The time cost to investigate pulmonary embolism in copd patients in the emergency room

SESSION TITLE: Obstructive Lung Disease Posters 6 SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/11/2023 12:00 pm - 12:45 pm PURPOSE: Crowding in Canadian emergency departments (EDs) is a major health system concern and may result in poor patient outcomes. We sought to investigate diagnostic inefficiencies that adversely impact patient transitions through the ED. Acute exacerbation of COPD (AECOPD) is a common ED condition and pulmonary embolism (PE) is commonly considered in its differential diagnosis. Little is known about the frequency of testing for the presence of PE within the ED or the impact of these investigations upon patient flow through the ED. This study examined the impact of PE investigation upon length of stay (LOS) in the ED. METHODS: We conducted a retrospective cohort study of adults presenting with AECOPD to six EDs in Edmonton, Alberta between 01/2015 and 06/2021. We analyzed information on demographics, comorbidities, ED investigations performed to rule out PE (e.g., D-dimer, ventilation-perfusion [V/Q] lung scans and computerized tomography [CT]), and ED LOS from provincial administrative health data. RESULTS: There were 12,185 unique patients (median age 70 years, 50% males, 46% hospitalized) that met study inclusion criteria and 2,072 (17%) underwent testing for PE (D-dimer testing (84%), CT scan (44%) , and/or a VQ scan (2%)). Overall, 41 (0.3%) were diagnosed with a PE in the ED. Of the 1,735 patient who received D-Dimer testing, 944 (54%) were classified as negative using the age-adjusted D-dimer (AADD) cut-offs. Among those with a positive AADD result, the prevalence of PE was 3%. The overall LOS in ED was longer in those undergoing testing for PE than those not tested at (483 vs. 374 minutes; p<0.0001). LOS in ED for those discharged from hospital without PE testing was shorter (321 vs. 435 minutes ;p<0.0001) than those receiving PE testing. LOS in ED for those admitted to hospital without PE testing was shorter (443 vs. 541 minutes; p<0.0001) than those receiving PE testing. PE testing added 3,764 hours or the equivalent of 600 more patients with AECOPD accessing an ED bed. CONCLUSIONS: The overall prevalence of PE among ED patients presenting with AECOPD was less than 1%. Our sample showed 1 in 5 patients were investigated for PE; of the 45.6% who had a positive D-dimer, only 3.2% were found to have a PE with advanced imaging. Conversely 54.4% of the population had a negative D-dimer and in those where advanced imaging was ordered, only 0.5% were found to have evidence of PE. A positive D-dimer test is common in this population and is not a sole reason to search for PE. A negative D-dimer continues to provide guidance that PE is highly unlikely. CLINICAL IMPLICATIONS: Positive D-dimer tests are neither sensitive nor specific for the presence of PE in this ED population. Patient factors that increase the risk of PE (e.g., malignancy, prior history of DVT/PE, immobility, recent surgery/trauma, unilateral swollen limb) or alternative factors that increase the risk of an acute COPD exacerbation (e.g., congestive heart failure, pneumonia) should guide PE testing. Careful clinical assessment might improve patient transitions through the ED and mitigate severe ED crowding. DISCLOSURES: Speakers bureau relationship with Astra Zeneca Please note: 2020- by Mohit Bhutani, value=Honoraria Advisory Committee Member relationship with Boerhinger Ingelheim Please note: 2020- by Mohit Bhutani, value=Honoraria Advisory Committee Member relationship with GSK Please note: 2020- by Mohit Bhutani, value=Honoraria Advisory Committee Member relationship with Novartis Please note: 2020- by Mohit Bhutani, value=Honoraria Advisory Committee Member relationship with Sanofi Genzyme Please note: 2020- by Mohit Bhutani, value=Honoraria Speaker's Bureau relationship with Valeo Please note: 2020- by Mohit Bhutani, value=Honoraria Speaker's Bureau relationship with Covis Pharmaceuticals Please note: 2020- by Mohit Bhutani, value=Honoraria No relevant relationships by Irvin Mayers No relevant relationships by Brian Rowe No relevant relationships by Cristina Villa-Roel No relevant relationships by Esther Yang No relevant relationships by Bo Zheng