Quality statement 2All patients with confirmed acute PE or on an outpatient pathway for suspected acute PE should have their clinical risk assessed including the use of a validated risk score (PESI, s-PESI, Hestia).
Rationale
  • Early risk stratification of patients with suspected or confirmed acute PE identifies those at higher and lower risk of death. The use of a risk stratification tool, such as PESI and s-PESI (online supplementary appendices 1-2), therefore enables patients to be optimally managed in the most appropriate setting within hospital or in their own home.

  • Clinical exclusion tools, such as the Hestia criteria (online supplementary appendix 3), have also been developed to identify people who are not suitable for outpatient management.

  • It is recommended that all patients with confirmed acute PE or on an outpatient pathway for suspected acute PE undergo risk stratification using one of these tools before a decision is made to manage them in an outpatient setting.

Quality measureStructure:
  • Evidence that all patients with confirmed acute PE or on an outpatient pathway for suspected acute PE have been risk-stratified using a validated clinical risk score (eg, PESI, s-PESI, Hestia).


Process:
  • The proportion of patients presenting to hospital with a new presentation of confirmed acute PE or on an outpatient pathway for suspected acute PE who have been risk stratified using a validated clinical risk score.


Numerator: The number of patients presenting to hospital with a new presentation of confirmed acute PE or on an outpatient pathway for suspected acute PE who have been risk stratified using a validated clinical risk score.
Denominator: The total number of patients presenting to hospital with a new presentation of confirmed acute PE or on an outpatient pathway for suspected acute PE.
Description of what the quality statement means for each audienceService providers:
  • Should ensure that clinicians who assess patients with confirmed acute PE or patients on an outpatient pathway for suspected acute PE are appropriately trained and have sufficient time to carry out clinical risk assessments in these patients.

  • Should ensure that local guidelines and standard operating procedures are in place which provide sufficient guidance on carrying out risk assessments.


Healthcare professionals:
  • Should ensure that they are adequately trained to carry out risk assessments in patients with confirmed acute PE or patients on an outpatient pathway for suspected acute PE, and that they use the outcomes from risk assessments to guide management.


Commissioners:
  • Should ensure that they commission services that have local guidelines and standard operating procedures in place regarding clinical risk assessments and that are adequately resourced to carry these out.


People who present with confirmed acute PE or patients on an outpatient pathway for suspected acute PE
  • Should expect to undergo a clinical risk assessment to help determine the most appropriate place for them to receive their initial care.

Relevant existing indicators/data sources
  • BTS Guideline for the Initial Outpatient Management of Pulmonary Embolism (2018).2

  • NICE Clinical Guidelines 144 (2015).3

  • NICE Quality Standards 29 (2016).4

  • Royal College of Physicians of Edinburgh and Society of Acute Medicine; Standards for Ambulatory Emergency Care (2019)5

Source references
  • BTS Guideline for the Initial Outpatient Management of Pulmonary Embolism (2018).2

  • Derivation and validation of a prognostic model for pulmonary embolism (2005).6

  • Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism (2010).7

  • Outpatient treatment in patients with acute pulmonary embolism: the Hestia Study (2011).8

DefinitionsSuspected PE: clinical suspicion of PE (history, symptoms, signs, PE likelihood score and initial investigations including D-Dimer) without a radiological diagnosis.