American College of Emergency Physicians

View all recommendations from this society

October 27, 2014

Avoid CT pulmonary angiography in emergency department patients with a low-pretest probability of pulmonary embolism and either a negative Pulmonary Embolism Rule-Out Criteria (PERC) or a negative D-dimer.

Advances in medical technology have increased the ability to diagnose even small blood clots in the lung. Now, the most commonly used test is known as a CT pulmonary angiogram (CTPA). It is readily available in most hospitals and emergency rooms. However, disadvantages of the CTPA include patient exposure to radiation, the use of dye in the veins that can damage kidneys and high cost.

Studies have demonstrated that certain findings in a patient’s medical history put them at very low risk for having a blood clot in the lung. In some cases, a blood test called a D-dimer may be additionally used to screen for the possibility of a clot. If patient historical factors and physical examination findings are negative, along with a negative D-dimer (if the physician chooses to order it), evidence shows that the risk of an undiagnosed blood clot is the same as if the patient had a negative CTPA. Such a strategy saves the risk of radiation, kidney injury and the high cost of a CTPA.


These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

1–5: The American College of Emergency Physicians (ACEP) developed five Choosing Wisely® recommendations through a multi-step process that included input from ACEP members, an expert panel of emergency physicians and the ACEP Board of Directors. In 2012, ACEP appointed a task force to address cost effective emergency care. The Cost Effective Care Task Force conducted a survey that was open to all ACEP members asking for strategies to reduce cost and improve value in emergency medicine. The task force received over 200 individual suggestions, which were grouped into a set of strategies. A technical expert panel, including representatives from all aspects of emergency medicine practice, reviewed and prioritized the recommendations using a modified Delphi technique. The panel prioritized the strategies using multiple rounds of voting based on contribution to cost reduction, benefit to patients and actionability by emergency physicians. A literature review including data on cost was assembled for the highest-rated strategies. Strategies were further refined and a final list of strategies that received majority support of the panelists was created. Five of these were ultimately selected by the Board of Directors to be included in Choosing Wisely®.

6–10: The entire ACEP membership (30,000+) was surveyed and given an opportunity to provide input on what in their view would be cost effective and improve the quality of patient care. A Delphi panel of emergency physicians was convened and the list was winnowed using the Delphi process to the top twelve. To be included in the top twelve, there must be research to demonstrate cost effectiveness and improvement of patient care if implemented with reason, caution and explanation to the patient. Also of importance was the consideration that the recommendations would be or are also in concert with some of the other specialties participating in the Choosing Wisely® campaign.

ACEP’s disclosure and conflict of interest policy can be found at www.acep.org.

Sources

Quaseem A, Snow V, Barry P, Hornbake ER, Rodnick JE, Tobolic T, Ireland B, Segal J, Bass E, Weiss KB, Green L, Owens DK; Joint American Academy of Family Physicians/American College of Physicians Panel on Deep Venous Thrombosis/Pulmonary Embolism. Current diagnosis of venous thromoboembolism in primary care: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Fam Med. 2007 Jan-Feb;5(1):57-62.

Corwin MT, Donohoo JH, Partridge R. Do emergency physicians use serum D-dimer effectively to determine the need for CT when evaluating patients for pulmonary embolism? A review of 5,344 consecutive patients. AJR Am J Roentgenol. 2009 May;192(5):1319-23.

Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, Bengel F, Brady AJ, Ferreira D, Janssens U, Klepetko W, Mayer E, Remy-Jardin M, Bassand JP; ESC Committee for Practice Guidelines (CPG).Guidelines on the diagnosis and management of acute pulmonary embolism. European Heart J. 2008 Sep;29(18):2276–315.

Kline JA, Webb WB, Jones AE, Hernandez-Nino J. Impact of a rapid rule-out protocol for pulmonary embolism on the rate of screening, missed cases, and pulmonary vascular imaging in an urban US emergency department. Ann Emerg Med. 2004 Nov;44(5):490-502.

Tiesman NA, Cheung PT, Frazee B. Is the ordering of imaging for suspected venous thromboembolism consistent with D-dimer result? Ann Emerg Med. 2009 Sep;54(3):442-6.

Kline JA, Courtney DM, Kabrhel C, Moore CL, Smithline HA, Plewa MC, Richman PB, O’Neil BJ, Nordenholz K. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haemost. 2008 May;6(5):772-80.

Physician Fee Schedule Search. Washington (DC): Centers for Medicare & Medicaid Services; [updated 2-14 Oct 1; cited 2014 Oct 2]. Available from: http://www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx?Y=2&T=0&HT=0&CT=3&H1=71275&M=4.

Fesmire FM, Brown M, Espinosa JA, Shih RD, Silvers SM, Wolf SJ, Decker WW; American College of Emergency Physicians. Critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected pulmonary embolism. Ann Emerg Med. 2011 Jun;57(6):628-52.

Venkatesh AK, Kline JA, Courtney M, Camargo CA, Plewa MC, Nordenholz KE, Moore CL, Richman PB, Smithline HA, Beam DM, Kabrhel C. Evaluation of pulmonary embolism in the emergency department and consistency with a national quality measure. Arch Intern Med. 2012 Jul 9;172(13):1028-32.