Response to: The Emergency Department Utility of Simplify™ D-dimer to Exclude Pulmonary Embolism in Patients With Pleuritic Chest Pain

Introduction: Pulmonary embolism (PE) is a potentially life-threatening condition that is in the differential diagnosis of many emergency department (ED) presentations. However, no diagnostic code for suspected PE exists. Thus, identifying the population of patients undergoing PE workup from administrative data for use as a denominator in clinical research and quality improvement can be difficult. To overcome this, we used standardized triage complaint codes and investigations to develop search algorithms useful to identify patients undergoing PE workup from an administrative dataset. Our objective was to quantify the sensitivity, specificity, and case yield of these search algorithms in order to identify a superior search strategy. Methods: Hospital administrative data for adult patients (age ≥18 years), which included standardized triage complaint codes and ICD-10 diagnostic codes for PE, were obtained from four urban EDs between July 2013 to January 2015. Standardized triage complaint codes were evaluated for the proportion of patients diagnosed with PE. Combinations of high-yield presenting complaints, in combination with D-dimer testing or imaging orders, were evaluated for sensitivity, specificity, and predictive values for PE. Results: Of 479,937 patients presenting with 174 different complaints, 1,048 were diagnosed with PE. The best-performing search strategy was the combination of standardized CEDIS complaints of Cardiac Pain, Chest Pain (Cardiac Features), Chest Pain (Non-Cardiac Features), Shortness of Breath, Syncope/Pre-syncope, Hemoptysis, and Unilateral Swollen Limb/Pain, along with with D-dimer testing and/or CTPA, or V/Q scan. This combination captured 808 PE diagnoses for a sensitivity of 77.1% (95%CI 74.4-79.5%) and specificity of 86.8% (95%CI 86.7-86.6%). Conclusion: We identified a high-yield combination of presenting complaints and test ordering that can be used to define an ED population with suspected PE. This population of patients can be used as a denominator in research or quality improvement work that evaluates the utilization of diagnostic testing for PE.

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Use of Simplify D-Dimer in Emergency Department Patients With Pleuritic Chest Pain. (Response to LTE #2005-1083 Propp)

Annals of Emergency Medicine ◽

10.1016/j.annemergmed.2005.12.035 ◽

2006 ◽

Vol 47 (5) ◽

pp. 507

Author(s):

Kerstin Hogg ◽

Deborah Dawson ◽

Kevin Mackway-Jones

Keyword(s):

Emergency Department ◽

Chest Pain ◽

Pain Response ◽

Pleuritic Chest Pain ◽

Emergency Department Patients ◽

D Dimer

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Pleuritic chest pain: infection, infarction or musculoskeletal?

Acute Medicine Journal ◽

10.52964/amja.0014 ◽

2002 ◽

Vol 1 (2) ◽

pp. 64-66

Author(s):

S Gill ◽

◽

A Pope ◽

Keyword(s):

Pulmonary Embolism ◽

Chest Pain ◽

Initial Presentation ◽

Pulmonary Emboli ◽

Pleuritic Chest Pain ◽

X Ray ◽

Blood Tests ◽

Chest X Ray ◽

Initial Blood ◽

D Dimer

A 52 year old patient, originally thought to have musculoskeletal chest pain was found to have features consistent with infective pleurisy on initial blood tests and chest x-ray, with a negative d-dimer indicating a low likelihood of pulmonary embolism. Two weeks later he represented with continued symptoms and investigations revealed extensive pulmonary emboli, which were thought to have developed after his initial presentation.

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Information technology tools can automate imaging measures for Emergency Department patients with suspected pulmonary embolism

10.21203/rs.2.14724/v1 ◽

2019 ◽

Author(s):

Vlad I Valtchinov ◽

Ivan Ip ◽

Ramin Khorasani ◽

Laila Cochon ◽

Ronilda Lacson ◽

...

Keyword(s):

Emergency Department ◽

Pulmonary Embolism ◽

Chest Pain ◽

Language Processing ◽

Signs And Symptoms ◽

Pulmonary Angiography ◽

Audit And Feedback ◽

Pleuritic Chest Pain ◽

Suspected Pulmonary Embolism ◽

Ed Visits

Abstract CT pulmonary angiography (CTPA) utilization rates for patients with suspected pulmonary embolism (PE) in the Emergency Department (ED) have increased steadily with associated radiation exposure, costs and overdiagnosis. A new measure is needed to more precisely assess efficiency of CTPA utilization normalized to numbers of patients presenting with suspected PE, based on patient signs and symptoms. This study used natural language processing (NLP) to develop, automate, and validate SPE (“Suspected Pulmonary Embolism [PE]”), a measure determining CTPA utilization in ED patients with suspected PE. This retrospective study was conducted 4/1/2013-3/31/2014 in a Level-1 ED. A NLP engine processed “Chief Complaint” sections of ED documentation, identifying patients with PE-suggestive symptoms based on four Concept Unique Identifiers (CUIs: shortness of breath, chest pain, pleuritic chest pain, anterior pleuritic chest pain). SPE was defined as proportion of ED visits for patients with potential PE undergoing CTPA. Manual reviews determined specificity, sensitivity and negative predictive value (NPV). Among 5,768 ED visits with 1+SPE CUI, and 795 CTPAs performed, SPE=13.8% (795/5,768). NLP identified patients with relevant CUIs with specificity=0.94 [95%CI (0.89-0.96)]; sensitivity=0.73 [95%CI (0.45-0.92)]; NPV=0.98. Using NLP on ED documentation can identify patients with suspected PE to computate a more clinically-relevant CTPA measure. This measure might then be used in an audit-and-feedback process to increase the appropriateness of imaging of patients with suspected PE in the ED.

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Pulmonary embolism in patients attending the accident and emergency department with pleuritic chest pain.

Emergency Medicine Journal ◽

10.1136/emj.8.1.48 ◽

1991 ◽

Vol 8 (1) ◽

pp. 48-51 ◽

Cited By ~ 4

Author(s):

L Thomas ◽

M Reichl

Keyword(s):

Emergency Department ◽

Pulmonary Embolism ◽

Chest Pain ◽

Pleuritic Chest Pain ◽

Accident And Emergency ◽

Accident And Emergency Department

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Wells’ Score in Diagnosis of Pulmonary Embolism in Patient with Thrombocytopenia: A Case Report

Serbian Journal of Experimental and Clinical Research ◽

10.1515/sjecr-2017-0061 ◽

2019 ◽

Vol 20 (3) ◽

pp. 281-285

Author(s):

Dragan Panic ◽

Andreja Todorovic ◽

Milica Stanojevic ◽

Violeta Iric Cupic

Keyword(s):

Pulmonary Embolism ◽

Chest Pain ◽

Acute Pulmonary Embolism ◽

Pretest Probability ◽

Clinical Prediction ◽

Clinical Prediction Rules ◽

Prediction Rules ◽

Clinical Probability ◽

Wells Score ◽

D Dimer

Abstract Current diagnostic workup of patients with suspected acute pulmonary embolism (PE) usually starts with the assessment of clinical pretest probability, using clinical prediction rules and plasma D-dimer measurement. Although an accurate diagnosis of acute pulmonary embolism (PE) in patients is thus of crucial importance, the diagnostic management of suspected PE is still challenging. A 60-year-old man with chest pain and expectoration of blood was admitted to the Department of Cardiology, General Hospital in Cuprija, Serbia. After physical examination and laboratory analyses, the diagnosis of Right side pleuropne monia and acute pulmonary embolism was established. Clinically, patient was hemodynamically stable, auscultative slightly weaker respiratory sound right basal, without pretibial edema. Laboratory: C-reactive protein (CRP) 132.9 mg/L, Leukocytes (Le) 18.9x109/L, Erythrocytes (Er) 3.23x1012/L, Haemoglobin (Hgb) 113 g/L, Platelets (Plt) 79x109/L, D-dimer 35.2. On the third day after admission, D-dimer was increased and platelet count was decreased (Plt up to 62x109/L). According to Wells’ rules, score was 2.5 (without symptoms on admission), a normal clinical finding with clinical manifestation of hemoptysis and chest pain, which represents the intermediate level of clinical probability of PE. After the recidive of PE, Wells’ score was 6.5. In summary, this study suggests that Wells’ score, based on a patient’s risk for pulmonary embolism, is a valuable guidance for decision-making in combination with knowledge and experience of clinicians. Clinicians should use validated clinical prediction rules to estimate pretest probability in patients in whom acute PE is being consiered.

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