EMERGENCY DEPARTMENT UTILIZATION OF CAT SCANS IN EMBOLISM (EDUCATE)
A pulmonary embolism is a blood clot in the pulmonary vasculature that potentially has a high morbidity and mortality. Diagnosis can be difficult given a wide variety of clinical presentations. At this time, the gold standard for diagnosis of a pulmonary embolism is CT angiography. Per Glenn et al, nearly 120 million people visit an emergency department a year nationally, of which 1.5% receive a CT angiogram. Although CTA is highly sensitive, it warrants further consideration including increased costs of imaging, radiation exposure, as well as over-diagnosis and anti-coagulation of clinically irrelevant pulmonary emboli with minimal clot burden. Thus, it is important to risk stratify which subset of the population is appropriate for CTA. Currently, clinical decision making tools including the Wells criteria and PERC criteria aid physicians in the diagnostic decision making process of a pulmonary embolism.
OBJECTIVE: The aim of this study is to determine whether the implementation of an electronic clinical decision making tool (eCDT) prompt within the EMR system affected change in the utilization of CTA in the diagnosis of pulmonary embolism in non-pregnant patients at least 18 years of age and older at Borgess Medical Center Emergency Department.
METHODS: A retrospective study was conducted to analyze the rate of CTA utilization 12 months prior to and 12 months after the implementation of the Wells’ eCDT using the Pearson Chi-square test of independence. All non-pregnant patients at least 18 years of age and older at Borgess medical Center Emergency Department were included. In May of 2016, Borgess Medical Center implemented an electronic medical record (EMR) prompt requiring all ED providers to calculate a Wells’ score prior to ordering a CTA in the effort to prevent improper utilization of imaging.
RESULTS: Prior to implementation of the eCDT between May 29, 2015 and May 29, 2016, a total of 53,421 patients were seen at Borgess Medical Center of which 612 patients or 1.15% of patients received a CTA. Following implementation of the eCDT between May 30, 2016 and May 30, 2017, a total of 51,446 patients were seen at Borgess Medical Center of which 560 or 1.09% received a CTA.
CONCLUSIONS: The implications of this study are clinically relevant as the current belief is that the mandatory eCDT prompt prior to ordering a CTA is time consuming to complete in a busy emergency department and likely does not accomplish the goal of improving proper CT utilization in the diagnosis of a pulmonary embolism. The results of this study may improve physician willingness to accurately complete the eCDT and validates further research into implementing additional eCDT EMR prompts at Borgess such as a NEXUS eCDT prompt in the CT evaluation of cervical spine injuries in trauma.