Dataset Information

Systematic screening versus clinical gestalt in the diagnosis of pulmonary embolism in COVID-19 patients in the emergency department.

ABSTRACT:

Background

Diagnosing concomitant pulmonary embolism (PE) in COVID-19 patients remains challenging. As such, PE may be overlooked. We compared the diagnostic yield of systematic PE-screening based on the YEARS-algorithm to PE-screening based on clinical gestalt in emergency department (ED) patients with COVID-19.

Methods

We included all ED patients who were admitted because of COVID-19 between March 2020 and February 2021. Patients already receiving anticoagulant treatment were excluded. Up to April 7, 2020, the decision to perform CT-pulmonary angiography (CTPA) was based on physician's clinical gestalt (clinical gestalt cohort). From April 7 onwards, systematic PE-screening was performed by CTPA if D-dimer level was ≥1000 ug/L, or ≥500 ug/L in case of ≥1 YEARS-item (systematic screening cohort).

Results

1095 ED patients with COVID-19 were admitted. After applying exclusion criteria, 289 were included in the clinical gestalt and 574 in the systematic screening cohort. The number of PE diagnoses was significantly higher in the systematic screening cohort compared to the clinical gestalt cohort: 8.2% vs. 1.0% (3/289 vs. 47/574; p<0.001), even after adjustment for differences in patient characteristics (adjusted OR 8.45 (95%CI 2.61-27.42, p<0.001) for PE diagnosis). In multivariate analysis, D-dimer (OR 1.09 per 1000 μg/L increase, 95%CI 1.06-1.13, p<0.001) and CRP >100 mg/L (OR 2.78, 95%CI 1.37-5.66, p = 0.005) were independently associated with PE.

Conclusion

In ED patients with COVID-19, the number of PE diagnosis was significantly higher in the cohort that underwent systematic PE screening based on the YEARS-algorithm in comparison with the clinical gestalt cohort, with a number needed to test of 7.1 CTPAs to detect one PE.

SUBMITTER: Luu IHY

PROVIDER: S-EPMC10035852 | biostudies-literature | 2023

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Systematic screening versus clinical gestalt in the diagnosis of pulmonary embolism in COVID-19 patients in the emergency department.

Luu Inge H Y IHY Frijns Tim T Buijs Jacqueline J Krdzalic Jasenko J de Kruif Martijn D MD Mostard Guy J M GJM Ten Cate Hugo H Martens Remy J H RJH Mostard Remy L M RLM Leers Math P G MPG van Twist Daan J L DJL

PloS one 20230323 3

<h4>Background</h4>Diagnosing concomitant pulmonary embolism (PE) in COVID-19 patients remains challenging. As such, PE may be overlooked. We compared the diagnostic yield of systematic PE-screening based on the YEARS-algorithm to PE-screening based on clinical gestalt in emergency department (ED) patients with COVID-19.<h4>Methods</h4>We included all ED patients who were admitted because of COVID-19 between March 2020 and February 2021. Patients already receiving anticoagulant treatment were ex ...[more]

PMID: 36952456

Similar Datasets

Project description:ObjectivesWhile our understanding of coronavirus disease 2019 (COVID-19) has evolved, uncertainty remains regarding utility of previously established pulmonary embolism (PE) screening guidelines in patients with COVID-19. Many studies have investigated the efficacy of D-dimer (DD) screenings for patients with COVID-19 admitted to inpatient services, but few have evaluated patients in the emergency department (ED). The purpose of this study was to investigate utility of DD threshold for PE screening in patients with COVID-19 presenting to the ED.MethodsThis was a retrospective, multicenter cohort including patients presenting to three EDs between March 1, 2020 and February 1, 2021 who tested positive for COVID-19 during ED visit or in 60 days prior to presentation and had DD ordered in ED. Patients were grouped by those who underwent computed tomography pulmonary angiogram (CTPA) to evaluate for PE and those who did not, and descriptive statistics were performed. Those who underwent CTPA were further divided into PE-positive and PE-negative groups. The discriminative ability of DD in predicting PE in patients with COVID-19 was analyzed using the receiver operating characteristic (ROC) curve.ResultsA total of 570 patients with COVID-19 were included in the study, of which 107 underwent CTPA to evaluate for PE. History of diabetes, elevated glucose, elevated lactate dehydrogenase, elevated white blood cell count, elevated platelets, elevated respiratory rate, and lower temperature were associated with increased risk for PE. Compared to those without PE, patients with PE were significantly more likely to be hospitalized (100% vs. 82%, p = 0.020) and admitted to the ICU (64% vs. 24%, p = 0.002). Those with PE had a significantly higher median DD value (21,177 ng/mL) compared to PE-negative group (952 ng/mL, p < 0.001). The ROC curve for DD in predicting PE had an area under the curve of 0.91 (95% confidence interval [0.84, 0.98]). In our study population, the optimal DD threshold for predicting PE was 1815 ng/mL (sensitivity 93% and specificity 80%). A conservative threshold of 1089 ng/mL could be used with sensitivity 100% and specificity 58%.ConclusionDD is often elevated in patients with COVID-19, regardless of PE. While the classically used DD cutoff is 500 ng/mL, our study demonstrated a threshold of 1089 ng/mL safely predicted PE in patients with COVID-19 .

Project description:ObjectivesTo identify which level of D-dimer would allow the safe exclusion of pulmonary embolism (PE) in COVID-19 patients presenting to the emergency department (ED).MethodsThis retrospective study was conducted on the COVID database of Assistance Publique - Hôpitaux de Paris (AP-HP). COVID-19 patients who presented at the ED of AP-HP hospitals between March 1 and May 15, 2020, and had CTPA following D-dimer dosage within 48h of presentation were included. The D-dimer sensitivity, specificity, and positive and negative predictive values were calculated for different D-dimer thresholds, as well as the false-negative and failure rates, and the number of CTPAs potentially avoided.ResultsA total of 781 patients (mean age 62.0 years, 53.8% men) with positive RT-PCR for SARS-Cov-2 were included and 60 of them (7.7%) had CTPA-confirmed PE. Their median D-dimer level was significantly higher than that of patients without PE (4,013 vs 1,198 ng·mL-1, p < 0.001). Using 500 ng·mL-1, or an age-adjusted cut-off for patients > 50 years, the sensitivity and the NPV were above 90%. With these thresholds, 17.1% and 31.5% of CTPAs could have been avoided, respectively. Four of the 178 patients who had a D-dimer below the age-adjusted cutoff had PE, leading to an acceptable failure rate of 2.2%. Using higher D-dimer cut-offs could have avoided more CTPAs, but would have lowered the sensitivity and increased the failure rate.ConclusionThe same D-Dimer thresholds as those validated in non-COVID outpatients should be used to safely rule out PE.Key points• The median D-dimer level was significantly higher in COVID-19 patients with PE as compared to those without PE (4,013 ng·mL-1 vs 1,198 ng·mL-1 respectively, p < 0.001). • Using 500 ng·mL-1, or an age-adjusted D-dimer cut-off to exclude pulmonary embolism, the sensitivity and negative predictive value were above 90%. • Higher cut-offs would lead to a reduction in the sensitivity below 85% and an increase in the failure rate, especially for patients under 50 years.

Project description:IntroductionMany emergency department (ED) patients with acute pulmonary embolism (PE) who meet low-risk criteria may be eligible for a short length of stay (LOS) (<24 hours), with expedited discharge home either directly from the ED or after a brief observation or hospitalization. We describe the association between expedited discharge and site of discharge on care satisfaction and quality of life (QOL) among patients with low-risk PE (PE Severity Index [PESI] Classes I-III).MethodsThis phone survey was conducted from September 2014 through April 2015 as part of a retrospective cohort study across 21 community EDs in Northern California. We surveyed low-risk patients with acute PE, treated predominantly with enoxaparin bridging and warfarin. All eligible patients were called 2-8 weeks after their index ED visit. PE-specific, patient-satisfaction questions addressed overall care, discharge instruction clarity, and LOS. We scored physical and mental QOL using a modified version of the validated Short Form Health Survey. Satisfaction and QOL were compared by LOS. For those with expedited discharge, we compared responses by site of discharge: ED vs. hospital, which included ED-based observation units. We used chi-square and Wilcoxon rank-sum tests as indicated.ResultsSurvey response rate was 82.3% (424 of 515 eligible patients). Median age of respondents was 64 years; 47.4% were male. Of the 145 patients (34.2%) with a LOS<24 hours, 65 (44.8%) were discharged home from the ED. Of all patients, 89.6% were satisfied with their overall care and 94.1% found instructions clear. Sixty-six percent were satisfied with their LOS, whereas 17.5% would have preferred a shorter LOS and 16.5% a longer LOS. There were no significant differences in satisfaction between patients with LOS<24 hours vs. ≥24 hours (p>0.13 for all). Physical QOL scores were significantly higher for expedited-discharge patients (p=0.01). Patients with expedited discharge home from the ED vs. the hospital had no significant difference in satisfaction (p>0.20 for all) or QOL (p>0.19 for all).ConclusionED patients with low-risk PE reported high satisfaction with their care in follow-up surveys. Expedited discharge (<24 hours) and site of discharge were not associated with differences in patient satisfaction.

Project description:BackgroundMany evidence-based clinical decision tools are available for the diagnosis of pulmonary embolism (PE). However, these clinical decision tools have had suboptimal uptake in the everyday clinical practice in emergency departments (EDs), despite numerous implementation efforts. We aimed to test the feasibility of a multi-faceted intervention to implement an evidence-based PE diagnosis protocol.MethodsWe conducted an interrupted time series study in three EDs in Ontario, Canada. We enrolled consecutive adult patients accessing the ED with suspected PE from January 1, 2018, to February 28, 2020. Components of the intervention were as follows: clinical leadership endorsement, a new pathway for PE testing, physician education, personalized confidential physician feedback, and collection of patient outcome information. The intervention was implemented in November 2019. We identified six criteria for defining the feasibility outcome: successful implementation of the intervention in at least two of the three sites, capturing data on ≥ 80% of all CTPAs ordered in the EDs, timely access to electronic data, rapid manual data extraction with feedback preparation before the end of the month ≥ 80% of the time, and time required for manual data extraction and feedback preparation ≤ 2 days per week in total.ResultsThe intervention was successfully implemented in two out of three sites. A total of 5094 and 899 patients were tested for PE in the period before and after the intervention, respectively. We captured data from 90% of CTPAs ordered in the EDs, and we accessed the required electronic data. The manual data extraction and individual emergency physician audit and feedback were consistently finalized before the end of each month. The time required for manual data extraction and feedback preparation was ≤ 2 days per week (14 h).ConclusionsWe proved the feasibility of implementing an evidence-based PE diagnosis protocol in two EDs. We were not successful implementing the protocol in the third ED.RegistrationThe study was not registered.

Dataset Information

Systematic screening versus clinical gestalt in the diagnosis of pulmonary embolism in COVID-19 patients in the emergency department.

Background

Methods

Results

Conclusion

Publications

Systematic screening versus clinical gestalt in the diagnosis of pulmonary embolism in COVID-19 patients in the emergency department.

Similar Datasets

OmicsDI is part of the ELIXIR infrastructure

Tweets