The PE Test: EM Efficacy in Sweden

Published on February 7, 2013
In a recent Swedish study, it was shown that emergency physicians are more accurate in detecting pulmonary embolism in the emergency department than internal medicine physicians.

Detecting the emergency of non-fulminant pulmonary embolism (PE) still is one of the major problems presenting to the emergency physician. Signs and symptoms of PE most often are discrete and non-specific. Non-invasive investigation and laboratory parameters can be misleading, and the final diagnosis often is stated by radiologic investigation. To help physicians to suspect PE several scoring systems have been developed. In Sweden, the use of the Wells score is emphasized by the national board of health.

Emergency medicine in Sweden still is a developing field of medicine and was recognized as late as 2008 as a subspecialty. Thus, most of the emergency physicans working at the emergency department still are residents under continuous education and the guards are shared by emergency physicians and physicians otherwise working at the different wards.

Objective

Due to their specialisation in the field of emergency medicine, it could be suspected that emergency physicians might be better in detecting the otherwise discrete findings of pulmonary embolism in emergency patients. To confirm this hypothesis, a single center restrospective cohort-study was performed.

Methods

During the three-month periods (March to May) 2007 and 2008 the findings in all patients undergoing pulmonary CT-angiography at the emergency department of our university hospital were reviewed. The investigations were attributed to emer- gency physician (EP) or internal medicine physician (IP). Both negative and positive findings were evaluated, and the number of medical patients treated by the respective group were calculated according to the computerized triage system as each emergency physician signs for the patient he is treating. Statistical analysis was performed by the Students-T-test, and probability levels of 5% were accepted as significant.

Results

During March till May 2007, a total of 2847 patients attended for medical problems, 576 of which were treated by EP (20.23%). The rest of the patients (79.77%) were treated by IP. In March till May 2008, 2408 patients searched for medical problems and 625 (25.95%) were attended by EP. During this period, EPs ordered a total of 34 pulmonary CT in 2007 and 35 in 2008. 17.64% (2007) and 22.86% (2008) of these resulted in confirmation of the diagnosis of pulmonary embolism. IP ordered 77 (2007) and 64 (2008) pulmonary CTs during this period, resulting in 12.98% (2007) and 10.93% (2008) of positive findings, respectively. Calculating these numbers on the total of patients attended by the dif- ferent groups, EPs ordered pulmonary CT for 5.9% (2007) resp. 5.6% (2008) of their patients, whilst IP performed CT-scans in 3.39% (2007) resp. 3.59% (2008) of their patients (p=0.0108). This means that EPs had a higher index of suspicion for the diagnosis of PE in the context of the emergency department (1.74 (2007) resp 1.56 (2008) vs 1.0 for the IP).

For the total of patients attended at the emergency department, this resulted in positive findings for pulmonary CT in 1.04% (2007) and 1.28% (2008) for the EP, and in 0.43% (2007) and 0.39% (2008) for the IP (p<0.01). This means that emergency physicians are more accurate in detecting PE in the context of the emergency department.

Thus, the odds-ratio to have a positive finding on a pulmonary CT by an EP compared to an IP was 2.43 in 2007 and 3.26 in 2008. The total percentage of positive findings for the hospital including the emergency department was 14.29% (2007) and 14.15% (2008) on a total of 259 resp 212 CT-scans, and excluding the emergency department 14.19% (2007) and 13.27% (2008) on 148 resp 113 CT-scans. No significant difference could be found between the positive findings for all the hospital compared to the EP (p=0.38) or IP (p=0.27).

Conclusion

Emergency physicians seem to have a higher index of suspicion for PE than internal medicine physicians and are more accurate in detecting PE in the emergency department. Compared with the total of our university hospital, emergency physicians are at least comparable in diagnosing PE.

EPI Editorial Note: To learn more about emergency medicine efficacy, read “The efficacy and value of emergency medicine: a supportive literature review,” written by, among others, EPI executive editors Jim Holliman, Terrence Mulligan, Peter Cameron and Lee Wallis.

From the Fall 2012 issue of Emergency Physicians International

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