Healthcare watchdog, HSIB, has published its national investigation report, Clinical decision making: diagnosis and treatment of pulmonary embolism in emergency departments.
The report highlights the safety risk to patients from incorrect decisions by medical staff in emergency departments (EDs or A&Es) and resulting delays in diagnosis and treatment of this serious condition.
Factors which led to incorrect clinical decisions, misdiagnosis, substandard treatment or delay included recognising pulmonary embolism (PE) in patients with unusual or non-specific signs and symptoms, or who arrive at A&E in a critically ill condition. Lack of experience, training, and helpful guidance for junior doctors; difficulty accessing scans, emergency medicines and expertise from senior doctors; and emergency department deadlines and demands were common themes which increased the risk of harm to patients with PE.
Where patients suffer severe or fatal injury as a result of failings in care which lead to PE, or failure to diagnose and treat PE promptly, they or their family may be entitled to compensation.
What is pulmonary embolism or PE?
A pulmonary embolism (PE) is a partial or complete blockage in one or more of the arteries of the lung. PE is often caused by a deep vein thrombosis (DVT), in which blood clots form, usually in the lower leg, and are then carried through the patient’s venous system and block one or more blood vessels in the lung.
A person’s risk of PE may be increased by factors, such as cancer, inflammation/infection, obesity, pregnancy, blood clotting disorders or a family history of blood clots, during surgery or after a major injury, taking medicines containing oestrogen or as a result of immobility.
PE is a serious condition, which if untreated can lead to death or other life-threatening complications, such as heart failure, heart rhythm abnormalities (arrhythmias) and damage to the lungs (pulmonary infarction). Patients with suspected PE require urgent treatment. Delays or mistakes in diagnosis or treatment increase the patient’s risk of serious harm.
Delays in diagnosis and treatment of PE are common. In 2019 the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) found delays in the processes for treating PE patients in nearly 40% of the 526 cases it reviewed, with 20% of patients experiencing delays in starting anticoagulation (blood thinning) medication. An MBRRACE-UK report into maternal deaths from 2017-2019 found that 31 women died from PE, and that for nearly two thirds of the women who died from blood clots, better care might have made a difference to their outcome.
Diagnosis and treatment of pulmonary embolism (PE)
Doctors diagnose a PE by assessing the patient’s symptoms and signs, and then by the results of various tests. The classic symptoms of PE include chest pain that is worse when breathing in, shortness of breath and coughing up blood. However, patients may also have non-specific, fewer or unexpected symptoms, or may be critically ill when they arrive at the emergency department, from a collapse or cardiac arrest.
NICE guidelines say that patients with symptoms and/or signs of PE should have a full medical history taken, examination and chest X-ray. If PE is suspected, a Wells score (which adds up the patient’s score from points given for each risk factor, sign or symptom) should be used. A high Wells score suggests that PE is likely and patients should have a scan. A low score suggests that PE is unlikely, and the patient should have a D-dimer blood test (to test for blood clots). If the D-dimer test is positive, NICE recommends that the patient has a scan to look for a PE. D-dimer levels may also be raised by other factors, such as the patient’s age, ethnicity, pregnancy, trauma or recent surgery, or conditions such as bleeding disorders, cancer, heart disease and COVID-19. Most patients needing a scan will have computerised tomography pulmonary angiography (CTPA).
Treatment for suspected or confirmed PE is usually with anticoagulant (blood thinning) medicines which reduce the formation of further clots. If the patient’s scan or D-dimer test result is delayed, NICE recommends interim treatment with anticoagulation, to reduce the risk of clots increasing in size. Patients with PE may continue on anticoagulant medicines. Other treatments for life-threatening PEs include thrombolytic (clot-busting) drugs, or more invasive procedures to directly remove the clots.
What did HSIB’s investigation find?
HSIB reviewed 14 serious incident investigation reports from NHS hospitals involving delayed or missed diagnosis or treatment of pulmonary embolism in emergency departments during 2020 in England. Some of these reports related to patients who had died as a result of PE, or from other conditions alongside a PE, or from another condition that had been misdiagnosed as a PE.
HSIB found that ‘incorrect’ decisions, including missed or delayed diagnosis, regularly featured in the diagnosis and treatment of PE. Other conditions, such as an aortic dissection (a tear in the layers of the wall of the aorta) were initially incorrectly suspected to be PE.
Staff decisions were often influenced by factors including:
- where COVID-19 had similar symptoms or occurred at the same time as PE;
- lack of time to pause and consider the diagnosis owing to demands on the ED/A&E and the pressure from the national targets requiring people attending ED to be admitted to hospital, transferred or discharged within 4 hours of arrival;
- shortage of senior doctors available to review patients, who were therefore assessed by more junior staff;
- pathways which did not prompt clinicians to consider PE when patients had symptoms that were unexplained or not typical of PE, or consider the risk of discharging patients with an unknown diagnosis on anticoagulation medication, whilst they waited to have a scan;
- difficulties in requesting scans for patients owing to limited scanning resources and conflict between ED and radiology departments;
- staff did not always use the available decision-making tools and guidelines to them to help make decisions;
- the use of D-dimer blood tests, which, if requested, then assumed PE as the lead diagnosis, potentially causing clinicians to fail to consider other diagnoses, or, if not requested led to PE being given less consideration;
- review of abnormal test or observation results often took place after a patient was already given a diagnosis or discharged.
HSIB found that patients’ symptoms were not always typical of PE or were non-specific, and included nausea and vomiting, abdominal pain and dizziness. Patients’ risk factors for blood clots, such as being less active during COVID-19, were not always recognised.
In relation to treatment, HSIB found that anticoagulation medication was delayed or given incorrectly. Dosage errors occurred where prescribing was based on the patient’s estimated (instead of checked) weight. Doctors had difficulty accessing emergency medicine needed when giving thrombolysis (clot-busting drugs) to PE patients in emergency situations.
Following further investigation, HSIB concluded that the diagnosis of PE is challenging, particularly for less experienced staff and when the patient’s signs and symptoms are non-specific or atypical. The risk-balancing decision about whether to start treatment requires decision-making skills that are often developed through experience, without formal training or opportunities to practise making decisions.
In an emergency department setting, decision making is affected by workload, workforce availability, performance targets and the way emergency processes are designed. Pathways for diagnosis and treatment of PE in outpatient settings can create a safety risk for patients who are discharged on anticoagulants without a confirmed diagnosis. Lack of scanning capacity significantly contributes to this risk. The risk to patients is further increased if vital information, such as the results of D-dimer tests, are not followed up.
HSIB acknowledged the significant challenges faced by emergency department (A&E) staff, particularly during the pandemic, when caring for patients with complex health conditions against a background of limited resource and capacity. HSIB’s recommendations included updating NICE guidance, and action by RCEM and the NHS to help clinicians develop decision-making skills and use best practise in caring for patients with symptoms and signs of PE. HSIB also observed that emergency departments would benefit from having rapid access to scans for patients who need them for the diagnosis of pulmonary embolism, and more realistic and user-friendly working procedures.
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