P123 Don’t forget your PE kit – improving thrombolysis decision making in a district general hospital (DGH)

IntroductionMultiple patients with massive/submassive pulmonary emboli (PE) were admitted in a short timeframe to a DGH. Inconsistency in management was noted, prompting discussion surrounding thrombolysis decisions.MethodsAll PE-related admissions to the Cardiac Monitoring Unit (CMU) between 2016–2020 were reviewed. Thrombolysis decision, relevant test results and outcomes were recorded and their concordance to local and national recommendations and guidelines were analysed.Junior doctors were surveyed. Confidence in PE management was assessed, they were asked to select the appropriate management option for 5 clinical scenarios and if a ‘bundle’ would aid decision-making.Results57 patients were admitted over 4 years. 14 had a massive PE and 33 patients had a submassive PE. Of these, 12 (85.7%) and 17 (51.5%) were thrombolysed respectively. Departmental echocardiograms were organised within 24 hours in 74% and follow-up echocardiograms performed in 54%. The pooled mortality at 1 year was 21% with no significant difference between those thrombolysed and those not.The survey, to which 22 junior doctors responded, demonstrated that 73% described themselves as ‘very’ or ‘fairly’ confident in managing massive/submassive PE. There was disparity in case management with the polar options of ‘thrombolysis’ and ‘subcutaneous anticoagulation’ being chosen at least once in each scenario.All respondents supported a bundle. A consent form, information sheet and decision-making flowchart were created with stakeholder input and published locally.ConclusionWe show mostly guideline-concordant practice with the exception of echocardiogram follow up. Variability in opinion amongst juniors, despite perceived confidence, was observed. Bundle creation with respondent and consultant input standardises management and prompts escalation to seniors early to negate overconfidence in complex situations.