Pulmonary embolism: are we there yet?

Area of Science:

• Medical Imaging
• Diagnostic Decision Support

Background:

• Clinical prediction rules like the Wells model aid in diagnosing pulmonary embolism (PE).
• Combining these rules with D-Dimer testing can safely exclude PE in low-risk patients, avoiding unnecessary investigations.
• Adherence to local diagnostic imaging guidelines for suspected PE is crucial for appropriate patient management.

Purpose of the Study:

• To evaluate adherence to local diagnostic imaging guidelines for suspected pulmonary embolism (PE).
• To assess the impact of interventions aimed at improving guideline adherence.
• To identify areas for future improvement in PE diagnostic pathways.

Main Methods:

• Retrospective analysis of patients undergoing CT pulmonary angiography (CTPA) or V/Q scan before and after intervention.
• Interventions included educating Emergency Department (ED) doctors and modifying request forms for mandatory Wells score completion.
• Prevalence- and bias-adjusted kappa (PABAK) score used to assess agreement between documented scores.

Main Results:

• Deviation from guidelines decreased from 35% pre-intervention to 22% post-intervention (13% absolute reduction, P=0.017).
• Stamp compliance remained suboptimal at 55% despite mandatory completion requirements.
• Significant discordance observed between documented scores (S-score) and actual clinical assessment (R-score), particularly for CTPA.

Conclusions:

• Interventions successfully reduced inappropriate imaging practices for suspected PE but did not eliminate them.
• Further improvements in compliance may be achieved by implementing electronic request systems with integrated decision support.
• Optimizing PE diagnostic pathways remains an ongoing process.