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Overuse of Computed Tomography Pulmonary Angiography in the Evaluation of Patients with Suspected Pulmonary Embolism in the Emergency Department
Author(s) -
Crichlow Amanda,
Cuker Adam,
Mills Angela M.
Publication year - 2012
Publication title -
academic emergency medicine
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.221
H-Index - 124
eISSN - 1553-2712
pISSN - 1069-6563
DOI - 10.1111/acem.12012
Subject(s) - medicine , pulmonary embolism , emergency department , pulmonary angiography , d dimer , prospective cohort study , radiology , angiography , computed tomography , cohort , pre and post test probability , psychiatry
Background Clinical decision rules have been developed and validated for the evaluation of patients presenting with suspected pulmonary embolism ( PE ) to the emergency department ( ED ). Objectives The objective was to assess the percentage of computed tomographic pulmonary angiography ( CT ‐ PA ) procedures that could have been avoided by use of the Wells score coupled with D‐dimer testing (Wells/D‐dimer) or pulmonary embolism rule‐out criteria ( PERC ) in ED patients with suspected PE . Methods The authors conducted a prospective cohort study of adult ED patients undergoing CT ‐ PA for suspected PE . Wells score and PERC were calculated. A research blood sample was obtained for D‐dimer testing for subjects who did not undergo testing as part of their ED evaluation. The primary outcome was PE by CT ‐ PA or 90‐day follow‐up. Secondary outcomes were ED length of stay ( LOS ) and CT ‐ PA time as defined by time from order to initial radiologist interpretation. Results Of 152 suspected PE subjects available for analysis (mean ± SD age = 46.3 ± 15.6 years, 74% female, 59% black or African American, 11.8% diagnosed with PE ), 14 (9.2%) met PERC , none of whom were diagnosed with PE . A low‐risk Wells score (≤4) was assigned to 110 (72%) subjects, of whom only 38 (35%) underwent clinical D‐dimer testing (elevated in 33/38). Of the 72 subjects with low‐risk Wells scores who did not have D‐dimers performed in the ED , archived research samples were negative in 16 (22%). All 21 subjects with low‐risk Wells scores and negative D‐dimers were PE ‐negative. CT ‐ PA time (median = 160 minutes) accounted for more than half of total ED LOS (median = 295 minutes). Conclusions In total, 9.2 and 13.8% of CT ‐ PA procedures could have been avoided by use of PERC and Wells/D‐dimer, respectively.