title: Prospective study of the clinical features and outcomes of emergency department patients with delayed diagnosis of pulmonary embolism.
abstract: OBJECTIVE
  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.
authors.affiliation: Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA. jkline@carolinas.org
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Kline
authors.forename: Jackeline
authors.initials: J
authors.lastname: Hernandez-Nino
authors.forename: Alan E
authors.initials: AE
authors.lastname: Jones
authors.forename: Geoffrey A
authors.initials: GA
authors.lastname: Rose
authors.forename: H James
authors.initials: HJ
authors.lastname: Norton
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Camargo
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003072:Cognition Disorders / Q000175:diagnosis* / Q000453:epidemiology / Q000209:etiology; D015897:Comorbidity; D003954:Diagnostic Services / Q000706:statistics & numerical data*; D004636:Emergency Service, Hospital / Q000592:standards* / Q000706:statistics & numerical data; D006801:Humans; D008485:Medical Audit; D008603:Mental Health; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D011446:Prospective Studies; D011655:Pulmonary Embolism / Q000150:complications / Q000175:diagnosis* / Q000453:epidemiology / Q000523:psychology; D012720:Severity of Illness Index; D013997:Time Factors; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data; D019210:Troponin I / Q000097:blood; D014600:Utilization Review
chemical_list: D019210:Troponin I