Variable diagnostic approach to suspected pulmonary embolism in the ED of a major academic tertiary care center

doi:10.1053/ajem.2002.30010

The American Journal of Emergency Medicine

Volume 20, Issue 1, January 2002, Pages 5-9

https://doi.org/10.1053/ajem.2002.30010 Get rights and content

Abstract

The purpose of this study is to retrospectively examine the patterns of diagnostic modality utilization in the setting of suspected acute pulmonary embolism (PE) by physicians in the emergency department (ED) of a major academic tertiary care center. All patients (n=180) with a hospital discharge diagnosis of PE that were admitted through the ED during 1997 to 1999 were included. Overall test frequency and distribution, ancillary testing used when the initial ventilation-perfusion (V/Q) scan or spiral computed tomography (sCT) angiogram was nondiagnostic, concordance of V/Q and sCT, and sensitivities of D-dimer assays, arterial blood gas analysis, and deep venous imaging were assessed. There was a wide discrepancy in practice, most pronounced when first-line radiological studies were nondiagnostic. There was a poor correlation of PE detection between sCT and V/Q. D-dimer assay, arterial blood gas analysis, and deep venous imaging are insensitive tests for PE, and “gold standard” pulmonary angiography is rarely used. (Am J Emerg Med 2002;20:5-9. Copyright © 2002 by W.B. Saunders Company)

Section snippets

Methods

The setting for this study was The Cleveland Clinic Foundation, a tertiary care center located in Cleveland, Ohio with an ED annual census of approximately 54,000 patients. We conducted a retrospective analysis of all patients who received a hospital discharge diagnosis of PE that were admitted through the ED during the time period of 1997 to 1999.

The review specifically sought to determine the utilization patterns of each of the following diagnostic modalities in the setting of suspected PE:

Results

There were 180 patients diagnosed with PE. The sex distribution was similar, with 51% women and 49% men. The mean age was 65 years, with a standard deviation of 15 years. The frequency and distribution of diagnostic modalities used is depicted Fig 1.

. The frequency of diagnostic modality employment, expressed as a percentage of the total number of patients (n=180). AAG, alveolar-arterial gradient; sCT, spiral computed tomography of the chest. V/Q scan, lung nuclear ventilation-perfusion scan,

Discussion

We performed a retrospective analysis of 180 patients with a hospital discharge diagnosis of PE admitted through the ED of a major academic tertiary care center to characterize the methods used to arrive at their diagnosis. We found a wide discrepancy in practice regarding the approach to patients with suspected PE in the ED, including a subpopulation of patients who were diagnosed and treated for PE in the absence of our defined criteria for PE. This discrepancy was most pronounced when the

References (32)

SZ Goldhaber et al.
Acute pulmonary embolism: Clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER)
Lancet
(1999)
J Diebold
Venous thrombosis and pulmonary embolism. A study of 5039 autopsies
Pathol Res Pract
(1991)
JA Kline et al.
New diagnostic tests for pulmonary embolism
Ann Emerg Med
(2000)
JH Indik et al.
Detection of pulmonary embolism by D-dimer assay, spiral computed tomography, and magnetic resonance imaging
Prog Cardiovasc Dis
(2000)
BW Frazee et al.
Diagnositc role of ED ultrasound in deep venous thrombosis and pulmonary embolism
Am J Emerg Med
(1999)
RJ Lipchik et al.
Spiral computed tomography in the evaluation of pulmonary embolism
Clin Chest Med
(1999)
H Hatabu et al.
Magnetic resonance imaging of the thorax
Radiol Clin North Am
(2000)
N Sreeram
Value of the 12-lead electrocardiogram at hospital admission in the diagnosis of pulmonary embolism
Am J Cardiol
(1994)
PD Stein et al.
Alveolar-arterial oxygen gradient in the assessment of suspected acute pulmonary embolism
Chest
(1995)
TR Wolfe et al.
Pulmonary embolism: Making sense of the diagnostic evaluation
Ann of Emerg Med
(2001)

K Weiss

Pulmonary thromboembolism: Epidemiology and techniques of nuclear medicine

Semin Thromb Hemost

(1996)

JL Carson et al.

The clinical course of thromboembolism

N Engl J Med

(1992)

The Task Force on Pulmonary Embolism

Guidelines on diagnosis and management of pulmonary embolism

Eur Heart J

(2000)

The PIOPED investigators

Value of the ventilation-perfusion scan in acute pulmonary embolism: Results of the prospective investigation of pulmonary embolism diagnosis

JAMA

(1990)

SZ Goldhaber

Diagnosis of pulmonary embolism

Clin Cornerstone

(2000)

B Karwinski

Comparison of clinical and postmortem diagnosis of pulmonary embolism

J Clin Pathol

(1989)

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Citation Excerpt :
One of the main issues with V/Q scintigraphy is the rate of nondiagnostic interpretation, which results in further investigation and increasing costs. The rate of nondiagnostic V/Q scans ranges between 30% and 50%, and, in some studies (PIOPED I), it is as high as 70%.38,158–160 Indeterminate rates are more common among patients with significant cardiopulmonary disease, including acute and chronic airway disease, patients with abnormal chest radiography, and the elderly.161,162
Is E-mail Communication Effective in Changing Ordering Patterns in the Emergency Department?. A Case Study of Computed Tomography for Pulmonary Embolus
2008, Academic Radiology
We sought to evaluate the effectiveness of e-mail communication to reduce the utilization of computed tomography for pulmonary thromboembolism (PE) in young patients (aged 40 and under) in our institution.
An e-mail was sent to all of our institution’s emergency department (ED) physicians in response to a series of negative PE studies in young females. The periods 90 days before and 90 days after were evaluated to assess the total number of PE studies performed in patients aged 40 and younger, the rate of positivity, and the utilization of D-dimer and ventilation/perfusion scans during each period.
Over the 180-day period, a total of 65 PE studies were ordered in patients aged 40 and younger in the ED. Studies were positive for PE in 1 of 33 (3%) before the e-mail and 4 of 32 (12.5%) after (P = .343). There was no difference in the number of D-dimer studies ordered during each period for patients studied with computed tomography. Ventilation/perfusion scanning was not performed on any ED patients younger than 40 during the 180-day period.
One-time e-mail communication was not effective in changing ED ordering habits of PE studies. Scant information exists in regard to effective clinician-to-clinician communication. Further evaluation for successful mechanisms to promote health practice reform and quality improvement is necessary.
Computed tomography and pulmonary embolus: A review
2005, Seminars in Ultrasound, CT and MRI
Pulmonary embolus (PE) is a common clinical condition with significant morbidity and mortality that remains a diagnostic challenge for clinicians. Although many tests exist, multi-detector computed tomography (MDCT) pulmonary angiography has recently emerged as the test of choice. MDCT technique, diagnostic criteria, prognosis assessment and common causes of misdiagnosis are reviewed with a look toward future trends.
Spiral computed tomography is the first-line chest imaging test for acute pulmonary embolism: Yes
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A Rapid Quantitative Turbimetric D-dimer Assay Has High Sensitivity for Detection of Pulmonary Embolism in the ED
2004, American Journal of Emergency Medicine
Many rapid d-dimer assays are commercially available with wide ranges of reported sensitivities, often based on small sample sizes. This has limited their intended use as rapid and inexpensive tests to evaluate pulmonary embolism in the low-risk patient. We sought to determine the sensitivity of the STA-Liatest D-Di d-dimer assay in our ED. We performed a retrospective analysis of 103 patients seen in our ED with the admitting diagnosis of known or suspected pulmonary embolism. These charts were assessed to establish if a d- dimer assay was performed within 24 hours. These charts were then reviewed to determine what diagnostic studies were performed and what final diagnosis was reached. Of the 103 charts identified, 55 had d-dimer assays performed within 24 hours. Of those, 38 were diagnosed with pulmonary embolism; none had negative d-dimer assays (<400 ng/mL). Using the exact method, the sensitivity of this assay was calculated to be 100% with a 95% confidence interval (CI) of 91.4% to 100%. Our results suggest that the STA-Liatest D-Di d-dimer assay could have an adequate sensitivity to be used to rule out pulmonary embolism in low-risk patients. Further prospective studies with larger sample sizes are required to validate this observation.
CT Venography in Suspected Pulmonary Thromboembolism
2004, Seminars in Ultrasound, CT and MRI
Pulmonary embolism (PE) and deep venous thrombosis (DVT) are a continuum and are difficult to diagnose clinically. Combined CT venography and pulmonary angiography (CTVPA) is a single examination that combines multidetector CT pulmonary angiography (CTPA) and CT venography (CTV) of the abdomen, pelvis, and lower extremities, providing “one-stop shopping” for venous thromboembolism without additional venipuncture or IV contrast, and it adds only a few additional minutes to scanning time. CTVPA rapidly and accurately examines the deep veins, reveals the presence, absence, and extent of deep venous thrombosis, serves as a baseline, and helps guide patient management. Multiple investigators have reported a high degree of accuracy when CTV is compared with venous ultrasound. There are some pitfalls in image interpretation, especially with regard to mixing artifacts, and there are continuing controversies as to exactly which parts of the abdomen, pelvis, and legs should be scanned routinely, the ideal timing of CTV acquisition relative to contrast injection, and the slice thickness and gap, if any, that should be used.

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^*: Address reprint request to Jonathan Glauser, MD, CCF, 9500 Euclid Ave, Cleveland, OH 44106.

^**: 0735-6757/02/2001-0002$35.00/0

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Original ContributionsVariable diagnostic approach to suspected pulmonary embolism in the ED of a major academic tertiary care center*,**

Abstract

Section snippets

Methods

Results

Discussion

Lancet

Pathol Res Pract

Ann Emerg Med

Prog Cardiovasc Dis

Am J Emerg Med

Clin Chest Med

Radiol Clin North Am

Am J Cardiol

Chest

Ann of Emerg Med