Key result
Mandatory electronic Wells fields boost documentation to ~88% but fail to improve CTPA yield.
Why the study?
Inappropriate CTPA requests expose patients to unnecessary radiation and contrast, delay imaging, and burden radiology services despite NICE guidance recommending pretest probability evaluation using the two-level Wells score and D-dimer testing.
Does the introduction of mandatory request-form fields and education improve adherence to diagnostic pathways for CTPA in patients with suspected pulmonary embolism?
Observational (n=154)
No
Does the introduction of mandatory request-form fields and education improve adherence to diagnostic pathways for CTPA in patients with suspected pulmonary embolism?
Absolute Event Rate: 16.7% vs 19%
Implementing mandatory electronic request fields significantly improves adherence to pretest probability documentation for suspected pulmonary embolism, though it may not immediately alter CTPA diagnostic yield.
Low CTPA yield supports stricter Wells/D-dimer adherence in suspected PE; leaves open whether implementation reduces unnecessary scans.
Background CT pulmonary angiography (CTPA) is widely used in the evaluation of patients with suspected pulmonary embolism (PE); however, inappropriate requests can expose patients to unnecessary radiation and iodinated contrast, delay imaging for those with confirmed PE, and increase demand on radiology services. National guidance (National Institute for Health and Care Excellence (NICE) NG158) recommends applying the two-level Wells score and D-dimer testing to determine pretest probability before requesting CTPA. This two-cycle audit evaluated adherence to these standards at Croydon University Hospital and examined whether documentation and diagnostic pathway compliance improved over time. Methods A retrospective two-cycle audit was conducted. Cycle 1 reviewed all CTPAs requested for suspected PE between October 1 and 31, 2024. Cycle 2 repeated the audit in September 2025 using the same methodology and comparison standards. Data were extracted from the electronic health record and radiology system, including Wells score documentation, D-dimer testing, chest X-ray (CXR) findings, anticoagulation status, and CTPA outcomes. Audit standards were based on NICE NG158 and Royal College of Radiologists expectations for CTPA diagnostic yield (15-35%). Following Cycle 1, the Trust introduced mandatory Wells score and D-dimer fields in the Cerner CTPA request form and increased educational messaging regarding appropriate imaging. Results Cycle 1 included 58 patients, with 11 positive CTPAs (diagnostic yield, 19%). Wells score documentation was low, with only four documented cases (6.9%), and D-dimer testing was recorded in 45 requests (77%). In Cycle 2, 96 patients were included, with 16 positive CTPAs (diagnostic yield, 16.7%). Documentation improved markedly: Wells score recording increased to 84 cases (87.5%), and D-dimer documentation was present in 86 cases (89.6%). Among Cycle 2 patients, PE was detected in 14 of 61 patients (23%) with Wells scores greater than 4 and in two of 23 patients (8.7%) with Wells scores of 4 or less. Alternative diagnoses were identified on CXR in 25 cases (26%). Patterns of anticoagulation were similar between cycles. Conclusions Across two audit cycles, CTPA diagnostic yield remained stable and within the nationally expected range. However, documentation of the Wells score and D-dimer improved substantially by September 2025, reflecting better adherence to the recommended diagnostic pathway for suspected PE. These findings demonstrate the effectiveness of system-level changes, including mandatory request-form fields and improved clinician awareness. Continued monitoring is recommended to ensure sustained compliance and to support appropriate imaging utilization.
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Khadka et al. (2025) conducted an observational in Suspected pulmonary embolism (n=154). Mandatory electronic request fields and educational messaging vs. Standard practice (pre-intervention) was evaluated on Diagnostic yield (proportion of CTPAs positive for acute PE). The introduction of mandatory electronic request fields and educational messaging improved Wells score documentation from 6.9% to 87.5%, while the diagnostic yield of CTPA remained stable at 16.7%.
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