College statement on “Know the Score – a review of the quality of care provided to patients aged over 16 years with a new diagnosis of pulmonary embolism”

A review of the care provided to patients diagnosed with pulmonary embolism has been released by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD). NCEPOD is an independent body to which a corporate commitment has been made by the Medical and Surgical Royal Colleges, Associations and Facilities related to its area of activity.

The review noted there are key steps to effective care for patients, which are prevention, prompt diagnosis and treatment:

  • Prevention of healthcare-related deep vein thrombosis includes the use of anticoagulants or mechanical methods.
  • CT Pulmonary Angiography is commonly used to diagnose pulmonary embolism. To be effective, this service should be available promptly in all hospitals, especially out-of-hours.
  • The standard treatment is anticoagulation. Inadequate monitoring of some anticoagulant medications can lead to under-treatment of pulmonary embolism or adverse effects such as excessive bleeding.

It was also highlighted in the review that one delay or more in the process of care was identified in 161 out of 420 patients, with recognition, investigations and treatment being the most common. Where there is a delay to the diagnosis of acute pulmonary embolism, anticoagulation should be commenced. In a study undertaken, case reviewers reported an avoidable delay in commencing treatment in 90 out of 491 patients.

The Principal Recommendations from this review are:

  1. Give an interim dose of anticoagulant to patients suspected of having an acute pulmonary embolism (unless contraindicated) when confirmation of the diagnosis is expected to be delayed by more than one hour.
  2. Document the severity of acute pulmonary embolism immediately after the confirmation of diagnosis.
  3. Standardise CT pulmonary angiogram reporting. The proforma should include the presence or absence of right ventricular strain.
  4. Look for indicators of massive (high-risk) or sub-massive (intermediate-risk) pulmonary embolism, in addition to calculating the severity of acute pulmonary embolism.
  5. Assess patient suspected of having an acute pulmonary embolism for their suitability for ambulatory care and document the rationale for selecting or excluding it in the clinical notes.
  6. Provide every patient with an acute pulmonary embolism with a follow-up plan, patient information leaflet and a discharge letter.
  7. Calculate the clinical probability pf pulmonary embolism in all patients presenting to hospital with a suspected new diagnosis of pulmonary embolism using a validated score, such as the “Wells’ Score”.
  8. Ensure there are hospital protocols/guidance for assessing the severity of pulmonary embolism soon after diagnosis confirmation.
  9. Ensure there is a robust system in place to alert the clinician who requested a CTPA or V/Q scan or V/Q SPECT scan of any amendments or updates to the report.
  10. Develop and document a monitoring and treatment escalation plan for and with all patients diagnosed with acute pulmonary embolism.
  11. Document whether the inferior vena cava filter inserted into a patient with pulmonary embolism is intended to be permanent or temporary.
  12. Ensure an ambulatory care pathway is available seven days a week at all hospitals where patients with an acute pulmonary embolism present.
  13. Formalise pulmonary embolism treatment networks for access to catheter-directed thrombolysis, surgical embolectomy or mechanical thrombectomy for the treatment of patients with pulmonary embolism who either fail to improve or have absolute contraindications to systemic thrombolysis.

You can read the full review on the National Confidential Enquiry into Patient Outcome and Death's website.

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