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CT pulmonary angiography and perfusion imaging for the diagnosis of pulmonary embolism in pregnancy: a multi-cycle audit
Clinical Radiology 71 (2016) S11eS25
Contents lists available at ScienceDirect
Clinical Radiology journal homepage: www.clinicalradiologyonline.net
Audit Poster Competition
CT pulmonary angiography and perfusion imaging for the diagnosis of pulmonary embolism in pregnancy: a multi-cycle audit Authors: Neeral Patel, Rama Vancheeswaran, Nolan Walker, Ioanna Papadopolou, Claire Shakespeare, Fraser Ingham, Samanjit Hare, Pamini Santhiramogan, Hugo Farne, Thomas Peter-Campbell, Derfel Ap Dafydd Background to the audit: Pulmonary embolism (PE) in pregnancy is a major patient safety issue for the NHS. The clinical assessment of PE in pregnancy is difficult while computed tomography pulmonary angiogram (CTPA) and isotope perfusion scans expose both mother and foetus to ionising radiation. Standard: Royal College of Obstetricians and Gynaecologists (RCOG) guidelines indicate a combination of chest radiograph (CXR) and duplex Doppler ultrasound (DDU) of the lower limbs should be performed prior to CTPA/perfusion scan.1 Indicator: Percentage of patients who had a CXR and DDU prior to CTPA/ perfusion scan. Target: 100% of patients should have CXR and DDU prior to CTPA/perfusion scan. Methodology: A retrospective review of pregnant patients who had CTPA or perfusion scan performed over a two-year period between 2010e2012 at Barnet and Chase Farm Hospitals (BCFH). The audit was repeated in 2012 and 2013 to determine change in practice. Results of 1st audit round: 57 pregnant patients underwent CTPA (35%) or perfusion scan (65%) between 2010e2012. 81% of patients had a CXR and 68% underwent DDU prior to further imaging. Overall adherence to the guidelines was 56%. 1st action plan: 1. Co-ordinate with clinical teams in reiterating the importance of initial basic investigations. 2. Update local trust protocol for the investigation of PE in pregnancy. 3. Involve radiology superintendents to ensure patients are being selected for the appropriate imaging modality. Results of 2nd audit round: Between 2012e2013 and 2013e2014 there was 74% and 69% adherence respectively to RCOG guidelines. 2nd action plan: Initial improvement in compliance proceeded by deterioration possibly due to a recent hospital merger and migration of staff/ services between BCFH and Royal Free Hospital. 1. Re-implementation of initial action plan to ensure all new staff members are following guidance. 2. Repeat audit to determine change of practice between 2014e2015 (nearing completion). References: 1. Royal College of Obstetricians and Gynaecologists. Thromboembolic disease in pregnancy and the puerperium: acute management. London: Royal College of Obstetricians and Gynaecologists, 2015. CTPA; can we say no to a raised d-dimer? Authors: Eilidh Dempster, Dilrukshi Gunatillake, Uditha Kumarasena
Background to the audit: Radiologists in our trust noticed increasing use of computed tomography pulmonary angiography (CTPA) to investigate pulmonary embolism (PE) with a high negative yield. Unnecessary imaging is harmful to patients with contrast and radiation risks and prevents more appropriate use of healthcare worker and CT scanner time. Objectives: 1. Determine if CTPAs are performed appropriately and the positive diagnostic yield. 2. Identify strategies to reduce the number of negative CTPAs performed. Standard: Accepted standards suggest CTPA should detect PE in 15.4e37.4% of patients and alternative diagnoses in up to 56%.1 Indicator: Percentage of patients with PE confirmed on CTPA. Target: 20% of CTPAs positive for PE with alternative diagnoses in 50%. Methodology: CTPA requests and reports were retrospectively analysed for all CTPAs performed between 2 September 2012e31 October 2012 and 1 October 2015e30 November 2015. Results of 1st audit round: 89 CTPAs were performed: 22.5% were positive for PE, 43% were normal, 34.5% suggested alternative diagnoses. 1st action plan: Introduction of a local CTPA guideline based on clinical assessment, Wells Score and d-dimer. Results of 2nd audit round: 160 CTPAs were performed: 15.6% were positive for PE, 38.1% were normal, 46.3% suggested alternative diagnoses. 118 CTPAs were in line with the new guideline. 21 ‘inappropriate’ CTPAs were justified by extenuating circumstances. Six inappropriate CTPAs were authorised by an out-of-hours outsourced service. 2nd action plan: 1. Update the guideline to avoid out of hours CTPA unless the patient is in extremis and requires consultant-to-consultant referral for patients aged <50. 2. Review age adjusted d-dimer as a method of reducing false positive ddimers used to justify CTPA. In determining clinical probability of venous thromboembolism, this has been shown to increase specificity without impacting sensitivity.2 In our study 21 CTPAs could have been prevented, with one false negative. References: 1. The Royal College of Radiologists. iRefer: making the best use of clinical radiology, seventh edition. London: The Royal College of Radiologists, 2012. 2. Shouten HJ, Geersing GJ, Koek HL, et al. Diagnostic accuracy of conventional or age-adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis. BMJ 2013; 346: f2492. iRefer: are abdominal X-ray guidelines being followed? Authors: Richard Flood, Madeline Strugnell, Georgina Moritz Background to the audit: Abdominal radiographs (AXR) are commonly requested, an AXR is the radiation dose equivalent of 31 chest radiographs.1 AXR are often ordered without a valid clinical indication and often followed by computed tomography (CT). Our aim was to audit AXR use and to improve compliance with The Royal College of Radiologist (RCR) guidelines.2
Contents lists available at ScienceDirect
Clinical Radiology journal homepage: www.clinicalradiologyonline.net
Audit Poster Competition
CT pulmonary angiography and perfusion imaging for the diagnosis of pulmonary embolism in pregnancy: a multi-cycle audit Authors: Neeral Patel, Rama Vancheeswaran, Nolan Walker, Ioanna Papadopolou, Claire Shakespeare, Fraser Ingham, Samanjit Hare, Pamini Santhiramogan, Hugo Farne, Thomas Peter-Campbell, Derfel Ap Dafydd Background to the audit: Pulmonary embolism (PE) in pregnancy is a major patient safety issue for the NHS. The clinical assessment of PE in pregnancy is difficult while computed tomography pulmonary angiogram (CTPA) and isotope perfusion scans expose both mother and foetus to ionising radiation. Standard: Royal College of Obstetricians and Gynaecologists (RCOG) guidelines indicate a combination of chest radiograph (CXR) and duplex Doppler ultrasound (DDU) of the lower limbs should be performed prior to CTPA/perfusion scan.1 Indicator: Percentage of patients who had a CXR and DDU prior to CTPA/ perfusion scan. Target: 100% of patients should have CXR and DDU prior to CTPA/perfusion scan. Methodology: A retrospective review of pregnant patients who had CTPA or perfusion scan performed over a two-year period between 2010e2012 at Barnet and Chase Farm Hospitals (BCFH). The audit was repeated in 2012 and 2013 to determine change in practice. Results of 1st audit round: 57 pregnant patients underwent CTPA (35%) or perfusion scan (65%) between 2010e2012. 81% of patients had a CXR and 68% underwent DDU prior to further imaging. Overall adherence to the guidelines was 56%. 1st action plan: 1. Co-ordinate with clinical teams in reiterating the importance of initial basic investigations. 2. Update local trust protocol for the investigation of PE in pregnancy. 3. Involve radiology superintendents to ensure patients are being selected for the appropriate imaging modality. Results of 2nd audit round: Between 2012e2013 and 2013e2014 there was 74% and 69% adherence respectively to RCOG guidelines. 2nd action plan: Initial improvement in compliance proceeded by deterioration possibly due to a recent hospital merger and migration of staff/ services between BCFH and Royal Free Hospital. 1. Re-implementation of initial action plan to ensure all new staff members are following guidance. 2. Repeat audit to determine change of practice between 2014e2015 (nearing completion). References: 1. Royal College of Obstetricians and Gynaecologists. Thromboembolic disease in pregnancy and the puerperium: acute management. London: Royal College of Obstetricians and Gynaecologists, 2015. CTPA; can we say no to a raised d-dimer? Authors: Eilidh Dempster, Dilrukshi Gunatillake, Uditha Kumarasena
Background to the audit: Radiologists in our trust noticed increasing use of computed tomography pulmonary angiography (CTPA) to investigate pulmonary embolism (PE) with a high negative yield. Unnecessary imaging is harmful to patients with contrast and radiation risks and prevents more appropriate use of healthcare worker and CT scanner time. Objectives: 1. Determine if CTPAs are performed appropriately and the positive diagnostic yield. 2. Identify strategies to reduce the number of negative CTPAs performed. Standard: Accepted standards suggest CTPA should detect PE in 15.4e37.4% of patients and alternative diagnoses in up to 56%.1 Indicator: Percentage of patients with PE confirmed on CTPA. Target: 20% of CTPAs positive for PE with alternative diagnoses in 50%. Methodology: CTPA requests and reports were retrospectively analysed for all CTPAs performed between 2 September 2012e31 October 2012 and 1 October 2015e30 November 2015. Results of 1st audit round: 89 CTPAs were performed: 22.5% were positive for PE, 43% were normal, 34.5% suggested alternative diagnoses. 1st action plan: Introduction of a local CTPA guideline based on clinical assessment, Wells Score and d-dimer. Results of 2nd audit round: 160 CTPAs were performed: 15.6% were positive for PE, 38.1% were normal, 46.3% suggested alternative diagnoses. 118 CTPAs were in line with the new guideline. 21 ‘inappropriate’ CTPAs were justified by extenuating circumstances. Six inappropriate CTPAs were authorised by an out-of-hours outsourced service. 2nd action plan: 1. Update the guideline to avoid out of hours CTPA unless the patient is in extremis and requires consultant-to-consultant referral for patients aged <50. 2. Review age adjusted d-dimer as a method of reducing false positive ddimers used to justify CTPA. In determining clinical probability of venous thromboembolism, this has been shown to increase specificity without impacting sensitivity.2 In our study 21 CTPAs could have been prevented, with one false negative. References: 1. The Royal College of Radiologists. iRefer: making the best use of clinical radiology, seventh edition. London: The Royal College of Radiologists, 2012. 2. Shouten HJ, Geersing GJ, Koek HL, et al. Diagnostic accuracy of conventional or age-adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis. BMJ 2013; 346: f2492. iRefer: are abdominal X-ray guidelines being followed? Authors: Richard Flood, Madeline Strugnell, Georgina Moritz Background to the audit: Abdominal radiographs (AXR) are commonly requested, an AXR is the radiation dose equivalent of 31 chest radiographs.1 AXR are often ordered without a valid clinical indication and often followed by computed tomography (CT). Our aim was to audit AXR use and to improve compliance with The Royal College of Radiologist (RCR) guidelines.2