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Use of CT Pulmonary Angiograms (CTPA) in the Diagnosis of Pulmonary Embolism (PE) in the ED of a Community Hospital
Education, Research, and Quality Improvement SESSION TITLE: Education, Research, and Quality Improvement II SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 26, 2016 at 01:30 PM - 02:30 PM
Asad Shafiq MBBS* Muhammad Khan MBBS Najma Nawaz Amir Bista James Walsh; and Victor Kolade Guthrie Robert Packer Hospital, Sayre, PA PURPOSE: PE is one the most common medical emergencies. CTPA is considered investigation of choice for diagnosing PE and its use has rapidly increased since introduction. CTPA has potential harms, which include radiation exposure and possibility of detecting and treating clinically insignificant pulmonary emboli with anticoagulation. Current guidelines from multiple societies recommend against ordering CTPA in low risk patient population. Our study looks at the inappropriate use of CTPA through clinical risk stratification in the ED at time of initial presentation. METHODS: Adult patients who underwent a CTPA for suspicion of PE at initial presentation to the emergency department from January 1, 2014 to March 31, 2015 were retrospectively analyzed. Pregnant women and hemodynamically unstable patients (systolic blood pressure<90) were excluded. The CTPA was considered appropriate if Modified Wells score (MWS) was >4 or any score with positive d-dimer assay (>500). Definitive PE, questionable PE and sub-segmental PE on CTPA were considered positive while inconclusive or definitively negative studies were considered to be negative. Sensitivity, Specificity and negative predictive value (NPV) for D Dimer assay were calculated in low risk (MWS<¼4) and high-risk (MWS>4) patient population. RESULTS: A total of 396 patient charts were reviewed who underwent CTPA. 37.1% CTPA were inappropriately performed. Only 45 of the CTPA were actually positive out of which 89% (40) were appropriate studies while 11% (5) were inappropriate. DDimer was not performed in all the patients with pulmonary embolism and inappropriately performed CTPA. 40% of the positive CTPA that were inappropriate were read as questionable PE. 274 (69.2%) of total patients had D-dimer done, out of which 199 (72.6%) had positive d dimer. 95% confidence interval for NPV and sensitivity of D Dimer assay in patients with MWS of 4 or less was 94.56% to 100.00% and 79.41% to 100.00% respectively. CONCLUSIONS: In our study, more than one third of the CTPA ordered in the emergency department for diagnosis of Pulmonary embolism where inappropriate and are avoidable. CLINICAL IMPLICATIONS: We recommend adding electronic Health Record-Based decision making by integrating MWS for risk stratification and using d-dimer for low risk patient to encourage appropriate use of CTPA. This can help avoid excessive healthcare expenditures, radiation and contrast exposure, and bleeding associated with unnecessary anticoagulation. DISCLOSURE: The following authors have nothing to disclose: Asad Shafiq, Muhammad Khan, Najma Nawaz, Amir Bista, James Walsh, Victor Kolade No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.711
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
journal.publications.chestnet.org
619A
EDUCATION, RESEARCH, AND QUALITY IMPROVEMENT
Use of CT Pulmonary Angiograms (CTPA) in the Diagnosis of Pulmonary Embolism (PE) in the ED of a Community Hospital
Asad Shafiq MBBS* Muhammad Khan MBBS Najma Nawaz Amir Bista James Walsh; and Victor Kolade Guthrie Robert Packer Hospital, Sayre, PA PURPOSE: PE is one the most common medical emergencies. CTPA is considered investigation of choice for diagnosing PE and its use has rapidly increased since introduction. CTPA has potential harms, which include radiation exposure and possibility of detecting and treating clinically insignificant pulmonary emboli with anticoagulation. Current guidelines from multiple societies recommend against ordering CTPA in low risk patient population. Our study looks at the inappropriate use of CTPA through clinical risk stratification in the ED at time of initial presentation. METHODS: Adult patients who underwent a CTPA for suspicion of PE at initial presentation to the emergency department from January 1, 2014 to March 31, 2015 were retrospectively analyzed. Pregnant women and hemodynamically unstable patients (systolic blood pressure<90) were excluded. The CTPA was considered appropriate if Modified Wells score (MWS) was >4 or any score with positive d-dimer assay (>500). Definitive PE, questionable PE and sub-segmental PE on CTPA were considered positive while inconclusive or definitively negative studies were considered to be negative. Sensitivity, Specificity and negative predictive value (NPV) for D Dimer assay were calculated in low risk (MWS<¼4) and high-risk (MWS>4) patient population. RESULTS: A total of 396 patient charts were reviewed who underwent CTPA. 37.1% CTPA were inappropriately performed. Only 45 of the CTPA were actually positive out of which 89% (40) were appropriate studies while 11% (5) were inappropriate. DDimer was not performed in all the patients with pulmonary embolism and inappropriately performed CTPA. 40% of the positive CTPA that were inappropriate were read as questionable PE. 274 (69.2%) of total patients had D-dimer done, out of which 199 (72.6%) had positive d dimer. 95% confidence interval for NPV and sensitivity of D Dimer assay in patients with MWS of 4 or less was 94.56% to 100.00% and 79.41% to 100.00% respectively. CONCLUSIONS: In our study, more than one third of the CTPA ordered in the emergency department for diagnosis of Pulmonary embolism where inappropriate and are avoidable. CLINICAL IMPLICATIONS: We recommend adding electronic Health Record-Based decision making by integrating MWS for risk stratification and using d-dimer for low risk patient to encourage appropriate use of CTPA. This can help avoid excessive healthcare expenditures, radiation and contrast exposure, and bleeding associated with unnecessary anticoagulation. DISCLOSURE: The following authors have nothing to disclose: Asad Shafiq, Muhammad Khan, Najma Nawaz, Amir Bista, James Walsh, Victor Kolade No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.711
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
journal.publications.chestnet.org
619A
EDUCATION, RESEARCH, AND QUALITY IMPROVEMENT
Use of CT Pulmonary Angiograms (CTPA) in the Diagnosis of Pulmonary Embolism (PE) in the ED of a Community Hospital