Use anonymised case identifiers only. Do not enter patient name, NHS number, hospital number, date of birth or address.
Case and context
Presentation and stability
Clinical probability and D-dimer
Imaging
Anticoagulation
Risk stratification, escalation and follow-up
Audit criteria — Presentation and initial assessment
1. Symptoms and clinical features suggestive of PE documented.
NICE NG158
2. Initial observations and haemodynamic stability documented.
NICE NG158 / local policy
3. Alternative diagnoses considered where appropriate.
NICE NG158
4. Relevant initial investigations completed where indicated.
Local policy
Audit criteria — Clinical probability and D-dimer
5. Clinical probability assessed.
NICE NG158
6. PE Wells score documented where PE suspected.
NICE NG158
7. PE Wells category documented or clearly inferable.
NICE NG158
8. PERC considered where low clinical suspicion and local pathway supports it.
Local PE diagnostic pathway
9. D-dimer requested where indicated.
NICE NG158
10. D-dimer result documented and acted on appropriately.
NICE NG158
Audit criteria — Imaging
11. CTPA or alternative imaging requested where indicated.
NICE NG158
12. VQ imaging or alternative pathway considered where CTPA unsuitable.
NICE NG158
13. Reason CTPA unsuitable documented where applicable.
Local imaging protocol
14. Imaging completed within locally agreed timeframe where indicated.
Local imaging protocol
15. Imaging result documented and acted on.
NICE NG158
Audit criteria — Anticoagulation
16. Interim therapeutic anticoagulation started where indicated.
NICE NG158
17. Reason interim anticoagulation not given documented where applicable.
Local anticoagulation policy
18. Baseline blood tests completed or reviewed when anticoagulation started.
NICE NG158
19. Renal function reviewed before anticoagulant choice or dosing where relevant.
NICE NG158 / local renal dosing guidance
20. Bleeding risk and contraindications to anticoagulation considered.
NICE NG158
21. Anticoagulant choice appropriate to local policy, renal function and clinical context.
Local anticoagulation policy
22. Anticoagulant dose appropriate to renal function, weight and indication where relevant.
Local anticoagulation policy
Audit criteria — Risk stratification and escalation
23. Confirmed PE risk-stratified according to local policy.
Local PE management policy
24. Low-risk PE outpatient / ambulatory suitability assessed where appropriate.
BTS outpatient management of PE
25. Monitoring and follow-up agreed for outpatient or ambulatory PE management.
BTS quality standards for outpatient PE
26. Haemodynamic instability, shock or high-risk PE escalated urgently where relevant.
Local escalation pathway
27. Critical care, senior, respiratory, thrombosis or specialist review completed where indicated.
Local escalation pathway
28. Thrombolysis / reperfusion pathway considered where indicated by local policy.
Local thrombolysis pathway
Audit criteria — Discharge, counselling and follow-up
29. Anticoagulation duration or review plan documented.
NICE NG158
30. Patient anticoagulation counselling and safety-netting documented.
NICE NG158 / local patient information standard
31. Discharge summary included PE diagnosis or exclusion, anticoagulation plan and follow-up where relevant.
Local discharge and follow-up policy
32. Thrombosis, anticoagulation, respiratory or ambulatory follow-up arranged where required.
NICE NG158 / local policy
Audit criteria — Documentation and safety
33. Reason for delayed, missing or incomplete PE pathway step documented where applicable.
Local policy
34. Documentation clear enough for another clinician to understand PE probability, diagnostic decision, treatment and follow-up.
Local documentation standard
35. Any PE-related safety concern escalated or actioned where identified.
Local governance policy
Comments
No records yet. Completed records appear here and in Submissions.