Clinical Radiology (2009) 64, 339e340
CORRESPONDENCE Investigating suspected acute pulmonary embolism d what are hospital clinicians thinking? SirdWe read with interest the study by McQueen et al.1 investigating the familiarity of clinicians with the British Thoracic Society (BTS) guidelines on the investigation of suspected acute pulmonary embolism (PE). We have recently completed an audit into the investigation of suspected pulmonary embolism, studying the use of clinical probability scoring and D-dimer testing. From 1 January to 27 February 2008, 80 consecutive requests for computed tomography pulmonary angiography (CTPA) were analysed. Ten percent of patients had a clinical probability score documented in the medical notes, although only 5% had the score documented on the radiology request form. The recommended probability score in the hospital is the Geneva score, and of these 5%, none had the Geneva score documented. Twenty-nine percent had a D-dimer undertaken of which 91% were positive. Of the 80 requests, 10 (13%) CTPA examinations were positive. As a result of the audit, an educational session was undertaken as part of the directorate’s audit programme. Emphasis was placed on the fact that patients with a low clinical probability of PE and a negative D-dimer result did not need a CTPA and because the D-dimer used at our hospital is the SimpliRed test, those with intermediate and high clinical probability scores did not require a Ddimer prior to CTPA. In addition to reinforce this, the hospital’s management algorithm for PE including the Geneva score and indications for D-dimer testing were sent to all junior and senior doctors working in the hospital. The requests for CTPA were subsequently reaudited. Out of a sample of 66 consecutive request forms, 5% had the clinical probability and Geneva score documented. Twenty percent of forms had a D-dimer result documented, 85% of which were positive. The percentage of positive CTPA examinations increased from 13 to 15%. The 2003 BTS guidelines state that ‘‘all patients with possible PE should have clinical probability assessed and documented’’.2 As well as improving clinical assessment of the patient, it reduces the need for imaging and avoids exposing the patient to unnecessary radiation. Miller and Boldy, in an accompanying editorial, state ‘‘clinical probability must be recorded in the admission notes and be included on every request form for CTPA’’ and suggest ‘‘request
forms for CTPA which do not state clinical probability and (where appropriate) D-dimer results are automatically rejected by the radiology department’’.3 The present study supports that of McQueen et al. by demonstrating an under-utilization of clinical probability scoring and D-dimer testing in the investigation of suspected PE. Studies from European, Canadian, and USA centres have also shown variable success in the appropriateness and application of diagnostic strategies for pulmonary embolism.4e6 McQueen et al. suggests that ‘‘various aspects of the national guidelines are unfamiliar to many UK hospital clinicians’’.1 This may explain the poor use of clinical probability and D-dimer in our study, but fails to explain why our intervention did not result in significant improvements. Considerable research has been undertaken to assess the most effective strategies for implementation of guidelines,7,8 but we agree with the conclusions of McQueen et al. that further work is required to improve the knowledge and use of guidelines in the investigation of suspected PE.
References 1. McQueen AS, Worthy S, Keir MJ. Investigating suspected acute pulmonary embolism d what are hospital clinicians thinking? Clin Radiol 2008;63:642e50. 2. British Thoracic Society Standards of Care Committee Pulmonary Embolism Guideline Development Group. British Thoracic Society guidelines for the management of suspected acute pulmonary embolism. Thorax 2003;58:470e84. 3. Miller AC, Boldy DAR. Pulmonary embolism guidelines: will they work? Thorax 2003;58:463. 4. Hagen PJ, van Strijen MJ, Kieft GJ, et al. The application of a Dutch consensus diagnostic strategy for pulmonary embolism in clinical practice. Neth J Med 2001;59:161e9. 5. Arnason T, Wells PS, Foster AJ. Appropriateness of diagnostic strategies for evaluating suspected venous thromboembolism. Thromb Haemost 2007;97:195e201. 6. Weiss CR, Haponik EF, Diette GB, et al. Pretest risk assessment in suspected acute pulmonary embolism. Acad Radiol 2008;15:3e14. 7. Effective health care. Getting evidence into practice. York: University of York; 1999. 8. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet 2003;362:1225e30.
K. Foley, S. Packham, P. Ebden Singleton Hospital, Sketty, Swansea, UK E-mail address:
[email protected] ª 2008 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.crad.2008.09.014
