Clinical decision making: diagnosis of pulmonary embolism in emergency departments

National investigation

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.

PE can form when clots from the deep veins of the body, mostly originating in the legs, travel through the venous system and become lodged in the lungs.

The diagnostic tool most commonly used to detect PE is a computerised tomography pulmonary angiogram (CTPA). The most common treatment is giving of anticoagulants which can breakdown existing clots and prevent further clots from forming.

Any delay in recognising the symptoms of PE and treatment of the suspicion of PE increases risk that a patient may suffer harm.

Reference event

We started this investigation after analysis of evidence from another HSIB investigation: management of venous thromboembolism risk in patients following thrombolysis for an acute stroke.

At the time of investigation access to emergency departments was limited because of the COVID-19 pandemic, and the investigatory approach was therefore adapted.

Rather than examining a reference event, the investigation reviewed 14 serious incident reports obtained from hospitals across England. This review identified the terms of reference for the national investigation.

Investigation summary

The national investigation focused on emergency departments and:

examined clinical decision making in the diagnosis and treatment of 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.

Safety recommendations

Health Education England

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 (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

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.

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

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.

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.