ObjectivesAn evidence-based pathway for pulmonary embolism testing was implemented in two academic emergency departments as part of a prospective management study (the PEGeD study). This study aimed to identify factors associated with emergency physicians not following (deviating from) the PEGeD pulmonary embolism testing pathway.MethodsThis was a health records review of cases from the PEGeD study which enrolled emergency patients with suspected pulmonary embolism. Emergency physicians documented the Wells score on hard-copy PEGeD pathway forms which guided the use of diagnostic imaging. Patient visits were classified as having pulmonary embolism testing adhering to or else deviating from the PEGeD pathway. Patient data were collected from electronic medical records. We calculated adjusted odds ratios (aORs) for prespecified predictors of deviation: patient age, patient sex, arrival day of week, arrival time of day, documented hypotension, higher Canadian Triage and Acuity Score (CTAS) allocation, active cancer, and a history of venous thromboembolism. The multivariable logistical regression analysis was clustered by individual physician.ResultsIn total 1570 PEGeD forms were received, 78 were excluded and 1492 patients were included for analysis. The mean age was 55, 62% female, 27% presented at the weekend, 44% presented after 4 pm, 19% with cancer history, 13% with prior venous thromboembolism, 3% had a systolic blood pressure less than 100 mmHg and 46% had a CTAS score of 1 or 2. The treating physician deviated from the PEGeD pathway in 81/1492 (5.4%, 95% CI 4.4, 6.7%)) patients, of whom 7 were diagnosed with pulmonary embolism. Deviation from the PEGeD pathway was associated with a CTAS score of 1 or 2 (aOR 2.02; 1.26, 3.24) and prior venous thromboembolism (aOR 1.85; 1.04, 3.30).ConclusionsEmergency physician deviated from the PEGeD pathway infrequently. Physicians should question whether imaging is needed when D-dimer blood testing has already excluded pulmonary embolism.ObjectifsUne voie de d & eacute;pistage fond & eacute;e sur des donn & eacute;es probantes pour les tests d'embolie pulmonaire a & eacute;t & eacute; mise en oe uvre dans deux services universitaires d'urgence dans le cadre d'une & eacute;tude prospective de gestion (l'& eacute;tude PEGeD). Cette & eacute;tude visait & agrave; identifier les facteurs associ & eacute;s aux m & eacute;decins d'urgence qui ne suivent pas (s'& eacute;cartent de) la voie de test de l'embolie pulmonaire PEGeD.M & eacute;thodesIl s'agissait d'un examen des dossiers de sant & eacute; portant sur les cas de l'& eacute;tude PEGeD qui a inclus des patients en urgence avec une suspicion d'embolie pulmonaire. Les m & eacute;decins urgentistes ont document & eacute; le score de Wells sur des formulaires de voie PEGeD papier qui ont guid & eacute; l'utilisation de l'imagerie diagnostique. Les visites de patients ont & eacute;t & eacute; class & eacute;es comme ayant des tests d'embolie pulmonaire adh & eacute;rant ou s'& eacute;cartant de la voie PEGeD. Les donn & eacute;es des patients ont & eacute;t & eacute; recueillies & agrave; partir de dossiers m & eacute;dicaux & eacute;lectroniques. Nous avons calcul & eacute; les rapports de cotes ajust & eacute;s (aORs) pour des pr & eacute;dicteurs pr & eacute;d & eacute;termin & eacute;s de l'& eacute;cart : & acirc;ge du patient, sexe du patient, jour d'arriv & eacute;e de la semaine, heure d'arriv & eacute;e de la journ & eacute;e, hypotension document & eacute;e, allocation plus & eacute;lev & eacute;e selon le Canadian Triage and Acuity Score (CTAS), cancer actif, et des ant & eacute;c & eacute;dents de thromboembolie veineuse. L'analyse de r & eacute;gression logistique multivariable a & eacute;t & eacute; regroup & eacute;e par m & eacute;decin individuel.R & eacute;sultatsAu total, 1570 formulaires PEGeD ont & eacute;t & eacute; re & ccedil;us, 78 ont & eacute;t & eacute; exclus et 1492 patients ont & eacute;t & eacute; inclus pour l'analyse. L'& acirc;ge moyen & eacute;tait de 55 ans, 62 % femmes, 27 % pr & eacute;sentaient une thrombose veineuse ant & eacute;rieure, 44 % apr & egrave;s 16 h, 19 % avaient des ant & eacute;c & eacute;dents de cancer, 3 % avaient une pression art & eacute;rielle systolique inf & eacute;rieure & agrave; 100 mmHg et 46 % avaient un score CTAS de 1 ou 2. Le m & eacute;decin traitant s'est & eacute;cart & eacute; de la voie PEGeD dans 81/1492 (5,4 %, IC & agrave; 95 % 4,4, 6,7 %)) des patients, dont 7 ont & eacute;t & eacute; diagnostiqu & eacute;s avec une embolie pulmonaire. La d & eacute;viation par rapport & agrave; la voie PEGeD & eacute;tait associ & eacute;e & agrave; un score CTAS de 1 ou 2 (aOR 2,02; 1,26, 3,24) et & agrave; une thromboembolie veineuse ant & eacute;rieure (aOR 1,85; 1,04, 3,30).ConclusionsLe m & eacute;decin urgentiste s'est & eacute;cart & eacute; de la voie PEGeD peu fr & eacute;quemment. Les m & eacute;decins devraient se demander si l'imagerie est n & eacute;cessaire lorsque le test sanguin D-dim & egrave;re a d & eacute;j & agrave; exclu l'embolie pulmonaire.
Predictors of emergency physician adherence to standardized pulmonary embolism testing
Germini, Federico;
2025-01-01
Abstract
ObjectivesAn evidence-based pathway for pulmonary embolism testing was implemented in two academic emergency departments as part of a prospective management study (the PEGeD study). This study aimed to identify factors associated with emergency physicians not following (deviating from) the PEGeD pulmonary embolism testing pathway.MethodsThis was a health records review of cases from the PEGeD study which enrolled emergency patients with suspected pulmonary embolism. Emergency physicians documented the Wells score on hard-copy PEGeD pathway forms which guided the use of diagnostic imaging. Patient visits were classified as having pulmonary embolism testing adhering to or else deviating from the PEGeD pathway. Patient data were collected from electronic medical records. We calculated adjusted odds ratios (aORs) for prespecified predictors of deviation: patient age, patient sex, arrival day of week, arrival time of day, documented hypotension, higher Canadian Triage and Acuity Score (CTAS) allocation, active cancer, and a history of venous thromboembolism. The multivariable logistical regression analysis was clustered by individual physician.ResultsIn total 1570 PEGeD forms were received, 78 were excluded and 1492 patients were included for analysis. The mean age was 55, 62% female, 27% presented at the weekend, 44% presented after 4 pm, 19% with cancer history, 13% with prior venous thromboembolism, 3% had a systolic blood pressure less than 100 mmHg and 46% had a CTAS score of 1 or 2. The treating physician deviated from the PEGeD pathway in 81/1492 (5.4%, 95% CI 4.4, 6.7%)) patients, of whom 7 were diagnosed with pulmonary embolism. Deviation from the PEGeD pathway was associated with a CTAS score of 1 or 2 (aOR 2.02; 1.26, 3.24) and prior venous thromboembolism (aOR 1.85; 1.04, 3.30).ConclusionsEmergency physician deviated from the PEGeD pathway infrequently. Physicians should question whether imaging is needed when D-dimer blood testing has already excluded pulmonary embolism.ObjectifsUne voie de d & eacute;pistage fond & eacute;e sur des donn & eacute;es probantes pour les tests d'embolie pulmonaire a & eacute;t & eacute; mise en oe uvre dans deux services universitaires d'urgence dans le cadre d'une & eacute;tude prospective de gestion (l'& eacute;tude PEGeD). Cette & eacute;tude visait & agrave; identifier les facteurs associ & eacute;s aux m & eacute;decins d'urgence qui ne suivent pas (s'& eacute;cartent de) la voie de test de l'embolie pulmonaire PEGeD.M & eacute;thodesIl s'agissait d'un examen des dossiers de sant & eacute; portant sur les cas de l'& eacute;tude PEGeD qui a inclus des patients en urgence avec une suspicion d'embolie pulmonaire. Les m & eacute;decins urgentistes ont document & eacute; le score de Wells sur des formulaires de voie PEGeD papier qui ont guid & eacute; l'utilisation de l'imagerie diagnostique. Les visites de patients ont & eacute;t & eacute; class & eacute;es comme ayant des tests d'embolie pulmonaire adh & eacute;rant ou s'& eacute;cartant de la voie PEGeD. Les donn & eacute;es des patients ont & eacute;t & eacute; recueillies & agrave; partir de dossiers m & eacute;dicaux & eacute;lectroniques. Nous avons calcul & eacute; les rapports de cotes ajust & eacute;s (aORs) pour des pr & eacute;dicteurs pr & eacute;d & eacute;termin & eacute;s de l'& eacute;cart : & acirc;ge du patient, sexe du patient, jour d'arriv & eacute;e de la semaine, heure d'arriv & eacute;e de la journ & eacute;e, hypotension document & eacute;e, allocation plus & eacute;lev & eacute;e selon le Canadian Triage and Acuity Score (CTAS), cancer actif, et des ant & eacute;c & eacute;dents de thromboembolie veineuse. L'analyse de r & eacute;gression logistique multivariable a & eacute;t & eacute; regroup & eacute;e par m & eacute;decin individuel.R & eacute;sultatsAu total, 1570 formulaires PEGeD ont & eacute;t & eacute; re & ccedil;us, 78 ont & eacute;t & eacute; exclus et 1492 patients ont & eacute;t & eacute; inclus pour l'analyse. L'& acirc;ge moyen & eacute;tait de 55 ans, 62 % femmes, 27 % pr & eacute;sentaient une thrombose veineuse ant & eacute;rieure, 44 % apr & egrave;s 16 h, 19 % avaient des ant & eacute;c & eacute;dents de cancer, 3 % avaient une pression art & eacute;rielle systolique inf & eacute;rieure & agrave; 100 mmHg et 46 % avaient un score CTAS de 1 ou 2. Le m & eacute;decin traitant s'est & eacute;cart & eacute; de la voie PEGeD dans 81/1492 (5,4 %, IC & agrave; 95 % 4,4, 6,7 %)) des patients, dont 7 ont & eacute;t & eacute; diagnostiqu & eacute;s avec une embolie pulmonaire. La d & eacute;viation par rapport & agrave; la voie PEGeD & eacute;tait associ & eacute;e & agrave; un score CTAS de 1 ou 2 (aOR 2,02; 1,26, 3,24) et & agrave; une thromboembolie veineuse ant & eacute;rieure (aOR 1,85; 1,04, 3,30).ConclusionsLe m & eacute;decin urgentiste s'est & eacute;cart & eacute; de la voie PEGeD peu fr & eacute;quemment. Les m & eacute;decins devraient se demander si l'imagerie est n & eacute;cessaire lorsque le test sanguin D-dim & egrave;re a d & eacute;j & agrave; exclu l'embolie pulmonaire.I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
