Buntine Paul, Thien Francis, Stewart John, Woo Yee Ping, Koolstra Martin, Bridgford Lindsay, Datta Mineesh, Gwini Stella M
Eastern Health, Monash University, Melbourne, Victoria, Australia.
Box Hill Hospital, Monash University, Melbourne, Victoria, Australia.
Emerg Med Australas. 2019 Apr;31(2):216-224. doi: 10.1111/1742-6723.13125. Epub 2018 Jul 15.
To assess the association between the use of a flowchart incorporating Wells score, PERC rule and age-adjusted D-dimer and subsequent imaging and yield rates of computed tomography pulmonary angiogram and nuclear medicine ventilation perfusion scans being ordered in the ED for the assessment of pulmonary embolism.
A flowchart governing ED pulmonary embolism investigation was introduced across three EDs in Melbourne, Australia for a 12 month period. Comparison of pulmonary embolism imaging rates and yield with the preceding 12 months was performed.
A total of 1815 pre-implementation scans were performed compared with 1116 scans post-implementation. Because of growth in patient attendances over this time, this equated to an imaging rate of 14.5 per 1000 presentations pre-implementation and 8.6 per 1000 presentations post-implementation (P < 0.001). Overall pulmonary embolism imaging yield rates rose from 9.9% to 16.5% (P < 0.001). A total of 179 pre-implementation pulmonary embolisms were identified, with an incidence of 1.4 per 1000 presentations. This compared to 184 pulmonary embolisms post-implementation, with an incidence of 1.4 per 1000 presentations (P = 0.994).
The introduction of a clinical flowchart incorporating Wells score, PERC rule and age-adjusted D-dimer was associated with an increase in ED computed tomography pulmonary angiogram and nuclear medicine ventilation perfusion yield rate from 9.9% to 16.5% across the three enrolment hospitals when investigating possible pulmonary embolism. This corresponded to a 40% relative reduction in pulmonary embolism imaging. Diagnosis rates remained unchanged and no cases of missed pulmonary embolism attributable to the flowchart were identified.
评估采用包含Wells评分、PERC规则和年龄校正D-二聚体的流程图与后续影像学检查以及急诊科为评估肺栓塞而开具的计算机断层扫描肺动脉造影和核医学通气灌注扫描的检出率之间的关联。
在澳大利亚墨尔本的三个急诊科引入了一份用于急诊科肺栓塞检查的流程图，为期12个月。将肺栓塞影像学检查率和检出率与前12个月进行比较。
实施前共进行了1815次扫描，实施后为1116次扫描。由于这段时间患者就诊人数的增加，这相当于实施前每1000次就诊的影像学检查率为14.5，实施后为每1000次就诊8.6（P<0.001）。总体肺栓塞影像学检查检出率从9.9%升至16.5%（P<0.001）。实施前共发现179例肺栓塞，每1000次就诊的发生率为1.4。相比之下，实施后有184例肺栓塞，每1000次就诊的发生率为1.4（P=0.994）。
在调查可能的肺栓塞时，引入包含Wells评分、PERC规则和年龄校正D-二聚体的临床流程图，使得三家参与研究的医院急诊科计算机断层扫描肺动脉造影和核医学通气灌注扫描的检出率从9.9%提高到了16.5%。这相当于肺栓塞影像学检查相对减少了40%。诊断率保持不变，且未发现因该流程图导致漏诊肺栓塞的病例。
