Adherència a les guies de pràctica clínica en el diagnòstic d'embolisme pulmonar en un Servei d'Urgències : impacte clínic d'una intervenció formativa

Abstract

Pulmonary embolism (PE) is a frequent cause of morbidity, mortality and hospitalization admittance. Clinical practice guidelines (CPG) implementation that use clinical prediction rules (CPR) and the D-dimer test (DD) to guide the realization of computed tomography pulmonary angiography (CT_PA) has been useful in improving sensitivity and diagnostic specificity. In spite of this, adherence to CPGs is low. In ED there are a significant admission increase in elderly populations. The variable and nonspecific presentation of PE and the possible association with other diseases can complicate and delay the diagnosis in this group of patients. The DD increases with patients' age, conditioning a low diagnostic specificity, generating an age-adjusted DD cut-off, which corresponds to the age x10 in patients older than 50 years. To ensure a quality management adjusted to CPG recommendations we should assumes an ED organization challenge. The aim of this study was to assess the change in adherence to CPGs on suspicion of EP of health professionals in ED after a training intervention for improvement, to assess the frequency of the diagnosis of EP, to know the effect of the age-adjusted DD and clinical features of patients with PE. A first retrospective observation was made of all patients admitted in 2012 with suspicion of PE in ED. In May-2015 a formative intervention was realized directed to homogenize the handling of the patients with suspicion of PE. Subsequently, a new observational retrospective analysis was carried out from June to November-2015 to evaluate the changes after the formative intervention. We included 785 patients with suspicion of PE in the first period and 256 in the second one. Mean age in the first period was 62. 22 years (18-97, SD 17. 65) and 69. 22 years (25-98, SD 16. 27) in the second one. In both periods more than half of patients included were women. The frequency of PE diagnosis was 8. 3% in the first period and 19. 5% in the second, with a 30-day mortality rate that dropped from 12. 7 to 6%. In both periods, the clinical presentation of the youngest patients with clinical suspicion of PE was pleuritic pain, meanwhile in elderly was dyspnea, tachypnea, edema and rales. Both samples are comparable in terms of associated pathologies and risk factors for presenting PE, being more frequent in the elderly group. The adherence to CPG in the evaluation of suspicions of EP in our ED before the formative intervention was higher than that described in the literature, with a progressive and significant decrease with age. In the second period, the compliance presenting a tendency to decrease with the increase of patients' age, without significant differences by age groups. The training intervention carried out has led to a substantial improvement in adherence (+14. 6%) in the diagnosis of PE in ED, being able to correct age effect on the degree of compliance. After formative intervention, consequence of the adherence increase in all ages and especially in elderly population, an important and significant increase in diagnostic sensitivity and PE diagnosis frequency with a decrease in the mortality The best performance of the CPG has also led to a more reasoned use of the applications of DD and CT-PA (improvement in specificity) with the associated benefits of decreasing the risks for patients and healthcare costs.

Date of Award	15 Oct 2018
Original language	English
Supervisor	Salvador Benito Vales (Director) & Mireia Puig Campmany (Director)