Royal Adelaide Hospital, University of Adelaide, Adelaide, South Australia, Australia.
Central Adelaide Local Health Network, Adelaide, South Australia, Australia.
Intern Med J. 2019 Nov;49(11):1371-1377. doi: 10.1111/imj.14234.
Clinical decision rules for suspected pulmonary embolism are proposed to identify patients suitable for discharge without radiological investigation. Their use varies between institutions.
To quantify unnecessary radiological investigations for suspected pulmonary embolism (PE) as defined by a newly proposed three-tiered clinical decision rule incorporating the revised Geneva score, Pulmonary Embolism Rule-Out Criteria and D-dimer. To quantify missed diagnosis of PE if the proposed clinical decision rule were followed.
A retrospective audit was conducted; applying the proposed clinical decision rule to 584 emergency department (ED)-based encounters at the Royal Adelaide Hospital from May to November 2015. Encounters were confined to emergency presentations where suspected acute PE was investigated with computed tomography pulmonary angiography or ventilation-perfusion scanning; inpatient and follow-up studies were excluded. Sensitivity, specificity, positive predictive value and negative predictive value of the proposed clinical decision rule within the studied population were calculated.
Data were obtained for 584 patient encounters where suspected PE was investigated radiologically. Applied retrospectively, the proposed clinical decision rule had a negative predictive value of 97.7% and a sensitivity of 98.5% for radiologically proven PE; 9.2% of scans could have been avoided. One case of PE would have been missed; a false-negative rate of 1.5%.
Retrospective application of the proposed clinical decision rule to the studied cohort indicates at least 9% of radiological investigations were unnecessary. A prospective study is needed to assess the safety and cost-effectiveness of applying such a pathway to all patients presenting to ED with suspected PE.
临床决策规则被提出用于疑似肺栓塞（PE），以识别适合无需影像学检查即可出院的患者。不同机构之间的使用情况有所不同。
定量评估新提出的三阶梯临床决策规则（纳入修订后的日内瓦评分、肺栓塞排除标准和 D-二聚体）对疑似 PE 进行不必要的影像学检查的情况。如果遵循新提出的临床决策规则，定量评估漏诊 PE 的情况。
对 2015 年 5 月至 11 月在阿德莱德皇家医院急诊科就诊的 584 例疑似急性 PE 患者进行回顾性审核，采用计算机断层扫描肺动脉造影或通气灌注扫描进行影像学检查。排除住院和随访研究。计算该研究人群中新提出的临床决策规则的敏感性、特异性、阳性预测值和阴性预测值。
获得了 584 例疑似 PE 患者的影像学检查数据。回顾性应用该规则，对已证实的 PE，该规则的阴性预测值为 97.7%，敏感性为 98.5%；9.2%的扫描可以避免。可能漏诊 1 例 PE，假阴性率为 1.5%。
将新提出的临床决策规则回顾性应用于研究队列，表明至少有 9%的影像学检查是不必要的。需要前瞻性研究来评估将这种途径应用于所有因疑似 PE 就诊于急诊科的患者的安全性和成本效益。
