HSIB - Clinical decision making: diagnosis of pulmonary embolism in emergency departments (24 March 2022)

Summary

This investigation by the Healthcare Safety Investigation Branch (HSIB) explores the timely recognition and treatment of suspected pulmonary embolism in emergency departments.

Pulmonary embolisms can form when clots from the deep veins of the body, usually originating in the legs, travel through the venous system and become lodged in the lungs. A person suffering from a pulmonary embolism requires urgent treatment to reduce the chance of significant harm or death.

Content

Investigation scope

This national investigation:

• examined clinical decision making in the diagnosis and treatment of pulmonary embolism (PE) and the role of expertise (significant knowledge and skill that supports effective and practical decision making) using an Applied Cognitive Task Analysis (ACTA).
• identified factors in the wider healthcare system that support or inhibit diagnostic decision making when staff are seeing patients with non-specific symptoms and signs that may suggest PE.

Findings

• Recognising that a person may have a PE is challenging, particularly for less experienced staff and when the person’s signs and symptoms are non-specific or atypical.
• Deciding whether to initiate treatment for a suspected PE requires a decision that balances risks, and this decision can benefit from expert knowledge and skill.
• Despite expertise and the available tools to help identify patients who may have a PE, a small number of PEs may always be missed.
• Experts use different thought processes and show different behaviours when making decisions compared to more novice staff.
• Decision-making skills in healthcare are commonly developed through experience, without formal training or opportunities to practise making decisions.
• Simulation-based learning has the potential to help staff acquire decision making skills more quickly.
• Other industry sectors, such as aviation and the fire service, aim to accelerate the development of decision-making skills through structured training and the use of ‘generic decision tools’ for analytical decisions.
• Emergency departments (EDs) do not always provide the conditions which support the development of decision-making skills.
• Decision making in EDs is affected by workload, workforce availability, and performance targets.
• ED staff asked for further guidance to be provided on the use of decision aids to support the diagnosis of PE.
• The design of ED processes influences the decisions staff make. There is no standard model of initial patient assessment in EDs; this contributes to variation in the requesting of tests which can affect later decisions.
• Pathways for the diagnosis and treatment of PE in outpatient settings may create a safety risk where patients are discharged on anticoagulation medicines without a confirmed diagnosis; the capacity of imaging services is a significant contributor to this.
• Loss of clinical information when a patient’s care is handed over was identified as a further safety risk. This can contribute to harm if tests, such as D-dimer (a blood test used as part of the assessment of likelihood of PE), are not followed up.
• Work procedures for the diagnosis and treatment of PE are not routinely designed in line with human factors principles to support their access and use.
• The physical design of environments may also affect decision making.

Safety observations

1. 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; and consideration of the role of simulation in competency assessments for key skills.
2. 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; and regular multidisciplinary case review.
3. 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.
4. 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.
5. 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.
6. 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.