POLICY UNDER REVIEW Please note that this policy is under review. It does, however, remain current Trust policy subject to any recent legislative changes, national policy instruction (NHS or Department of Health), or Trust Board decision. For guidance, please contact the Author/Owner. Document Title Suspected Pulmonary embolus Ambulatory Pathway Date Issued/Approved: Date Valid From: 11/11/17 Date Valid To: 11/05/18 Directorate / Department responsible (author/owner): Contact details: 01872 253827 Andrew McSorley, Thrombosis Nurse Specialist Brief summary of contents Suggested Keywords: Target Audience Executive Director responsible for Policy: Date revised: This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Divisional Manager confirming approval processes Name and Post Title of additional signatories Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Links to key external standards Related Documents: Training Need Identified? Suspected Pulmonary embolus Ambulatory Pathway RCHT PCH CFT KCCG Medical Director Under review Vicky Peverelle {Original Copy Signed} Internet & Intranet Intranet Only Clinical / Anticoagulation and Thrombosis Page 1 of 2
This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Page 2 of 2
15 Minutes Arrival Appendix 1. Suspected Pulmonary Embolus Ambulatory - Pathway Click here for the Suspected Pulmonary Embolus Ambulatory Pathway guidance Key: General Notes ED/MAU/SRU/Acute GP/Amb-Care Start GP/SWASFT In-patient wards Symptoms suggestive of a Pulmonary Embolus Senior first assessment if possible Clinically assess patient and take a full history Any indicators of clinical instability including: Altered level of consciousness. Systolic BP of less than 100 mmhg. Heart rate of more than 110 beats per minute. Respiratory rate of more than 30 breaths per minute. Oxygen saturation of less than 94%. No - commence ambulatory pathway Perform a Wells Score Chest Xray, ECG, Bloods including FBC, UE, LFT, CRP, D- Dimer, clotting Yes senior clinical review Follow ambulatory pathway to expedite investigation if senior assessment indicates this is clinically safe Consider admission and initiate urgent management <4 Wells Score 4 Wells score 4 Do not perform D-Dimer. CTPA indicated. 1 Suspected Pulmonary Embolus Ambulatory - Pathway Page 1 of 4 2
4 hours 2 hours 1 2 Negative Consider alternative diagnosis D-Dimer Positive Request CTPA. If it is not possible to perform a CTPA on the same day then use clinical assessment, ECG and PESI score to ensure patient is suitable to go home after appropriate dose of anticoagulation. Consider community management Consider transfer to ambulatory care unit if patient in ED Positive for PE Consider whether PE was provoked or unprovoked. Anticoagulate as appropriate CTPA Negative for PE Consider alternative diagnosis including DVT Request troponin and combine with ECG findings and PESI score to assess whether patient is safe to be managed in the community Discharge to GP care if clinically stable End Suspected Pulmonary Embolus Ambulatory Pathway Page 2 of 4
Wells Probability Scoring Clinical Features Score Signs of DVT (swelling and tenderness) 3 PE most Likely diagnosis 3 HR > 100 1.5 Previous PE or DVT 1.5 Surgery or Immobilisation 1.5 Cancer diagnosis, recently treated 1 Haemoptysis 1 Total Score <4 (Low Probability) D-Dimer Negative No need to give LMWH prior to investigation <4 D-Dimer Positive Needs LMWH if delayed investigation >4 High Probability LMWH if investigation Delay PES1 Predictor Table Independent Predictors of 30 Day Mortality and points assigned Predictor Points Age per year Age in years Male Sex +10 Cancer +30 Heart Failure +10 Chronic Lung Disease +10 Pulse >110 +20 Systolic BP <100 +30 RR >30 +20 Temp <36 +20 Altered Mental State +60 SATS <90% +20 Total Class 1 Very Low Risk 66-85 Class 2 Low Risk 86-105 Class 3 Intermediate Risk 106-125 Class 4 High Risk >125 Suspected Pulmonary Embolus Ambulatory Pathway Page 3 of 4
Notes Out of Hours If a community GP or an out of hours GP or ED staff suspect a PE, in a stable patient, when the Acute GP service is closed, they can perform an ECG, treat with appropriate anticoagulation and book the patient into the Acute GP Clinic by phoning the Serco call handlers on 01872 226704. The Acute GP service is open 8.30am 7pm weekdays and 10am 5pm weekends Please do not give the patient an appointment or ask the patient to arrive at the Acute GP service the following morning; the Acute GP will contact the patient by phone before 10.30 am the following morning, 7 days a week. The patient should be given the phone number for the Acute GP service 01872 253566 with instructions to ring if they have not been contacted by 10.30am the following morning. Suspected Pulmonary Embolus Ambulatory Pathway Page 4 of 4