Department of Emergency Medicine, Auckland City Hospital, Private Bag 92024, Auckland Mail Centre, Auckland 1142, New Zealand.
Emerg Med J. 2010 Jan;27(1):43-7. doi: 10.1136/emj.2009.075838.
D-dimer tests were inappropriately overused in our emergency department as a result of bloods being taken before clinical assessment to help meet the "4-hour target". We introduced a multifaceted intervention to reduce the number of inappropriate D-dimer tests. The secondary aim was to improve the diagnostic workup of suspected pulmonary embolism (PE).
Rate of D-dimer test and ventilation/perfusion scan requests were compared before, during and after a staggered intervention at two hospitals in one National Health Service Trust. Audits before and after the intervention were done to determine whether test use was appropriate and whether the diagnostic workup was complete.
At hospital 1, D-dimer testing after the intervention was almost halved: ratio 0.59 (95% CI 0.55 to 0.63) (p<0.0001). There was also a small reduction at hospital 2 (control): rate 0.88 (95% CI 0.78 to 0.99) (p = 0.03). After the formal introduction of change at hospital 2, there was a further reduction in tests: ratio 0.67 (95% CI 0.58 to 0.76) (p<0.0001). In hospital 1, pretest probability assessment improved by 42% (p = 0.0004) and D-dimer test use was reduced by 12.5% (p = 0.04) between audits. Improvement in the use of D-dimer test according to the pathway was not significant (32.5%, p = 0.11), and there was no change in the proportion of patients with completion of their diagnostic workup for PE: 47.6% (95% CI 38.3% to 56%) before and 45.6% (95% CI 38.3% to 53.1%) after the intervention.
Implementation of a multifaceted change program reduced the number of D-dimer test requests in both hospitals and may have improved the diagnostic workup for PE at hospital 1. Processes that speed patient transit through the emergency department may impact negatively on other aspects of patient care. This should be the subject of further studies.
由于在进行临床评估之前采集血液以帮助达到“4 小时目标”，因此我们的急诊部门过度使用了 D-二聚体检测。我们引入了一种多方面的干预措施来减少不适当的 D-二聚体检测数量。次要目标是改善疑似肺栓塞 (PE) 的诊断工作流程。
在一家国民保健信托的两家医院分阶段实施干预措施前后，比较了 D-二聚体检测和通气/灌注扫描的请求率。在干预前后进行审核，以确定检测是否合理，诊断工作是否完整。
在医院 1，干预后 D-二聚体检测几乎减少了一半：比值 0.59（95%置信区间 0.55 至 0.63）（p<0.0001）。医院 2（对照组）的检测率也略有下降：比率 0.88（95%置信区间 0.78 至 0.99）（p = 0.03）。在医院 2 正式引入变更后，检测进一步减少：比值 0.67（95%置信区间 0.58 至 0.76）（p<0.0001）。在医院 1，在两次审核之间，患者的术前概率评估提高了 42%（p = 0.0004），D-二聚体检测使用率降低了 12.5%（p = 0.04）。根据途径使用 D-二聚体检测的改善不显著（32.5%，p = 0.11），且完成 PE 诊断工作流程的患者比例也没有变化：干预前为 47.6%（95%置信区间 38.3%至 56%），干预后为 45.6%（95%置信区间 38.3%至 53.1%）。
实施多方面的变革方案减少了两家医院的 D-二聚体检测请求数量，并可能改善了医院 1 的 PE 诊断工作流程。加快患者通过急诊部门的流程可能会对患者护理的其他方面产生负面影响。这应该是进一步研究的主题。
