Study of compliance with a clinical pathway for suspected pulmonary embolism

Background/Aims: Clinical pathways to guide the investigation of suspected pulmonary embolism have been increasingly adopted by emergency departments worldwide. This study evaluated the compliance with a clinical pathway that combines risk assessment (Wells score) with d-dimer, ventilation-perfusion scanning or computed tomographic pulmonary angiography (CTPA). The aims of this study were to identify factors that contribute to compliance and to assess patient outcomes and resource utilization. Methods: Repeated retrospective chart reviews of 239 patients who underwent investigation for pulmonary embolism through our emergency department extracted patient demographics, pathway parameters and patient outcomes. A phone interview at 3-month follow up was carried out. Results: Incidence of pulmonary embolism was 8.4% (n= 20). Compliance to the clinical pathway occurred in 120 subjects (50.2%). Non-compliance occurred in 71 subjects (29.7%). Forty-eight subjects (20.1%) underwent risk assessments, but subsequent diagnostic tests did not conform to the stated pathway (partial compliance). Compliance was poor in subjects assessed by non-emergency department doctors (χ ²= 27.95, P≤ 0.001). Compliance occurred less in pregnant subjects (χ ²= 7.27, P= 0.007) and those with chronic respiratory disease (χ ²= 5.31, P= 0.021). Subjects in the compliant group were less likely to undergo CTPA (odds ratio 2.07 (1.16-3.70), P= 0.012). Conclusions: Compliance with this clinical pathway allowed emergency department doctors in an Australian university teaching hospital to complete diagnostic testing for suspected pulmonary embolism appropriately unless non-emergency department doctors became involved. Compliance with this pathway altered the distribution of diagnostic tests performed with less reliance on CTPA, but was not associated with better patient outcomes.