Screening protocol catches more pulmonary embolisms
If untreated, pulmonary embolism (PE) has a mortality rate of 25%-30%. Isn’t that a frightening statistic?
To make things more challenging, PE is extremely difficult to rule out in the ED based upon a standard history and physical examination, says Jeffrey A. Kline, MD, research and fellowship director for the department of emergency medicine at Carolinas Medical Center in Charlotte, NC. To address this challenge, a point-of-care protocol was developed to rule out PE cases, which caught twice as many cases in the ED at Carolinas Medical Center.1 For an eight-month baseline period in early 2001, clinicians relied only on standard imaging (computed tomography or ventilation perfusion scans) to rule out PE, but during a 12-month intervention period, clinicians used the point-of-care rapid PE rule out protocol.
Of 1,200 patients with suspected PE who had a D-dimer test and alveolar dead-space measurement performed, 448 had positive results for one or both tests, and 752 had negative results for both tests. Less than 1% of patients who were discharged after a negative protocol had an adverse event on 90-day follow-up.
"We found that the protocol allowed us to diagnose one additional patient with PE per 7,000 ED visits that would otherwise go undiagnosed," says Kline, the study’s principal investigator.
If the PE rule out is done at the bedside, it also may result in a decreased length of stay, reports Kline. When the protocol was used, length of stay decreased to 297 minutes from 385 minutes. Assuming that an arterial blood gas analyzing machine is available in the ED, the needed materials (a standard portable capnometer and the Simplify D-dimer test, distributed by Stamford, CT-based American Diagnostica) can be purchased for less than $3,500, Kline says. The direct cost per patient is less than $20, he estimates.
"Data from two hospitals suggest that the rapid PE rule out will not increase the number of radiological studies for PE, which is another benefit," he adds.
If a rapid rule-out protocol for PE is implemented, ED nurses would need to perform a point-of-care D-dimer assay and document the result, says Kline. "In the future, ED nurses may do this test autonomously for patients with unexplained dyspnea, oxygen saturation under 95% without a good reason, or a risk factor for PE — similar to the way nurses order electrocardiograms for chest pain patients in many EDs," he adds.
Reference
- Kline JA, Webb WB, Jones AE, et al. Impact of a rapid rule-out protocol for pulmonary embolism on the rate of screening, missed cases, and pulmonary vascular imaging in an urban U.S. emergency department. Ann Emerg Med 2004; 44:490-502.
Source
For more information on assessment of pulmonary embolism, contact:
- Jeffrey A. Kline, MD, Department of Emergency Medicine, Carolinas Medical Center, P.O. Box 32861, Charlotte, NC 28323-2861. Telephone: (704) 355-7092. Fax: (704) 355-7047. E-mail: [email protected].
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