pathologic values make a CTPA mandatory. This challenging situation in emergency departments has led to various clinical retrospective studies, evaluating the probability of PE in the general patient population [8, 9]. However, little is known about PE in young patient groups in which this diagnosis is usually not expected.…”
Objective: The clinical presentation of pulmonary embolism (PE) can be various and misleading. We analyzed patients with suspicion of PE and subsequently performed computed tomography pulmonary angiography (CTPA) in an emergency department of Internal Medicine, focusing on patient groups in which PE might be underestimated in the emergency setting, such as young patients and patients with low clinical probability. Material and Methods: In 2016 and 2017, all patients receiving a CTPA for investigation of PE were retrospectively evaluated for clinical parameters (age, symptoms, and vital parameters) and D-dimers. The Wells score was calculated. Results: CTPA was performed in 323 patients (158 female and 165 male; mean age 62 years). The leading symptoms for admission were dyspnea or chest pain; 62% showed intermediate or high risk for PE, calculated by applying the Wells score. In 123 (38%) of all patients, a PE was proved and pathologic age-adjusted D-dimers were found in 97.6%. Thirty of 121 (25%) patients with low risk according to Wells score had a PE. Deep vein thrombosis was verified in 67/123 (55%) patients; 43% (15/35) of all suspicions for PE in patients <40 years were positive with 4/15 (26%), showing a central PE. Younger patients (<40 years) with PE presented more often with tachycardia or tachypnea and chest pain or dyspnea than elderly patients with PE. Conclusion: CTPA frequently proves a PE in patients with suspicion of PE in an emergency department of Internal Medicine. If PE is suspected and CTPA performed accordingly, the presence of PE is quite common even in low-risk patient groups (Wells score) or in young patients <40 years with chest pain or dyspnea.
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