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Lazomis QI · Audit Tool

Pulmonary Embolism Audit

Baseline audit

Planning
Data Collection

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

Recent records

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