Group 1 Presentation Pulmonary Embolism

1. Group 1 PresentationPulmonary Embolism • Introduction to Pulmonary Embolism • Typical Scenario • Team Based Approach • Nurse • Physician • History and Examination • Barriers to Care • Decision Support Tools • General Overview • Prediction Rules and Calculators • EHRs and Applications • Tests • Diagnosis and Treatment Plan

2. Introduction to Pulmonary Embolism http://video.about.com/quitsmoking/Pulmonary-Embolism.htm

3. Patient Scenario • 65 year old woman • Sudden onset of shortness of breath • Has not seen this physician before • No electronic health record on file • Non-Smoker • Moderate exercise each week • Traveled to see relatives on a five hour plane ride

4. Team-Based Diagnosis and Treatment of PE • Many members of the healthcare team are involved in helping diagnose, treat, and educate patients • Patients with Pulmonary Embolism frequently enter the system through the ER • Triage personnel, including nurses play a major role in early assessment, information gathering, and patient comfort

5. The Role of NursesFirst Step in the Process • Nurses are at the forefront of patient care • Estimated shortage of 340,000 nurses by 2020 • Govern every clinical aspect of medicine, from ER care to geriatrics

6. Nurse Responsibilities Taking vital signs Providing Initial Assessments Providing patient notes for clinicians Implement physician orders

7. Nurse Interview Nurse : Hello my name is ____, I will be your nurse today. Just in case you forget, I will write my name on the board as well as the hours I am here today. Mr.____, I see that you’re here because you’re not feeling well. Can you please explain to me what’s going on? Patient’s response: Nurse: I see, well I will certainly convey these details to Dr.___. Now Mr. ____, I need to take your pulse, blood pressure, and temperature, is that ok? Patient’s response: Yes. Nurse takes his blood pressure. Nurse: I see that your blood pressure is a bit elevated. Do you normally have high blood pressure? Patient’s response:

8. Nurse: Assessing Situations • First protective barrier in preventing epidemics • Nursing process includes – methods to assess, diagnose, plan, and intervene Note: For information only, no narrative included on this slide

9. Nurse’s Next Step: Consulting the Physician • Effectively communicate with physician regarding the patient’s health • Take detailed notes for the physician • Take down orders from the physician

10. Physician Interview • Time is of the essence • Time management is critical and the physician must be efficient. • Making the correct diagnosis • A physician is not always so lucky to find an easy diagnosis of say a dislocated finger or someone needing stiches. • Difficult diagnoses such as Pulmonary embolisms can slow a down a physician in the emergency department, but special care must be taken to not miss this potentially fatal diagnosis. • Use clues given to you by the nurse • Nurses will gather a lot of clues during the initial interview, one must not duplicate efforts by repeating questions.

11. The Interview ProcessOpen vs Closed Questions • Open Questions: • Questions that require a longer response • A dialog form • “Tell me more about that” • “What brought you in today” • Closed Questions: • Have a limited scope of appropriate answers • Sometimes require just “yes” or “no” responses. • “Do either of your legs hurt?” • “Is there any pain while breathing?” • Both used to gain “clues”.

12. Provider Interview: Open and Closed Questions Physician: Hello Ms. Benes, I’m Dr. Van Nostrand, why don’t we start with you telling me a little bit about what brought you in today. Patient: Well, it started yesterday when I was gardening with my grandchildren. I stood up too quickly and became lightheaded. After that happened I went inside to rest for a bit and since then I have been finding it difficult to catch my breath. I really think it is nothing, but my daughter insisted that I come in to see you. I don’t see the point in wasting time when we have so much to do before I leave on Friday. Physician: Yes, the nurse tells me you are here visiting and you flew in from Texas. So it sounds like you have shortness of breath and some lightheadedness. Is this correct? Is there anything else are you experiencing? Patient: I suppose, I have had a little bit of a cough since I have arrived, but a lot of times the air here will bother me. I think it is all of the car exhaust. Physician: What about any pain in one or both of your legs? Patient: No, I don’t believe so. Physician: I noticed you have been coughing a little bit. Is that new? Patient: Yes, it started this morning.

13. Provider Interview: Open and Closed Questions Cont. Physician : When you cough is it productive? That is, does anything come out? Patient : No, not really, it is just a tickle in my throat really. Physician : Have you been traveling a lot recently, before this trip? Patient : Yes, I just retired so I’m seeing all my grandchildren. Physician : Do you happen to know if you have ever had a pulmonary embolism before? Patient : I haven’t even heard of that before, so I don’t think so. Physician : Have you had surgery recently? Patient : No, I have not. Physician : Okay, I understand. If it is alright with you, I’m going to preform my examination now.

14. Barriers to for Making Diagnosis • Limits to patients information • No access the patients medical record. • Pulmonary embolism is a difficult diagnosis to make • There is no one thing that established or negates diagnosis • The symptoms like dyspnea are very common • PE is potentially fatal so special concerns must be given. • There are a lot of potential indicators of PE, it would be hard to remember all of them • Testing does not solve the problem on its own • Most tests lack appropriate sensitivity or specificity to be used in isolation

15. How Evidence Based Health Information Helps With Diagnoses • Clinical Trials • ClinicaltTrials.Gov • Clinical prediction rules • Clinical prediction pathways • Diagnosis decision support tools • MedCal • Wells PE Scoring System • Revised Geneva Scoring System • EHR • Shared Electronic Health Records

16. Physician ResourcesClinical Trials http://www.clinicaltrials.gov/ct2/results/map?cond=%22Pulmonary+Embolism%22

17. Physician ResourcesClinical Decision Pathways http://www.imagingpathways.health.wa.gov.au/includes/dipmenu/pe/chart.html

18. Physician ResourcesClinical Decision Pathways http://www.hearthealthywomen.org/tests-diagnosis/featured/deep-vein-thrombosis-a-pulmonary-embolism-diagnosis.html

19. Physician ResourcesWells PE Scoring System

20. Physician ResourcesRevised Geneva PE Scoring System

21. EHR and CDS Tools • Clinical prediction tools have been shown to be efficient, accurate, and safe for guiding non-invasive testing for PE • Providers aren’t always willing to use systematic approaches • Educational interventions and paper guidelines generally have little effect • Computer-based clinical decision support tools may be beneficial

22. Shared Electronic Health Records

23. Shared Electronic Health Record • Benefits • Decease duplicated effort • Increased efficiency • Decease cost • Increase patient safety • Complete patient profile • In This Case Study • Presence of previous diagnoses of pulmonary embolisms or vein thrombosis would have altered the patients Wells PE scoring system

24. EHR and CDS Tools Diagnostic Work-Up PE Prediction

25. EHR and CDS Tools Diagnostic Work-Up PE Prediction

26. EHR and CDS Tools CT Pulmonary Angiography Decision Support d-Dimer level and clinical suspicion entry tools and decision support statements 1 and 2. Raja A S et al. Radiology 2012;262:468-474

27. EHR and CDS Tools I-Phone QxMD PE Clinical Probability Calculator

28. Medical Informatics and Nursing • Picture Archiving and Communication System (PACS) • Computerized Physician Order Entry (CPOE) • Epic System

29. Pulmonary Embolism Tests • D-Dimer Blood Test • High levels may suggest clotting • Chest X-Ray • Can’t detect PE • Ventilation-Profusion Scan (lung scan) • Show blood flow to lungs • Not as reliable for smokers • Spiral Computed Tomography (CT) • Increased precision for detection • Faster than conventional CT scan • CT Pulmonary Angiogram (CTPA) • Very precise – “Gold Standard” • Expensive, invasive, risky • Ultrasound • Bedside U/S in EDs • MRI • Pregnant/dye-sensitive patients

30. Case Diagnosis

31. Treatment Plan