Kline Jeffrey A, Webb William B, Jones Alan E, Hernandez-Nino Jackeline
Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC 28323-2861, USA.
Ann Emerg Med. 2004 Nov;44(5):490-502. doi: 10.1016/j.annemergmed.2004.03.018.
This study tests the hypothesis that implementation of a point-of-care emergency department (ED) protocol to rule out pulmonary embolism would increase the rate of evaluation without increasing the rate of pulmonary vascular imaging or ED length of stay and that less than 1.0% of patients with a negative protocol would have an adverse outcome.
A baseline study was conducted on patients with suspected pulmonary embolism at an urban ED to establish baseline measurements performed when only pulmonary vascular imaging was available to rule out pulmonary embolism. The intervention protocol used pretest probability assessment, a whole-blood d -dimer assay, and an alveolar dead-space measurement to rule out pulmonary embolism. The main outcomes were diagnosis of venous thromboembolism or sudden unexpected death within 90 days.
During baseline, 453 of 61,322 patients (0.74%; 95% confidence interval [CI] 0.67% to 0.81%) underwent pulmonary vascular imaging, and 8% (95% CI 6% to 11%) of scan results were positive; 1.20% (95% CI 0.39% to 2.78%) of untreated discharged patients were anticoagulated for venous thromboembolism or died unexpectedly within 90 days. The median length of stay was 385 minutes. After intervention, 1,460 of 102,848 patients (1.42%; 95% CI 1.35% to 1.49%) were evaluated for pulmonary embolism. Seven hundred fifty-two patients had a negative protocol and 5 of 752 (0.66%; 95% CI 0.20% to 1.54%) had venous thromboembolism within 90 days, none with unexpected death. After intervention, the rate of pulmonary vascular imaging tended to decrease (0.64%; 95% CI 0.59% to 0.69%), and more scans (11%; 95% CI 9% to 14%) were read as positive; the length of stay decreased to 297 minutes.
A point-of-care pulmonary embolism rule-out protocol doubled the rate of screening for pulmonary embolism in the ED, had a false negative rate of less than 1.0%, did not increase the pulmonary vascular imaging rate, and decreased length of stay.
本研究旨在验证以下假设：实施一种用于排除肺栓塞的即时检验急诊科（ED）方案，将提高评估率，同时不增加肺血管成像率或急诊科住院时间，且方案结果为阴性的患者中不良结局发生率低于1.0%。
对一家城市急诊科疑似肺栓塞患者进行基线研究，以确定仅通过肺血管成像排除肺栓塞时的基线测量值。干预方案采用预测试概率评估、全血D-二聚体检测和肺泡死腔测量来排除肺栓塞。主要结局为90天内静脉血栓栓塞症的诊断或意外猝死。
基线期，61322例患者中有453例（0.74%；95%置信区间[CI]0.67%至0.81%）接受了肺血管成像，扫描结果阳性率为8%（95%CI 6%至11%）；1.20%（95%CI 0.39%至2.78%）未接受治疗的出院患者因静脉血栓栓塞症接受抗凝治疗或在90天内意外死亡。中位住院时间为385分钟。干预后，102848例患者中有1460例（1.42%；95%CI 1.35%至1.49%）接受了肺栓塞评估。752例患者方案结果为阴性，其中5例（0.66%；95%CI 0.20%至1.54%）在90天内发生静脉血栓栓塞症，无一例意外死亡。干预后，肺血管成像率呈下降趋势（0.64%；95%CI 0.59%至0.69%），更多扫描结果（11%；95%CI 9%至14%）为阳性；住院时间缩短至297分钟。
一种即时检验肺栓塞排除方案使急诊科肺栓塞筛查率提高了一倍，假阴性率低于1.0%，未增加肺血管成像率，并缩短了住院时间。
