Time to diagnostic certainty for saddle pulmonary embolism in hospitalized patients

Abstract

There is a lack of diagnostic performance measures associated with pulmonary embolism (PE). We aimed to explore the concept of the time to diagnostic certainty, which we defined as the time interval that elapses between first presentation of a patient to a confirmed PE diagnosis with computed tomography pulmonary angiogram (CT PA). This approach could be used to highlight variability in health system diagnostic performance, and to select patient outliers for structured chart review in order to identify underlying contributors to diagnostic error or delay. We performed a retrospective observational study at academic medical centers and associated community-based hospitals in one health system, examining randomly selected adult patients admitted to study sites with a diagnosis of acute saddle PE. One hundred patients were randomly selected from 340 patients discharged with saddle PE. Twenty-four patients were excluded. Among the 76 included patients, time to diagnostic certainty ranged from 1.5 to 310 hours. We found that 73/76 patients were considered to have PE present on admission (CT PA ≤ 48 hours). The proportion of patients with PE present on admission with time to diagnostic certainty of > 6 hours was 26% (19/73). The median (IQR) time to treatment (thrombolytics/anticoagulants) was 3.5 (2.5-5.1) hours among the 73 patients. The proportion of patients with PE present on admission with treatment delays of > 6 hours was 16% (12/73). Three patients acquired PE during hospitalization (CT PA > 48 hours). In this study, we developed and successfully tested the concept of time to diagnostic certainty for saddle PE.

Figure 1.

Flowchart diagram. CT PA: Computed tomography pulmonary angiography; Dx: Diagnosis; PE: Pulmonary embolism; TDx: Time to diagnostic certainty; TDx ≤ 48 hours: PE present on admission; TDx > 48 hours: PE acquired during hospitalization.

Figure 2.

Time to diagnostic certainty for pulmonary embolism present on admission, hours. Analysis of the subgroup of patients with PE present on admission determined the median time to diagnostic certainty for PE was 3.4 (IQR 2.6–6.3) hours. Nineteen of 73 (26%) patients reached diagnostic certainty outside 6-hour time period. PE: Pulmonary embolism.

Figure 3.

Bivariate analysis of time to diagnostic certainty and time to treatment, hours. Figure describes the relationship between time to diagnostic certainty and time to treatment in the 73 patients with pulmonary embolism present on admission. Based on time to diagnostic certainty and time to treatment, there were four groups of patients: 1) those with perfect diagnostic performance (early diagnosis and treatment), 2) risk of harm from late treatment (early diagnosis and late treatment), 3) risk of harm from overtreatment (early treatment and late diagnosis), and 4) poor diagnostic performance (risk of harm from late diagnosis and treatment).