Egermayer P, Town G I
Department of Medicine, Christchurch School of Medicine.
N Z Med J. 1998 Mar 13;111(1061):70-3.
(1) To assess the level of compliance of clinicians at Christchurch Hospital with published local guidelines for the diagnostic management of indeterminate lung scans and for the treatment of pulmonary embolism. (2) To evaluate diagnostic outcomes and the methods used to arrive at the diagnosis.
Retrospective case analysis of 94 consecutive cases of suspected pulmonary embolism referred for a lung scan after August 1993 and a further 70 consecutive cases referred after August 1995.
Few clinicians followed the recommendations for the further assessment of indeterminate lung scans. Pulmonary angiography was rarely performed and serial femoral ultrasound was never employed. The majority of patients diagnosed with pulmonary embolism did not have a high probability ventilation/perfusion (VQ) scan or a pulmonary angiogram to support the diagnosis. The use of heparin was overcautious and inconsistent. Major divergences from recommendations were observed in over 50% of cases in which heparin was used to treat pulmonary embolism.
This audit has uncovered a wide diversity of practice in many aspects of the assessment and management of pulmonary embolism and significant deviations from the published guidelines. Underutilisation of objective imaging methods for establishing the diagnosis implies overreliance on clinical impressions, which are known to be unreliable. A review of the guidelines and further educational initiatives are indicated.
（1）评估克赖斯特彻奇医院临床医生对已发布的关于不确定肺部扫描诊断管理及肺栓塞治疗的本地指南的遵循程度。（2）评估诊断结果及用于得出诊断的方法。
对1993年8月后转诊进行肺部扫描的94例连续疑似肺栓塞病例以及1995年8月后转诊的另外70例连续病例进行回顾性病例分析。
很少有临床医生遵循对不确定肺部扫描进行进一步评估的建议。很少进行肺血管造影，从未采用连续股静脉超声检查。大多数被诊断为肺栓塞的患者没有高概率通气/灌注（V/Q）扫描或肺血管造影来支持诊断。肝素的使用过于谨慎且不一致。在超过50%使用肝素治疗肺栓塞的病例中，观察到与建议存在重大偏差。
本次审核发现，在肺栓塞评估和管理的许多方面存在广泛的实践差异，且与已发布的指南存在显著偏差。在确立诊断时对客观成像方法利用不足意味着过度依赖已知不可靠的临床印象。需要对指南进行审查并开展进一步的教育活动。
