Is pretest probability assessment on emergency department patients with suspected venous thromboembolism documented before SimpliRED D-dimer testing?
BACKGROUND
The SimpliRED D-dimer assay is commonly ordered by emergency physicians for suspected pulmonary embolus or deep venous thrombosis. A pretest probability (PTP) assessment is required for the results of this diagnostic test to be interpreted correctly and applied appropriately. Without this assessment, the physician may misinterpret the test results and proceed to unnecessary diagnostic imaging (DI) or inappropriate discharge. Our objectives were to measure the documentation rate of PTP for emergency department (ED) patients on whom a SimpliRED D-dimer assay was performed for suspected venous thromboembolism (VTE) and to determine if the clinical management decisions that followed were in keeping with current recommendations.


METHODS
In this medical record review, we used a random number generator to select 100 charts from all 760 patients who had a SimpliRED D-dimer performed during a 3-month period at an academic tertiary care centre with 3 EDs. Trained data abstractors, blinded to the study hypothesis, abstracted explicitly defined data from each chart. An independent abstractor assessed the reliability of 15 of the charts that were randomly chosen.


RESULTS
Suspicion of VTE was documented in 97 of the 100 charts. There was no documentation of PTP assessment for 62 of the 97 cases. Ten had a positive D-dimer but 5 of these had no evidence of subsequent DI. Of the 97 charts reviewed, 24 documented decisions were in discordance with published clinical management recommendations for VTE.


CONCLUSIONS
In the majority of ED cases of suspected VTE, PTP assessment was not documented and approximately one-quarter of these documented decisions were in discordance with established recommendations for the given test results. This suggests that PTP assessments are not being conducted in a significant proportion of cases and the diagnostic test results are misinterpreted, applied incorrectly or both.
Smith
Camala
C
Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada.
Mensah
Albert
A
Mal
Sameer
S
Worster
Andrew
A
D000465:Algorithms; D003663:Decision Trees; D004282:Documentation / Q000592:standards / Q000706:statistics & numerical data*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D004638:Emergency Treatment / Q000379:methods / Q000706:statistics & numerical data*; D005338:Fibrin Fibrinogen Degradation Products / Q000378:metabolism*; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006302:Health Services Research; D006386:Hemagglutination Tests / Q000379:methods / Q000706:statistics & numerical data*; D006801:Humans; D008485:Medical Audit; D009864:Ontario; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D011237:Predictive Value of Tests; D011336:Probability; D011655:Pulmonary Embolism / Q000175:diagnosis; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods / Q000706:statistics & numerical data*; D016037:Single-Blind Method; D054556:Venous Thromboembolism / Q000097:blood / Q000175:diagnosis*
D005338:Fibrin Fibrinogen Degradation Products; C036309:fibrin fragment D