Clinical decision making: diagnosis of pulmonary embolism in emergency departments
HSIB Legacy
Published
Communication and decision making
Hospital care
This investigation looks at the timely recognition and treatment of suspected pulmonary embolism (PE). A person suffering from a PE (a clot in the lung) requires urgent treatment to reduce the chance of significant harm or death.
3 recommendations
6 observations
3 of 3 responded
Safety Recommendations (3)
NHS England
R/2022/188
HSIB recommends that Health Education England works with appropriate professional bodies to develop and implement a strategy for supporting the education and training of clinical practitioners that can facilitate the development of decision-making skills. This strategy should consider the use of innovative approaches such as simulation and immersive learning.
Health Education England declined the recommendation, stating it was outside their statutory remit. HSIB subsequently escalated this to the Department of Health and Social Care due to a systemic gap.
Health Education England (HEE) were engaged in the development of this recommendation during the course of the investigation. Subsequently, HEE responded to this safety recommendation to suggest that the action requested was not within HEE's statutory remit or mandated responsibilities. As a result, HSIB has corresponded with HEE, NHS England, the General Medical Council, and the Academy of Medical Royal Colleges to seek a recipient for the recommendation who can take ownership of this action. No agency has been able to confirm that they have the remit or responsibility to act on this recommendation. As a result, HSIB has raised this issue to the Department of Health and Social Care to identify this potential ‘gap’ in the system. Response published on 9 May 2023.
National Institute for Health and Care Excellence
R/2022/189
HSIB recommends that the National Institute for Health and Care Excellence reviews the findings of this investigation in relation to its guidance NG158, ‘Venous thromboembolic diseases: diagnosis, management and thrombophilia testing’, and updates the guidance if required.
NICE committed to undertaking an exceptional surveillance review of guideline NG158 by summer 2022 to assess if an update is required based on the investigation findings.
We have considered the report and noted the specific concerns that have been raised in relation to our guideline on venous thromboembolic diseases: diagnosis, management and thrombophilia testing [NG158]. We propose to undertake an exceptional surveillance review of the guideline to see if an update to our recommendations is required. The review has been scheduled into the guideline surveillance team’s programme of work and we expect to complete this in summer 2022. I would like to assure you that we recognise the importance of the HSIB’s recommendation and will ensure that any actions identified by the surveillance review are prioritised. The National Institute for Health and Care Excellence (NICE) has committed to review its guideline on venous thromboembolic diseases: diagnosis, management and thrombophilia testing [NG158]. It will consider if an update to its recommendations is needed. Actions planned to deliver safety recommendation: Undertake an exceptional surveillance review of the NICE guideline on venous thromboembolic diseases: diagnosis, management and thrombophilia testing [NG158]. BY: Summer 2022. Resources in place: Project staff from the surveillance team. Other dependencies identified: The review will be scheduled in the surveillance team’s work programme as soon as possible, taking into account NICE’s existing workload and agreed priorities. Update NG158 if the exceptional surveillance review indicates this is required. BY: TBC. Other dependencies identified: An update is dependent on the outcome of the exceptional surveillance review. Response received on 20 June 2022.
Royal College of Emergency Medicine (‘RCEM’)
R/2022/190
HSIB recommends that the Royal College of Emergency Medicine promotes best practice around diagnostic decision making with respect to patients with potential symptoms and signs of pulmonary embolism.
The Royal College of Emergency Medicine is promoting best practice through ongoing work on initial assessment processes, a new curriculum for trainees, specific education on pulmonary embolism, and reviewing intelligence from safety organizations.
HSIB recommends that the Royal College of Emergency Medicine promotes best practice around the diagnostic decision making with respect to patients with potential symptoms and signs of pulmonary embolism. The HSIB investigation has identified pulmonary embolism as one of the conditions that can present with subtle and atypical symptoms and signs. This makes it a diagnostic challenge, further complicated by the many similar serious conditions which can also present in a similar fashion. The report also identifies the complexities associated with the clinical scoring system and diagnostic modalities that exist. The patient’s story within this report highlights the importance and would like to express our sympathy to Martin’s family, and the desire for the system to learn from this tragic event. The Royal College of Emergency Medicine has a role in the education and guidance of emergency department practitioners, but is not a statutory or regulatory body and as such has no powers to mandate action. Emergency departments are often described as a volatile, uncertain, complex, and ambiguous (‘VUCA’) environment and exists within an NHS which is often described as a ‘complex adaptive system’. Patients present in what is termed ‘undifferentiated’ fashion- that is they come with symptoms not a diagnosis, and it is one of the functions of the Emergency Department to try to come to the correct diagnosis. Consequently, the issue of identifying pulmonary embolism within this setting could be described as a “wicked problem” and the Royal College of Emergency Medicine’s approach to this recommendation is therefore multifaceted. Currently, there is on-going work regarding best practice around initial assessment of patients and although this is not limited to the diagnosis of pulmonary embolism, this report will inform this work. There is also on-going work on education provided by the College both in diagnostic decision making, but also specifically in the diagnosis and management of pulmonary embolism and the differentiation of the various conditions that may present in a similar fashion. This is delivered by the Education Department of the Royal College and includes education modules on its electronic learning platform, on many of their conferences and study days. Skill in diagnosis is imbedded within the curriculum for trainees within the emergency Medicine (specifically SLO2 which includes decision making in the physiological stable patient and management of the complexity and uncertainty). The Quality in Emergency Care committee of the Royal College includes safety and best practice Committees. These Committees review HSIB publications along with much other sources of intelligence such as the NHSLA, the GIRFT Programme and NICE Guidance. These Committees will consider whether further guidance is required and regularly publish safety alerts regarding decision making and important conditions such as pulmonary embolism. I hope this reassures the HSIB that this report has been given consideration and the Royal College is acting on this safety recommendation. Actions planned to deliver safety recommendation: Review of best practice for initial assessment processes. By: Current review and guidance update by end 2022. Implementation of new curriculum, including management of the ambulatory patient, and clinical decision making domains. By: First year of new curriculum ends August 2022, ongoing. Other dependencies: Delivery of curriculum by Deanery and local education providers. GMC approval of curriculum. Additional comments: Curriculum is reviewed 3 yearly, under auspices of GMC. Education activity specifically around Pulmonary embolism, including e-learning, and events. By: ongoing. Review of intelligence from safety, and other organisations related to Pulmonary Embolism. By: ongoing. Response received on 14 June 2022.
Safety Observations (6)
It may be beneficial for healthcare to learn from other industries and develop its own evidence base on strategies to accelerate the development of expert decision-making skills. These strategies may include:
development of a generic decision tool for implementation in healthcare training and clinical practice to support analytical decision making
incorporation into education programmes of theory around how people make decisions and influences on decision making
the use of simulation as a regular intervention to support practice and development of decision-making skills across scenarios with different levels of complexity
consideration of the role of simulation in competency assessments for key skills.
It may be beneficial if the findings of this investigation are used to support the development of staff expertise in decision making through:
building understanding of how experts think and make decisions
supporting reflection on the outcomes of simple and complex decisions
development of clinical supervision skills of senior staff
regular multidisciplinary case review.
It may be beneficial for individual organisations to understand the extent to which national guidance on the diagnosis and management of pulmonary embolism is implemented across their organisations. This would help to identify local barriers to implementation to address. In particular it may be helpful to consider, in line with the findings of this investigation, local engagement with the scoring systems available to help predict the likelihood of a pulmonary embolism.
It may be beneficial for emergency departments and same-day emergency care units to have rapid access to recommended imaging for patients who require it for the diagnosis of pulmonary embolism.
It may be beneficial for the positivity standard for computerised tomography pulmonary angiography (CTPA) (that at least 15% of CTPAs should show a pulmonary embolism) to be evaluated to understand its effects on emergency department decision making.
It may be beneficial for healthcare work procedures to be written in line with the principles for effectiveness and usability provided by the Chartered Institute of Ergonomics and Human Factors.