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Lazomis QI · Audit Tool

Pulmonary Embolism Audit

Baseline audit

Planning
Improvement

Move from findings to practical improvement planning for the Pulmonary Embolism Audit.

Use your baseline findings to plan improvement actions, PDSA cycles and re-audit. Start data collection

1. Baseline findings summary

Improvement summary will populate when sufficient submissions are available.

2. Key gaps identified

Analysis will populate when sufficient submissions are available.

3. Root causes and contributory factors

Consider people, process, environment, equipment/IT, documentation, communication, training, policy and workload.

4. Improvement aim

What are you trying to improve, by how much, for whom, and by when?

5. Suggested local improvement actions
Local implementation ideas, not national guidance
  • Use your baseline findings to plan improvement actions, PDSA cycles and re-audit.

PE improvement themes for local consideration

Recognition of suspected PE

Prompts to consider PE early in breathlessness, pleuritic pain and collapse presentations.

PE Wells documentation

Structured clerking fields for the PE Wells score and category.

D-dimer use

Align D-dimer requesting with the PE unlikely pathway and reduce inappropriate testing.

Imaging delays

Review CTPA turnaround, out-of-hours access and escalation for delayed imaging.

Interim anticoagulation

Ensure interim therapeutic anticoagulation is started where imaging is delayed and indicated.

Renal function and dosing

Check renal function before anticoagulant choice and dose, in line with local policy.

Bleeding risk

Document bleeding risk and contraindications before anticoagulation.

Confirmed PE risk stratification

Embed risk stratification into the confirmed PE pathway.

Ambulatory PE pathway

Increase appropriate use of the low-risk ambulatory PE pathway with clear follow-up.

Anticoagulation counselling

Standardise counselling on agent, duration, bleeding risk and safety-netting.

Discharge summary and follow-up

Include PE diagnosis or exclusion, anticoagulation plan and follow-up in the discharge summary.

Haemodynamic instability escalation

Clarify escalation to senior, critical care and the thrombolysis pathway.

Pharmacy and anticoagulation safety

Pharmacy review of anticoagulant choice and dose, particularly in renal impairment.

Weekend and out-of-hours variation

Compare pathway performance in and out of hours and address gaps.

Re-audit and sustainability

Plan repeat measurement and embed changes into routine practice.

6. Action plan

Add local improvement actions here.

7. PDSA cycle log

Add details of PDSA cycle or intervention here.

8. Intervention log, sustainability and learning

Changes that do not fit neatly into a PDSA cycle: name, date introduced, target group, lead and evidence of implementation.

What must continue, who owns it, and how will performance be monitored?

What worked well, what was difficult, what would be done differently?

Governance issue addressed, committee, escalation, action owner and evidence shared.

Your role, contribution to data collection, analysis, intervention design and dissemination, plus reflection.

Lazomis QIP supports quality improvement, audit and governance activity. It does not replace clinical judgement, professional responsibility, local policy or organisational governance processes.

Plan your re-audit