Prospective Study of the Clinical Features and Outcomes of Emergency Department Patients with Delayed Diagnosis of Pulmonary Embolism

Jeffrey Kline, Jackeline Hernandez-Nino, Alan E. Jones, Geoffrey A. Rose, H. James Norton, Carlos A. Camargo

Research output: Contribution to journalArticle

57 Citations (Scopus)

Abstract

Objectives: The authors hypothesized that emergency department (ED) patients with a delayed diagnosis of pulmonary embolism (PE) will have a higher frequency of altered mental status, older age, comorbidity, and worsened outcomes compared with patients who have PE diagnosed by tests ordered in the ED. Methods: For 144 weeks, all patients with PE diagnosed by computed tomographic angiography were prospectively screened to identify ED diagnosis (testing ordered from the ED) versus delayed diagnosis (less than 48 hours postadmission). Serum troponin I level, right ventricular hypokinesis on echocardiography, and percentage pulmonary vascular occlusion were measured at diagnosis; patients were prospectively followed up for adverse events (death, intubation, or circulatory shock). Results: Among 161 patients with PE, 141 (88%) were ED diagnosed and 20 (12%) had a delayed diagnosis. Patients with a delayed diagnosis were older than ED-diagnosed patients (61 [±15] vs. 51 [±17] years; p <0.001), had a longer median time to heparin administration (33 vs. 8 hours; p <0.001), and had a higher frequency of altered mental status (30% vs. 8%; p = 0.01) but did not have a higher frequency of prior cardiopulmonary disease (25% vs. 23%). Patients with a delayed diagnosis had equal or worse measures of PE severity (right ventricular hypokinesis on echocardiography, 60% vs. 58%; abnormal troponin I level, 55% vs. 24%); on computed tomographic angiography, ten of 20 patients with a delayed diagnosis had PE in lobar or larger arteries and >50% vascular obstruction. Patients with a delayed diagnosis had a higher rate of in-hospital adverse events (9% vs. 30%; p = 0.01). Conclusions: In this single-center study, the diagnosis of PE was frequently delayed and outcomes of patients with delayed diagnosis were worse than those of patients with PE diagnosed in the ED.

Original languageEnglish (US)
Pages (from-to)592-598
Number of pages7
JournalAcademic Emergency Medicine
Volume14
Issue number7
DOIs
StatePublished - Jul 2007
Externally publishedYes

Fingerprint

Delayed Diagnosis
Pulmonary Embolism
Hospital Emergency Service
Prospective Studies
Blood Vessels
Troponin I
Intubation
Echocardiography
Comorbidity
Shock
Angiography
Lung

Keywords

  • differential diagnosis
  • insurance
  • liability
  • malpractice
  • screening
  • thromboembolism
  • X-ray diagnosis

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

Prospective Study of the Clinical Features and Outcomes of Emergency Department Patients with Delayed Diagnosis of Pulmonary Embolism. / Kline, Jeffrey; Hernandez-Nino, Jackeline; Jones, Alan E.; Rose, Geoffrey A.; Norton, H. James; Camargo, Carlos A.

In: Academic Emergency Medicine, Vol. 14, No. 7, 07.2007, p. 592-598.

Research output: Contribution to journalArticle

Kline, Jeffrey ; Hernandez-Nino, Jackeline ; Jones, Alan E. ; Rose, Geoffrey A. ; Norton, H. James ; Camargo, Carlos A. / Prospective Study of the Clinical Features and Outcomes of Emergency Department Patients with Delayed Diagnosis of Pulmonary Embolism. In: Academic Emergency Medicine. 2007 ; Vol. 14, No. 7. pp. 592-598.
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abstract = "Objectives: The authors hypothesized that emergency department (ED) patients with a delayed diagnosis of pulmonary embolism (PE) will have a higher frequency of altered mental status, older age, comorbidity, and worsened outcomes compared with patients who have PE diagnosed by tests ordered in the ED. Methods: For 144 weeks, all patients with PE diagnosed by computed tomographic angiography were prospectively screened to identify ED diagnosis (testing ordered from the ED) versus delayed diagnosis (less than 48 hours postadmission). Serum troponin I level, right ventricular hypokinesis on echocardiography, and percentage pulmonary vascular occlusion were measured at diagnosis; patients were prospectively followed up for adverse events (death, intubation, or circulatory shock). Results: Among 161 patients with PE, 141 (88{\%}) were ED diagnosed and 20 (12{\%}) had a delayed diagnosis. Patients with a delayed diagnosis were older than ED-diagnosed patients (61 [±15] vs. 51 [±17] years; p <0.001), had a longer median time to heparin administration (33 vs. 8 hours; p <0.001), and had a higher frequency of altered mental status (30{\%} vs. 8{\%}; p = 0.01) but did not have a higher frequency of prior cardiopulmonary disease (25{\%} vs. 23{\%}). Patients with a delayed diagnosis had equal or worse measures of PE severity (right ventricular hypokinesis on echocardiography, 60{\%} vs. 58{\%}; abnormal troponin I level, 55{\%} vs. 24{\%}); on computed tomographic angiography, ten of 20 patients with a delayed diagnosis had PE in lobar or larger arteries and >50{\%} vascular obstruction. Patients with a delayed diagnosis had a higher rate of in-hospital adverse events (9{\%} vs. 30{\%}; p = 0.01). Conclusions: In this single-center study, the diagnosis of PE was frequently delayed and outcomes of patients with delayed diagnosis were worse than those of patients with PE diagnosed in the ED.",
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AU - Camargo, Carlos A.

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AB - Objectives: The authors hypothesized that emergency department (ED) patients with a delayed diagnosis of pulmonary embolism (PE) will have a higher frequency of altered mental status, older age, comorbidity, and worsened outcomes compared with patients who have PE diagnosed by tests ordered in the ED. Methods: For 144 weeks, all patients with PE diagnosed by computed tomographic angiography were prospectively screened to identify ED diagnosis (testing ordered from the ED) versus delayed diagnosis (less than 48 hours postadmission). Serum troponin I level, right ventricular hypokinesis on echocardiography, and percentage pulmonary vascular occlusion were measured at diagnosis; patients were prospectively followed up for adverse events (death, intubation, or circulatory shock). Results: Among 161 patients with PE, 141 (88%) were ED diagnosed and 20 (12%) had a delayed diagnosis. Patients with a delayed diagnosis were older than ED-diagnosed patients (61 [±15] vs. 51 [±17] years; p <0.001), had a longer median time to heparin administration (33 vs. 8 hours; p <0.001), and had a higher frequency of altered mental status (30% vs. 8%; p = 0.01) but did not have a higher frequency of prior cardiopulmonary disease (25% vs. 23%). Patients with a delayed diagnosis had equal or worse measures of PE severity (right ventricular hypokinesis on echocardiography, 60% vs. 58%; abnormal troponin I level, 55% vs. 24%); on computed tomographic angiography, ten of 20 patients with a delayed diagnosis had PE in lobar or larger arteries and >50% vascular obstruction. Patients with a delayed diagnosis had a higher rate of in-hospital adverse events (9% vs. 30%; p = 0.01). Conclusions: In this single-center study, the diagnosis of PE was frequently delayed and outcomes of patients with delayed diagnosis were worse than those of patients with PE diagnosed in the ED.

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