Dao, E Han

Miller, Matthew M, DO, MBA, MS

Rosentel, Joshua, BSN, RN

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health Network LVHN Scholarly Works USF-LVHN SELECT Choosing Wisely: Identifying Rates of Appropriate Imaging in ED Patients Evaluated for PE E Han Dao Joshua Rosentel BSN, RN Matthew M. Miller DO, MBA, MS Follow this and additional works at: https://scholarlyworks.lvhn.org/select-program  Part of the Medical Education Commons This Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by an authorized administrator. For more information, please contact LibraryServices@lvhn.org. © 2018 Lehigh Valley Health NetworkLehigh Valley Health Network, Allentown, Pennsylvania• The majority of patients presenting to the LVH-CC ED in 2019 with documented Wells scores who received CTPA had a quantitative indication for the study, whether by Wells score or positive D-dimer values.• Future re-examination of CTPA utilization may be considered if implementation of a care pathway for the evaluation of PE is implemented.Choosing Wisely: Identifying Rates of Appropriate Imaging in ED Patients Evaluated for PEREFERENCES• 264 patients meeting our criteria were identified (Figure 1).– 132 patients had a Wells score ≥ 2.– 80 patients had a Wells score < 2 and an elevated D-dimer value.– 38 patients had a Wells score < 2 and an absent D-dimer value.– 14 patients had a Wells score < 2 and a normal D-dimer value.• Method considers those patients who were risk-stratified using Wells score.• Of patients reviewed, most cases had quantitative evidence in support of imaging (80%).• Only 5% of identified patients received imaging with Wells score < 2 and normal D-dimer.• Patients may also have been assessed using other validated clinical tools not measured.• There are ongoing broader initiatives within the network regarding standardization evaluation and management of PE i.e.development of care pathways.• Ordering patterns may be re-assessed as future interventions are piloted.• Rapid assessment now and in the future of adherence to clinical guidelines may assist in demonstrating quality of patient care.• A retrospective study consisting of data queries of the network Epic EMR was performed.• Patients presenting to LVH-CC ED in 2019 with discretely recorded Wells scores and who received CT chest with PE protocol were identified and included for review.• Data were sorted by Wells score and D-dimer values to evaluate for quantitative evidence supporting the imaging order.• Risk stratification of included patients was based on original Wells three-tier classification.• A Wells scores ≥ 2 was considered sufficient evidence on its own.• For patients with Wells scores < 2, D-dimer lab values associated with the encounter were reviewed, if present. Values above the reference range were considered to be elevated.• Additional data for each patient encounter were reviewed including ordering provider, ED disposition, and final diagnosis.E. Han Dao, BS; Joshua Rosentel, BSN, RN; Matthew M Miller, DO, MBA, MSBackgroundMethodsResults DiscussionConclusions1. Goldhaber S. Deep Venous Thrombosis and Pulmonary Embolism. In: Jameson J, Fauci A, Kasper D, Hauser S, Longo D, Loscalzo J, eds. Harrison's Principles of Internal Medicine.New York, NY: McGraw-Hill; 2018.2. Wells PS, Anderson DR, Rodger M, et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thromb Haemost. 2000;83(3):416-420.3. American College of Radiology. ACR - Avoid imaging for suspected PE. American College of Radiology. Choosing Wisely Web site. http://www.choosingwisely.org/clinician-lists/american-college-radiology-imaging-for-suspected-pulmonary-embolism-without-moderate-or-high-pretest-probability/.4. Ferguson C, Low G, Fung C. Retrospective Analysis of the Computed Tomography Pulmonary Angiogram Utilization Patterns in the Emergency Department. Can Assoc Radiol J. 2019;70(4):388-393.Problem Statement• Pulmonary embolism (PE) can present with nonspecific symptoms, making diagnosis challenging.• Multiple validated risk-stratification tools and clinical guidelines exist for diagnosis of PE.• CT pulmonary angiography (CTPA) is a powerful noninvasive modality for detection and represents the current standard for diagnosis.• As with any other diagnostic test, there is a potential for over-utilization of imaging.• A Choosing Wisely guideline issued in concert with the American College of Radiology recommends: “Don’t image for suspected pulmonary embolism without moderate or high pre-test probability.”• We will identify the proportion of patients presenting to LVH-CC who received CT imaging for PE and evaluate for the presence of quantitative data (Wells scores, D-dimer values) supporting the order.50%30%15%5%Wells score >=2 Wells score <2; elevated D-dimerWells score <2; absent D-dimer Wells score <2; normal D-dimer• Figure 2. CTPA ordering by type of provider.• Patient Disposition: of the 264 patients, 17 patients were admitted and had a final diagnosis of MS175 or MS176 (pulmonary embolism with or without major complication and comorbidity, respectively).171101131606046 02752 0120020406080100120Attending Fellow Resident Physician AssistantCTPA Orders by Provider TypeWells score ≥ 2 Wells score < 2. Elevated D-dimer.Wells score <2. Absent D-dimer. Wells score <2. Normal D-dimer.• Figure 1. Breakdown of Wells score and D-dimer value for the patient population of interest.• The breakdown of studies by ordering provider was also reviewed (Figure 2).• Resident physicians ordered the majority of studies (200/264; 75.7%).

Choosing Wisely: Identifying Rates of Appropriate Imaging in ED Patients Evaluated for PE

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Choosing Wisely: Identifying Rates of Appropriate Imaging in ED Patients Evaluated for PE

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