MedicalResearch.com Interview with:
David R. Vinson, MD
Department of Emergency Medicine
Kaiser Permanente Sacramento Medical Center Sacramento, CA
MedicalResearch.com: What is the background for this study? What are the main findings?
Response: At least one-third of emergency department (ED) patients with acute blood clots in the lung, or pulmonary embolism (PE), are eligible for expedited discharged to home, either directly from the ED or after a short (<24 hour) period of observation. Yet in in most hospitals in the U.S. and around the world nearly all ED patients with acute PE are hospitalized. These unnecessary hospitalizations are a poor use of health care resources, tie up inpatient beds, and expose patients to the cost, inconvenience, and risk of inpatient care. The better-performing medical centers have two characteristics in common: they help their physicians identify which PE patients are candidates for outpatient care and they facilitate timely post-discharge follow-up. At Kaiser Permanente Northern California (KPNC), we have had the follow-up system in place for some time, but didn’t have a way to help our physicians sort out which patients with acute PE would benefit from home management.
To correct this, we designed a secure, web-based clinical decision support system that was integrated with the electronic health record. When activated, it presented to the emergency physician the validated PE Severity Index, which uses patient demographics, vital signs, examination findings, and past medical history to classify patients into different risk strata, correlated with eligibility for home care. To make use of the PE Severity Index easier and more streamlined for the physician, the tool drew in information from the patient’s comprehensive medical records to accurately auto-populate the PE Severity Index. The tool then calculated for the physician the patient’s risk score and estimated 30-day mortality, and also offered a site-of-care recommendation, for example, “outpatient management is often possible.” The tool also reminded the physician of relative contraindications to outpatient management. At the time, only 10 EDs in KPNC had an on-site physician researcher, who for this study served as physician educator, study promotor, and enrollment auditor to provide physician-specific feedback. These 10 EDs functioned as the intervention sites, while the other 11 EDs within KPNC served as concurrent controls. Our primary outcome was the percentage of eligible ED patients with acute PE who had an expedited discharge to home, as defined above.
During the 16-month study period (8-month pre-intervention and 8-months post-intervention), we cared for 1,703 eligible ED patients with acute PE. Adjusted home discharge increased at intervention sites from 17% to 28%, a greater than 60% relative increase. There were no changes in home discharge observed at the control sites (about 15% throughout the 16-month study). The increase in home discharge was not associated with an increase in short-term return visits or major complications.
MedicalResearch.com: What should readers take away from your report?
Response: We learned from this study that the implementation of an electronic clinical decision support system combined with structured promotion by an on-site physician champion can safely increase home discharge of ED patients with acute PE. Helping emergency physicians identify patients eligible for outpatient care in a healthcare system that facilitated post-discharge follow-up improved physician decision-making and helped better match health care resources with patient needs.
Other healthcare organizations may improve the management of their ED patients with acute PE by helping their physicians identify which patients are safe for treatment without hospitalization. To be successful, an identification program should be coupled with structured on-site promotion and a system for patients to be seen in the clinic within a week of ED discharge.
MedicalResearch.com: What recommendations do you have for future research as a result of this work?
Response: After the 8-month intervention period, we discontinued the structured promotion. Physician tool use rates in the post-study period are unknown. We will formally evaluate the effect on site-of-care decision-making of discontinuing promotion. We also discovered after the study was completed that the risk-class-specific mortality estimates we provided to the physicians, which we adopted from the literature, were actually twice the rate of our KPNC patients. This over-estimation of risk may have led to more conservative site-of-care decisions. We would like to study the effect of correcting the mortality estimates and adjusting the recommendations accordingly. Because of the study’s success, we have adopted the electronic clinical decision support system to assist with other complex decision-making processes in the ED. Ongoing studies are seeking to improve the management of children with abdominal pain and possible appendicitis and adults with chest pain and possible acute coronary syndrome.
Vinson DR, Mark DG, Chettipally UK, Huang J, Rauchwerger AS, Reed ME, et al. Increasing Safe Outpatient Management of Emergency Department Patients With Pulmonary Embolism: A Controlled Pragmatic Trial. Ann Intern Med. [Epub ahead of print ] doi: 10.7326/M18-1206
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