Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
Center for Evidence Based Imaging, Brigham and Women's Hospital, Boston, MA, USA; Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
Am J Emerg Med. 2018 Apr;36(4):540-544. doi: 10.1016/j.ajem.2017.09.004. Epub 2017 Sep 6.
Determine effects of evidence-based clinical decision support (CDS) on the use and yield of computed tomographic pulmonary angiography for suspected pulmonary embolism (CTPE) in Emergency Department (ED) patients.
This multi-site prospective quality improvement intervention conducted in three urban EDs used a pre/post design. For ED patients aged 18+years with suspected PE, CTPE use and yield were compared 19months pre- and 32months post-implementation of CDS intervention based on the Wells criteria, provided at the time of CTPE order, deployed in April 2012. Primary outcome was the yield (percentage of studies positive for acute PE). Secondary outcome was utilization (number of studies/100 ED visits) of CTPE. Chi-square and statistical process control chart assessed pre- and post-intervention differences. An interrupted time series analysis was also performed.
Of 558,795 patients presenting October 2010-December 2014, 7987 (1.4%) underwent CTPE (mean age 52±17.5years, 66% female, 60.1% black); 34.7% of patients presented pre- and 65.3% post-CDS implementation. Overall CTPE diagnostic yield was 9.8% (779/7987 studies positive for PE). Yield increased a relative 30.8% after CDS implementation (8.1% vs. 10.6%; p=0.0003). There was no statistically significant change in CTPE utilization (1.4% pre- vs. 1.4% post-implementation; p=0.25). A statistical process control chart demonstrated immediate and sustained improvement in CTPE yield post-implementation. Interrupted time series analysis demonstrated the slope of PE findings versus time to be unchanged before and after the intervention (p=0.9). However, there was a trend that the intervention was associated with a 50% increased probability of PE finding (p=0.08), suggesting an immediate rather than gradual change after the intervention.
Implementing evidence-based CDS in the ED was associated with an immediate, significant and sustained increase in CTPE yield without a measurable decrease in CTPE utilization. Further studies will be needed to assess whether stronger interventions could further improve appropriate use of CTPE.
确定基于证据的临床决策支持（CDS）对急诊科（ED）疑似肺栓塞（CTPE）患者 CTPE 使用和检出率的影响。
本多中心前瞻性质量改进干预研究在三个城市的 ED 进行，采用预/后设计。根据 Wells 标准，对 2012 年 4 月在 CTPE 订单下达时提供的标准，对 18 岁以上疑似 PE 的 ED 患者，比较了 19 个月前和 32 个月后 CDS 干预前后 CTPE 的使用和检出率。主要结局是检出率（急性 PE 阳性研究的百分比）。次要结局是 CTPE 的使用率（每 100 次 ED 就诊的检查次数）。卡方检验和统计过程控制图评估了干预前后的差异。还进行了中断时间序列分析。
2010 年 10 月至 2014 年 12 月期间，558795 例患者就诊，7987 例（1.4%）接受了 CTPE（平均年龄 52±17.5 岁，66%为女性，60.1%为黑人）；60.1%为黑人；34.7%的患者在 CDS 实施前和 65.3%的患者在 CDS 实施后就诊。总体 CTPE 诊断检出率为 9.8%（779 例/7987 例 PE 阳性）。CDS 实施后，检出率相对增加了 30.8%（8.1%比 10.6%；p=0.0003）。CTPE 的使用率无统计学显著变化（实施前为 1.4%，实施后为 1.4%；p=0.25）。统计过程控制图显示，实施后 CTPE 检出率立即且持续改善。中断时间序列分析表明，干预前后 PE 发现的斜率没有变化（p=0.9）。然而，有趋势表明干预与 PE 发现的概率增加了 50%（p=0.08），提示干预后立即而非逐渐发生变化。
在 ED 实施基于证据的 CDS 与 CTPE 检出率的立即、显著和持续增加相关，而 CTPE 的使用率无明显下降。需要进一步的研究来评估更强的干预措施是否可以进一步提高 CTPE 的合理使用。
