Audit Criteria — Pulmonary Embolism Audit

Audit criteria

35 criteria assessed for each included episode. Denominator is Yes plus No; Not applicable and Unable to determine are excluded from scoring.

Local compliance target: 95%. Criteria are recorded on the Data Collection form. National guidance is distinguished from local implementation below.

Presentation and initial assessment

#	Criterion	Source	Designation	Compliance
1	Symptoms and clinical features suggestive of PE documented.	NICE NG158	national guidance	—
2	Initial observations and haemodynamic stability documented.	NICE NG158 / local policy	national guidance	—
3	Alternative diagnoses considered where appropriate.	NICE NG158	national guidance	—
4	Relevant initial investigations completed where indicated.	Local policy	local policy	—

Clinical probability and D-dimer

#	Criterion	Source	Designation	Compliance
5	Clinical probability assessed.	NICE NG158	national guidance	—
6	PE Wells score documented where PE suspected.	NICE NG158	national guidance	—
7	PE Wells category documented or clearly inferable.	NICE NG158	national guidance	—
8	PERC considered where low clinical suspicion and local pathway supports it.	Local PE diagnostic pathway	local policy	—
9	D-dimer requested where indicated.	NICE NG158	national guidance	—
10	D-dimer result documented and acted on appropriately.	NICE NG158	national guidance	—

Imaging

#	Criterion	Source	Designation	Compliance
11	CTPA or alternative imaging requested where indicated.	NICE NG158	national guidance	—
12	VQ imaging or alternative pathway considered where CTPA unsuitable.	NICE NG158	national guidance	—
13	Reason CTPA unsuitable documented where applicable.	Local imaging protocol	local policy	—
14	Imaging completed within locally agreed timeframe where indicated.	Local imaging protocol	local QI target	—
15	Imaging result documented and acted on.	NICE NG158	national guidance	—

Anticoagulation

#	Criterion	Source	Designation	Compliance
16	Interim therapeutic anticoagulation started where indicated.	NICE NG158	national guidance	—
17	Reason interim anticoagulation not given documented where applicable.	Local anticoagulation policy	local policy	—
18	Baseline blood tests completed or reviewed when anticoagulation started.	NICE NG158	national guidance	—
19	Renal function reviewed before anticoagulant choice or dosing where relevant.	NICE NG158 / local renal dosing guidance	national guidance	—
20	Bleeding risk and contraindications to anticoagulation considered.	NICE NG158	national guidance	—
21	Anticoagulant choice appropriate to local policy, renal function and clinical context.	Local anticoagulation policy	local policy	—
22	Anticoagulant dose appropriate to renal function, weight and indication where relevant.	Local anticoagulation policy	local policy	—

Risk stratification and escalation

#	Criterion	Source	Designation	Compliance
23	Confirmed PE risk-stratified according to local policy.	Local PE management policy	local policy	—
24	Low-risk PE outpatient / ambulatory suitability assessed where appropriate.	BTS outpatient management of PE	national guidance	—
25	Monitoring and follow-up agreed for outpatient or ambulatory PE management.	BTS quality standards for outpatient PE	national guidance	—
26	Haemodynamic instability, shock or high-risk PE escalated urgently where relevant.	Local escalation pathway	local policy	—
27	Critical care, senior, respiratory, thrombosis or specialist review completed where indicated.	Local escalation pathway	local policy	—
28	Thrombolysis / reperfusion pathway considered where indicated by local policy.	Local thrombolysis pathway	local policy	—

Discharge, counselling and follow-up

#	Criterion	Source	Designation	Compliance
29	Anticoagulation duration or review plan documented.	NICE NG158	national guidance	—
30	Patient anticoagulation counselling and safety-netting documented.	NICE NG158 / local patient information standard	national guidance	—
31	Discharge summary included PE diagnosis or exclusion, anticoagulation plan and follow-up where relevant.	Local discharge and follow-up policy	local policy	—
32	Thrombosis, anticoagulation, respiratory or ambulatory follow-up arranged where required.	NICE NG158 / local policy	national guidance	—

Documentation and safety

#	Criterion	Source	Designation	Compliance
33	Reason for delayed, missing or incomplete PE pathway step documented where applicable.	Local policy	local policy	—
34	Documentation clear enough for another clinician to understand PE probability, diagnostic decision, treatment and follow-up.	Local documentation standard	local QI target	—
35	Any PE-related safety concern escalated or actioned where identified.	Local governance policy	local policy	—

Compliance will populate once included cases have been recorded.