David H. Wesorick, MD; Vineet Chopra, MD, MSc
Disclosures: Dr. Chopra reports grants from the Agency for Healthcare Research and Quality. Dr. Wesorick has disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1400.
The diagnosis of suspected pulmonary embolism (PE) is best approached by using an algorithm that includes the estimation of pretest probability, the selective use of D-dimer testing (in patients with low or moderate pretest probability), and the use of appropriate imaging tests (which can include lower-extremity compression ultrasonography, computed tomography (CT) pulmonary angiography, or ventilation–perfusion scanning). The authors provide a diagnostic algorithm incorporating these tests and strategies.
The use of pretest probability tools can help clinicians decide when imaging is necessary, but it can also be helpful in detecting false-positive imaging results. For example, the posttest probability of PE in a patient with low pretest probability and a positive CT pulmonary angiogram is only 30%. Positive scans in these patients should be reviewed with an imaging specialist.
Pretest probability tools have not been well-studied in hospitalized patients, and D-dimer testing is not useful in this population. Therefore, the authors recommend that the evaluation of hospitalized patients with suspected PE forgo the algorithmic approach and move directly to imaging.
Patients undergoing peripheral arterial revascularization have a very high 30-day readmission rate.
Although procedural complications account for the largest segment of these readmissions (28%), sepsis (8.3%), diabetes (7.5%), and congestive heart failure (4.4%) are also important causes of readmission.
Readmitted patients were more likely to have comorbid conditions, such as chronic limb ischemia, obesity, hypertension, congestive heart failure, diabetes, or renal disease.
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Jason Stein MD, Susan Shapiro PhD RN
1Unit and Nell Hodgson Woodruff School of Nursing at Emory University, Atlanta, Georgia.
March 2, 2018
Conflict of Interest:
Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-3334
Formal Response to Dr. Mossad
Dr. Mossad raises an important question about integrating consulting physicians in interdisciplinary rounds and accurately enumerates reasons why physical integration is usually impractical. We offer these additional considerations. First, consistent start times and structure are critical to the success of interdisciplinary rounds and therefore must be driven by the synchronized workflows of unit-based physicians and staff. Second, if specialists lack training and practice in interdisciplinary rounds they may adversely impact efficiency and effectiveness. Third, it is often sufficient to integrate the inputs of specialists, rather than the specialists themselves. The most viable approach is to treat the inputs of consulting physicians like any other data that should be shared during interdisciplinary rounds: the physician leading rounds should convey these inputs as part of the structured update and include specific recommendations as part of the proposed plan. We believe consulting physicians can contribute significantly to effectiveness and efficiency by actively pushing their inputs to the attending physician through face-to-face communication, phone, text, or video chat – or even indirectly via the chart – ahead of interdisciplinary rounds. Regarding the concept of online virtual interdisciplinary rounds, we share Dr. Mossad’s sense that static virtual inputs via the electronic medical record do not deliver enough value to supersede dynamic exchanges with the opportunity for questions or clarifications. However, we have been impressed with how smart phone-based video chats allow remote family members or loved ones a chance to attend virtually so they can hear, be heard, and positively influence interdisciplinary rounds.
Wesorick DH, Chopra V. Annals for Hospitalists - 16 January 2018. Ann Intern Med. ;168:HO1. doi: 10.7326/AFHO201801160
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Published: Ann Intern Med. 2018;168(2):HO1.
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