Baylor College of Medicine, Houston, TX. No Disclosures

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Robyn Fletcher
5 years ago
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Alexandre Frigini MD 1, Marc Willis DO 1, Karla Sepulveda MD 1, Rohit Ramanathan MD 1,

1 AVOIDING INAPPROPRIATE CT CHEST PE PROTOCOL IN A LARGE US ACADEMIC EMERGENCY CENTER. EXPERIENCE AS AN ACR VALUE-BASED PQI PROJECT BETA SITE L. Alexandre Frigini MD 1, Marc Willis DO 1, Karla Sepulveda MD 1, Rohit Ramanathan MD 1, Conrad Gibby MD 1, Shkelzen Hoxhaj MD 1, Milton Guiberteau MD 1 1 Baylor College of Medicine, Houston, TX No Disclosures

2 PURPOSE: Evaluate the rate of inappropriate CT chest pulmonary embolism protocol in a large U.S. academic emergency department applying ACR Select/appropriateness criteria and Choosing Wisely guidelines; if a high rate is observed, evaluate the efficacy of referring clinician educational intervention (utilizing ACR educational strategies and tools from PQI project Web Portal) in decreasing it by modifying physician ordering pattern.

3 MATERIALS AND METHODS: 100 CT Chest PE protocol studies performed in the Emergency Department between August and October 2014 were retrospectively identified by radiology IT. Studies were classified based on results (positive or negative for PE), indication, demographics, clinical probability of PE according to modified Wells criteria and results of D- dimer test (if obtained). Likelihood of PE based on modified Wells criteria was retrospectively determined by a group of Emergency Medicine Staff under the supervision of the Chief of Emergency Medicine. Evaluation of the data demonstrated a high rate of inappropriate CT exams based on the Choosing Wisely Campaign e.g. do not perform CT PE protocol in patients with a low probability of PE and negative results of a high sensitivity D-dimer test (see results below).

4 An educational intervention was planned for the referring Emergency Medicine clinicians in conjunction with EM leadership, consisting of a one hour Grand Rounds including a 15 minute presentation of our study results, a 30 minute presentation of Choosing Wisely campaign and an ACR video on appropriateness criteria from ACR value-based website, and a 15 minute presentation of Society of Emergency Medicine guidelines by the Chief of the Department of Emergency Medicine. The intervention also included serial messages from the Chief of emergency medicine to EM faculty, residents and allied health personnel regarding new protocol for requesting CT PE protocol (requisitions for CT PE protocol in EMR must include Wells score and results of D-dimer, if applicable). Notes were posted on ED workstations to remind staff.

Particular attention was paid to recording negative studies that were inappropriately performed in spite of low clinical

5 Four (4) weeks following clinician educational intervention, 48 CT PE protocol studies were performed in the ED and we repeated the same method of classifying studies as detailed above. Particular attention was paid to recording negative studies that were inappropriately performed in spite of low clinical probability and negative D-dimer results. Post-intervention data was then compared to pre-intervention data to evaluate if referring clinicians changed their imaging study request pattern.

6 RESULTS: Pre-Intervention data: 100 cases were reviewed (92 cases were PE protocol, 8 mislabeled as PE protocol when a regular CT chest had been performed for reason other than PE) of which: 1. Positive for PE: 5 cases (5.43%) 2. Negative for PE: 87 (94.56%), of which the following was observed: Low clinical probability and negative D-dimer: 8 (8.7%) Low clinical probability and positive D-dimer 0 (0%) Low clinical Probability and no D-dimer: (18.5%)

7 Moderate probability: 33 (35.83%) High probability: 30 (32.6%) Rate of inappropriate exams (low clinical probability with a negative D-dimer result and low clinical probability with no D-dimer obtained): 27.2%

8 Post-Intervention data: 48 cases were performed and reviewed: 1. Positive for PE: 2 cases (4.17%) 2. Negative for PE: 46 (95.83%), of which: Low clinical probability and negative D-dimer: 0 (0%) Low clinical probability and positive D-dimer: 12 (25%) Low clinical Probability and no D-dimer obtained: 7 (14.58%) Moderate Probability: 20 (41.66%) High probability: 8 (18.75%) Rate of inappropriate exams (low clinical probability with a negative D- dimer result and low clinical probability with no D-dimer obtained):14.58%

9 Pre-intervention data demonstrates a high rate of inappropriately requested CT PE protocol studies in patients who did not have a D- dimer test obtained (18.5%; ED protocol in our institution requires all patients with low probability to have a D-Dimer test prior to obtaining advanced imaging studies which is also recommended by the Choosing Wisely campaign). More importantly and surprisingly, it revealed a high rate of patients who, in spite of a low clinical probability and a negative D-Dimer result, still went on to have a CT Chest PE protocol. Post-intervention, there was a significant decrease in ordering of inappropriate exams (27.2% pre-intervention versus 14.58% postintervention). The improvement was solely due to no CT PE protocol performed on patients with a negative D-dimer.

10 CONCLUSION: The clinician educational intervention was successful in decreasing the rate of inappropriate CT chest for evaluation of pulmonary embolism. It is hoped that rates of inappropriate exams will decrease further with time since post data was obtained 4 weeks following intervention which we feel did allow enough time to reflect changes in exam ordering pattern. We are also in the process of changing the order entry in RIS which will prompt/require clinicians to enter the Modified Wells criteria score and the D-dimer value, if applicable, which should also contribute to improve adherence to guidelines. We plan to continue the study with collection of post-intervention data over a longer period of time and will repeat intervention in 3 to 4 month intervals to reinforce appropriateness criteria principles.

11 REFERENCES: 1. ACR s Value-Based PQI Project: A Step-by-step Description. Project 2. ACR Appropriateness criteria, February ACR Select Choosing Wisely Campaign: Policy/Imaging-3/PQI-Initiative/Choosing-Wisely-Topics 5. ACR Educational Tools, Resources and Programs: Initiative/Solution-Center

Husameddin El Khudari, MD. Shams Jubouri, MD, David Bader, MD, FACR. Saint Vincent Hospital Worcester, MA

Husameddin El Khudari, MD. Shams Jubouri, MD, David Bader, MD, FACR. Saint Vincent Hospital Worcester, MA None Providing evidence-based guidelines to collaborate with the ER physicians to guide appropriate