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D-dimer audit

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D-dimer audit

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D-dimer audit

  1. 1. D-DIMER AND CTPA HAN LU DAVID MOUNTAIN
  2. 2. OBJECTIVE ▸ What is a D-Dimer (DD) ▸ Introduction / Background ▸ Inclusion / Exclusion criteria ▸ Data Points ▸ Analysis ▸ Discussion / Conclusion
  3. 3. WHAT IS A D-DIMER (DD) ▸ D-Dimer (DD) introduced since 1990s ▸ Fibrin degradation product ▸ Small protein fragments in blood post fibrinolysis. ▸ Contains 2 D fragments of fibrin protein cross linked. ▸ Useful in diagnosing a range of thrombotic pathologies. ▸ Particularly useful when negative and used as a exclusion criteria for thrombosis.
  4. 4. INTRODUCTION / BACKGROUND ▸Recent retrospective audit on aged DD - population pt >50yo ▸≈ 500 patients per year had CTPAs ▸≈1/3rd had DD ▸≈2/3rd DID NOT have DD ▸DD omitted ?due to exclusion criteria such as e.g. symptoms >1/52, etc? ▸Audit to assess if CTPAs are requested appropriately for PE without DD ▸Can CTPAs be cut down? (Radiation CTPA = 2-3 years of BG radiation) ▸53 cases identified with a CTPA but without DD
  5. 5. INTRODUCTION / BACKGROUND ▸Recent retrospective audit on aged DD - population pt >50yo ▸≈ 500 patients per year had CTPAs ▸≈1/3rd had DD ▸≈2/3rd DID NOT have DD ▸DD omitted ?due to exclusion criteria such as e.g. symptoms >1/52, etc? ▸Audit to assess if CTPAs are requested appropriately for PE without DD ▸Can CTPAs be cut down? (Radiation CTPA = 2-3 years of BG radiation) ▸53 cases identified with a CTPA but without DD
  6. 6. INCLUSION CRITERIA ▸Cases with CTPA and ▸No D-Dimer beforehand and ▸Age >50 yo ‣ None SCGH ED patients (e.g. KEMH T/F) or IP ‣ Aged <50 yo ‣ CTPA not performed for acute PE, or for surveillance of a known acute PE EXCLUSION CRITERIA ‣ 53 notes were audited, 4 were excluded due to exclusion criteria
  7. 7. DATA POINTS ▸Demographic data ▸PC - from presentation Code/triage ▸D/C diagnosis in EDIS / Topas ▸Ix for DVT/PE (DD, US, VQ, CTPA,MRPA, PA, venogram) ▸WELLS score (Prospective OR Retrospective)
  8. 8. ▸Potential reasons for not performing DD ▸Delayed symptoms (>1/52) ▸Pregnant (3rd trimester) or <1/52 postpartum ▸Recent major trauma <1/52 ▸Invasive surgery <1/52 ▸Current inpatient ▸Severely unwell / unstable ▸Active cancer (<6/12 since therapy / palliative) ▸Other DVT / VTE / major thrombosis diagnosed prev 1/52 ▸High pre-test risk of PE ▸On Warfarin, NOAC, heparin ▸Reason for not performing a DD documented ▸Definitive alternative diagnosis documented before discharge home.
  9. 9. LIMITATIONS OF AUDIT ▸Based on documentation / reports ▸Auditing CTPAs for PE diagnosis ▸WELLS is subjective ▸Assumptions: ▸If calf examination not documented - assumed nil signs of DVT ▸PE most likely diagnosis - based on clinical history / examination findings documented / differential diagnosis listed ▸If no mention of previous DVT,PE / Cancer / Recent immobilisation / haemoptysis - assumed these were not present
  10. 10. DEMOGRAPHICS ▸Age range 50-88 (so none were PERC able) ▸Gender female 27, male 22 ▸Time / date attendance range 08/03/16 - 26/10/16 Fe ma l… Ma les 4…
  11. 11. TRIAGE CATEGORY ▸Triage category ▸2 = 35 ▸3 = 11 ▸4 = 3 2 71% 3 22% 4 6%
  12. 12. PRESENTING COMPLAINT
  13. 13. PRESENTING COMPLAINT ▸ Respiratory Short of Breath 17 ▸ Pain – Chest 15 ▸ Respiratory Cough 4 ▸ Pain – Back 2 ▸ Regional Problem –Infection / Inflammation 2 ▸ Temperature / Environmental Fever 2 ▸ Temperature / Environmental Acopia 1 ▸ Cardiovascular / Palpitations 1 ▸ Drug / Alcohol Use 1 ▸ Neurological – Altered Conscious State 1 ▸ Neurological – Syncopal 1 ▸ Provisional Diagnosis – ?DVT 1 ▸ Urology/Reproductive –urinary retention- (MS) 1
  14. 14. DISPOSITION ▸Admitted 42 ▸EDU 1 - TOC Ortho (CTPA - No PE) ▸Obs 2 ▸ DC 1 (CTPA - No PE) ▸ TOC Resp 1 (CTPA - No PE, progression interstitial pneumonitis) ▸DC from ED by MAU 1 (CTPA - No PE) ▸Discharged 7
  15. 15. DIAGNOSIS EDIS / TOPAS / DC SUMMARY 9 8 4 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 2 3 5 6 8 9 11 Chest Pain Unknown Cause PE Pneumonia Neoplasia - Respiratory System Dyspnoea Acute Cholecystitis Aspiration Pnuemonia Bronchitis Cardiogenic Pulmonary Oedema Coagulation Defect Diazepam / Traadol OD Fall Generalised Infection Generally unwell Haemoptysis Limb Swelling Neoplasia - Malignant Mesothelioma Neoplasia Metastasis to lung Neutropenia and Febrile Pleurisy Shortness of Breath Syncope not heat Tachycardia
  16. 16. D-DIMER USAGE ▸No = 49 ▸Yes = 0 ▸DD cancelled in 1 case and proceeded to CTPA ▸(No Reason documented, WELLS 0) ▸CTPA - No PE ▸Diagnosed as NSTEMI (Trop 2640 - 3060)
  17. 17. ULTRASOUND ▸No 42 ▸Yes 7 ▸1 Positive DVT / Thrombus (Positive CTPA) ▸6 Negative DVT / Thrombus.
  18. 18. CTPA Positive, 11 Negative, 36 Inconclusive, 2
  19. 19. COULD CTPA BE REDUCED? ▸Of 36 Negative CTPA: WELLS scores range 0-11 ‣ 3/36 WELLS > 6 (High pre-test probability) ‣ 33/36 WELLS <6 (Low / intermediate pre-test probability) ▸24 had appropriate reasons for not doing a D-Dimer ▸6 No reason documented ▸3 PE not on differentials in ED
  20. 20. COULD CTPA BE REDUCED? ▸Of 36 Negative CTPA: WELLS scores range 0-11 ‣ 3/36 WELLS > 6 (High pre-test probability) ‣ 33/36 WELLS <6 (Low / intermediate pre-test probability) ▸24 had appropriate reasons for not doing a D-Dimer ▸6 No reason documented ▸3 PE not on differentials in ED
  21. 21. CTPA Positive 11 Negative 36 Inconclusive 2
  22. 22. ▸Of 11 Positive CTPA: WELLS range 1-7 ▸1/11 WELLS > 6 (High pre-test probability) ▸10/11 WELLS <6 (Low / intermediate pre-test probability) ▸7 had appropriate reasons for not doing a D-Dimer ▸2 No reason documented ▸1 PE not on differentials in ED ▸Of the 2 Suboptimal - Both WELLS of 2.5 + Both had reason for not doing D-Dimer COULD CTPA BE REDUCED?
  23. 23. ▸Of 11 Positive CTPA: WELLS range 1-7 ▸1/11 WELLS > 6 (High pre-test probability) ▸10/11 WELLS <6 (Low / intermediate pre-test probability) ▸7 had appropriate reasons for not doing a D-Dimer ▸2 No reason documented ▸1 PE not on differentials in ED ▸Of the 2 Suboptimal - Both WELLS of 2.5 + Both had reason for not doing D-Dimer COULD CTPA BE REDUCED?
  24. 24. WELLS SCORE 1 1 1 1 5 1 1 5 2 7 10 2 2 3 1 1 1 1 1 1 1 0 3 6 9 12 15 0 1.5 3 4.5 6 7 Movement Artefact Suboptimal Negative Positive
  25. 25. WELLS CALCULATED / PROSPECTIVE VS RETROSPECTIVE Notes 41 PE Pathway 8 Prospective 9 Retrospective 40
  26. 26. REASON FOR NOT DOING D-DIMER 22 2 1 3 5 7 8 4 0 6 12 18 24 Active Cancer / Cancer… Current Thrombosis Inpatient On Warfarin / NOAC /… Prolonged Symptoms… Invasive Surgery <1/52 No Reason PE not on differential in ED ▸ No reason - 16% ▸PE not on differential in ED - 8%
  27. 27. REASON FOR NOT DOING D-DIMER 22 2 1 3 5 7 8 4 0 6 12 18 24 Active Cancer / Cancer… Current Thrombosis Inpatient On Warfarin / NOAC /… Prolonged Symptoms… Invasive Surgery <1/52 No Reason PE not on differential in ED ▸ No reason - 16% ▸PE not on differential in ED - 8%
  28. 28. TEXT
  29. 29. NO REASON DOCUMENTED FOR D-DIMER Positive: PE 2 Negative, 6 ▸WELLS score Range 0-4.5 ▸Based on PE Pathway - DD could have been done
  30. 30. PE NOT ON ED DIFFERENTIAL ▸All 4 were organised by admitting team. WELLS range 1.5-4.5 ▸ED differential: ▸3 No PE on CTPA - Pneumonia / Chest pain unknown / Generalised infection - PUO ▸1 CTPA: Right mid lobar + segmental PE, no right heart strain ▸ Acute Choleycystitis (EDIS) ▸PC - Neurological altered conscious state - noted to be more lethargic, T 40.1, P 120, RR 20, O2 88% RA, BP 120, nauseated (NH Res) ▸CT Triphasic - diverticulosis, potential Cholecystitis and PE
  31. 31. REASON FOR NOT DOING D-DIMER 22 2 1 3 5 7 8 4 0 6 12 18 24 Active Cancer / Cancer… Current Thrombosis Inpatient On Warfarin / NOAC /… Prolonged Symptoms… Invasive Surgery <1/52 No Reason PE not on differential in ED ▸ No reason - 16% ▸PE not on differential in ED - 8%
  32. 32. REASON FOR NOT PERFORMING D-DIMER ▸Not documented 42 ‣ 2 used PE Pathway but left this section blank ‣ 1 mentioned D-Dimer Cancelled ‣ Documented 7 ‣ 6 used PE Pathway ‣ 1 mentioned low index of suspicion of PE, but not suitable for D- Dimer thus exclude PE with CTPA (Active cancer/cancer treatment) (WELLS 2.5) CTPA - Neg
  33. 33. DEFINITIVE ED DIAGNOSIS DOCUMENTED BEFORE DISCHARGED ▸Of 7 discharged patient - diagnosis: ▸1 Atypical chest pain ▸1 Chest pain ▸1 Chest pain unknown cause ▸1 Lobar pneumonia ▸1 Pneumonia ▸2 Chest wall pain
  34. 34. DISCUSSION / CONCLUSION ▸Majority of PC are Cat 2 + SOB and/or chest pain ▸Other modality used for Ix is USS ▸No reason documented for not doing DD 8/49 (16%) ▸Neg CTPA - 6/33 (18%) - Low/Int for PE - No documented reason for not doing DD ▸Pos CTPA - 2/10 (20%) - Low/Int for PE - No documented reason for not doing DD ▸Majority of WELLS calculated retrospectively from notes. ▸Those that used PE pathway - Great compliance to documentation
  35. 35. ▸Most common reason for not doing DD was active cancer ▸Not an exclusion criteria, part of WELLS only ▸Still some benefit for doing DD ▸PE was not on differential in ED 4/49 (8%)
  36. 36. ▸Most common reason for not doing DD was active cancer ▸Not an exclusion criteria, part of WELLS only ▸Still some benefit for doing DD ▸PE was not on differential in ED 4/49 (8%) ▸Overall, CTPAs are being ordered appropriately, BUT… ▸Compliance with PE pathway will improve documentation and would reduce any unnecessary CTPAs

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