Min Adam, Chan Vivian W Y, Aristizabal Ruben, Peramaki Ed R, Agulnik David B, Strydom Nardia, Ramsey Damon, Forster Bruce B
Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
Vancouver Coastal Health, Vancouver, BC, Canada.
J Am Coll Radiol. 2017 Jul;14(7):889-899. doi: 10.1016/j.jacr.2017.03.005. Epub 2017 May 5.
To determine whether point-of-care clinical decision support can effectively reduce inappropriate medical imaging of patients who present to the emergency department (ED) with low-back pain (LBP).
This was a prospective, single-center study of lumbar imaging referrals made by 43 emergency physicians at a major acute care center. Each physician saw at least 10 LBP cases in both pre- and post-intervention periods. A point-of-care checklist of accepted red flags for LBP was designed by a working group of physicians and embedded in the computerized order entry form for lumbar imaging. We compared imaging rates of LBP and physician variation in imaging ordering before and after the implementation of the checklist. We then measured the potential harms of reduced imaging.
After intervention, the proportion of LBP patients with an imaging order fell significantly (median: 22% to 17%; mean: 23% to 18%; P = .0002) compared with pre-intervention baseline. The percentage of patients without imaging who were later imaged at a hospital outpatient clinic within 30 days was 2.3% before intervention and 2.2% after (P = .974). In addition, the proportion of patients discharged from the ED without imaging who returned to the ED within 30 days was 8.2% before intervention and 6.9% after (P = .170). One minor thoracic spine compression fracture was missed, but management was not impacted. No serious diagnoses were missed.
Clinical decision support integrated in electronic order entry forms can safely and effectively reduce imaging orders for LBP patients in the ED.
确定即时临床决策支持能否有效减少因腰痛（LBP）就诊于急诊科（ED）的患者进行不适当医学影像检查的情况。
这是一项在一家大型急症护理中心对43名急诊医生进行的腰椎影像转诊的前瞻性单中心研究。每位医生在干预前和干预后阶段至少诊治10例LBP病例。一个由医生工作小组设计的关于LBP公认警示信号的即时检查表被嵌入到腰椎影像的计算机化医嘱录入表单中。我们比较了检查表实施前后LBP的影像检查率以及医生在影像检查医嘱方面的差异。然后我们测量了减少影像检查可能带来的危害。
与干预前基线相比，干预后有影像检查医嘱的LBP患者比例显著下降（中位数：从22%降至17%；平均数：从23%降至18%；P = .0002）。干预前未进行影像检查但在30天内后来在医院门诊进行影像检查的患者百分比为2.3%，干预后为2.2%（P = .974）。此外，干预前从ED出院未进行影像检查且在30天内返回ED的患者比例为8.2%，干预后为6.9%（P = .170）。漏诊了1例轻微胸椎压缩性骨折，但治疗未受影响。没有漏诊严重诊断。
电子医嘱录入表单中整合的临床决策支持能够安全有效地减少ED中LBP患者的影像检查医嘱。
