Introduction: Utilization of CT pulmonary angiography (CTPA) to rule out pulmonary embolism (PE) has risen dramatically but diagnostic yield has fallen over the past several decades, suggesting that lower risk patients are being tested. Given little evidence to suggest improved patient outcomes with higher CTPA utilization, and increasing evidence of harm, evidence-based guidelines have been developed to reduce unnecessary CTPA use. The objective of this study was to assess the impact of an electronic clinical decision support (CDS) intervention to reduce unnecessary CTPA utilization for emergency department (ED) patients with suspected PE. Methods: This was a cluster-randomized, controlled trial with physicians as the unit of randomization. All emergency physicians (EPs) at 4 urban adult EDs and 1 urgent care center were randomly assigned to receive either evidence-based imaging CDS for patients with suspected PE (intervention) or no CDS (control) over a 1-year study period. CDS was launched in an external web browser whenever an intervention EP ordered a CTPA from the computerized physician order entry software for ED patients CTAS 2-5; however, physician interaction with CDS was voluntary. The CDS tool enabled calculation of patient-specific information, including the patients Wells score, PERC score, and age-adjusted D-dimer, as well as prediction of each patients pre-test risk of PE along with an imaging/no imaging recommendation. CDS recommendations could be printed for the medical record as could educational patient handouts to support physician decision-making. The primary outcome was CTPA utilization for patients with CEDIS chief complaints of shortness of breath or chest pain on the index visit. Secondary outcomes included index visit length of stay (LOS), and CTPA use or VTE diagnosis within 90-days. This study was REB approved. Results: Demographics were similar among intervention and control EPs; however, during a 2-year pre-intervention period control EPs had a higher baseline CTPA rate (8.5% vs 7.7%, p<0.001). In the first 8-months following CDS implementation, 94 intervention EPs saw 9,609 patients and voluntarily interacted with the CDS tool on 43.2% of eligible encounters while 91 control EPs saw 9,498 patients. CTPA utilization was higher among intervention EPs than control (9.6% vs 8.3%, p<0.001) as was ED LOS (302 vs 287 minutes, p<0.001). There was no difference in 90-day CTPA use or VTE diagnoses. Conclusion: In one of the largest RCTs of CDS to date, exposure to CDS was associated with higher rates of CTPA utilization and longer ED LOS on the index visit, and no difference in 90-day CT use or VTE diagnoses. These results differ from a concurrent study of CDS for patients with mild traumatic brain injury in the same physician population and may relate to the implementation of the CDS intervention and/or complexity of the underlying evidence-based algorithms.

Introduction: As utilization of CT imaging has risen dramatically, evidence-based decision rules and clinical decision support (CDS) tools have been developed to avoid unnecessary CT use in low risk patients. However, their ability to change physician practice has been limited to date, with a number of barriers cited. The purpose of this study was to identify the barriers and facilitators to CDS adoption following a local CDS implementation. Methods: All emergency physicians at 4 urban EDs and 1 urgent care center were randomized to voluntary evidence-based CT imaging CDS for patients with either mild traumatic brain injury (MTBI) or suspected pulmonary embolism (PE). CDS was integrated into the computerized physician order entry (CPOE) software and triggered whenever a CT scan for an eligible patient was ordered. Physicians in both the MTBI and PE arms were ranked according to their CDS use, and a stratified sampling strategy was used to randomly select 5 physicians from each of the low, medium and high CDS use tertiles in each study arm. Each physician was invited to participate in a 30-minute semi-structured interview to assess the barriers and facilitators to CDS use. Physician responses were reported using a thematic analysis. Results: A total of 202 emergency physicians were randomized to receive CDS for either MTBI or PE, triggering CDS 4561 times, and interacting with the CDS software 1936 times (42.4%). Variation in CDS use ranged from 0% to 88.9% of eligible encounters by physician. Fourteen physicians have participated in interviews to date, and data collection is ongoing. Physicians reported that CDS use was facilitated by their confidence in the evidence supporting the CDS algorithms and that it provided documentation to reduce medico-legal risk. CDS use was not impeded by concerns over missed diagnoses or patient expectations. Reported barriers to CDS use included suboptimal integration into the CPOE such as the inability to auto-populate test results, it disrupted the ordering process and was time consuming. A common concern was that CDS was implemented too late in workflow as most decision making takes place at the bedside. Physicians did not view CDS as infringing on physician autonomy, however they advised that CDS should be a passive educational option and should not automatically trigger for all physicians and eligible encounters. Conclusion: Physicians were generally supportive of CDS integration into practice, and were confident that CDS is an evidence-based way to reduce unnecessary CT studies. However, concerns were raised about the optimal integration of CDS into CPOE and workflow. Physicians also stated a preference to a passive educational approach to CDS rather than an automatic triggering mechanism requiring clinical documentation.

Introduction: Utilization of CT imaging has risen dramatically with increases in availability, but without corresponding improvements in patient outcomes for many clinical scenarios. Previous attempts to improve imaging appropriateness have met with limited success, with commonly cited barriers including a lack of confidence in patient outcomes, medicolegal risk, and patient expectations. The objective of this study was to assess the impact of an electronic clinical decision support (CDS) intervention to reduce CT utilization for emergency department (ED) patients with mild traumatic brain injury (MTBI). Methods: This was a cluster-randomized, controlled trial with physicians as the unit of randomization. All emergency physicians (EPs) at 4 urban adult EDs and 1 urgent care center were randomly assigned to receive evidence-based imaging CDS (intervention) or no CDS (control) for patients with MTBI over a 1-year study period. CDS was launched in an external web browser whenever an intervention EP ordered a non-enhanced head CT from the computerized physician order entry (CPOE) system for ED patients CTAS 2-5 with a CEDIS chief complaint of head injury; however, interaction with CDS was voluntary. The CDS tool provided detailed information to physicians about the Canadian CT Head Rule, including patient eligibility, exclusion criteria, risk factors and probability of serious injury, as well as an imaging recommendation (yes/no). CDS recommendations could be printed for the medical record as could educational patient handouts to support physician decision making. The primary outcome was CT utilization for patients with MTBI on the index visit. Secondary outcomes included ED length of stay (LOS), and return visits, CT use, hospital admission and traumatic head injury diagnoses over the next 30-days. This study was REB approved. Results: Physician demographics and baseline CT utilization for MTBI patients were similar among intervention and control EPs during a 2-year pre-intervention period. In the first 8-months following CDS implementation, 102 intervention EPs saw 2,189 eligible patients while 100 control EPs saw 1,707 patients. Intervention EPs voluntarily interacted with CDS on 36.2% of eligible encounters. Head CT utilization was lower among intervention EPs than controls (38.5% vs 45.1%, p<0.0001) as was ED LOS (201 vs 218.5 minutes, p<0.001). There was no difference in 30-day ED return visits, head CT utilization, hospital admission or traumatic head injury diagnoses. Conclusion: In one of the largest RCTs of CDS to date, exposure to CDS was associated with decreased head CT utilization and shorter LOS on the index visit, and no difference in 30-day head CT use, return ED visits or hospital admission. These results suggest that a comprehensive CDS implementation may be able to overcome several barriers to use of decision rules and may contribute to improved clinical decision making and decreased CT utilization.

Introduction: Age and systolic blood pressure (SBP) are important predictors of Acute Cerebrovascular Syndrome (ACVS). Yet, the effect of SBP is confounded by age, making its independent contribution to ACVS risk difficult to quantify. Here we use logistic regression to explore the role of SBP in younger and older ED patients. Methods: Data comprised 1019 ED patients (ACVS 70%, 30% non-ACVS) enrolled during a 28-month period of an ongoing prospective, observational, multi-site stroke biomarker study (SpecTRA). We used logistic regression to examine the effects of age, sex, and the age:SBP interaction as predictive markers of the diagnosis of ACVS. Results: Participants (53% male) ranged in age from 18 to 97 years (Q1=58, median=70, Q3=80). SBP ranged from 84 to 248 mmHg (Q1=137, median=154, Q3=174). In our initial regression model, age, sex, SBP and the age:SBP interaction were all significant (p<0.01). Using cubic regression splines for age, sbp and their interaction yields the same conclusion (p<0.01). To better understand the role of SBP in younger vs. older patients, we stratified the sample at the median age (70 years of age). In the younger group (n=510), participants were 55% male, 60% ACVS, and had SBP ranging from 91 to 236 mmHg (Q1=133, median=148, Q3=165). In the older group (n=509), participants were 51% male, 82% ACVS and had SBP ranging from 84 to 248 mmHg (Q1=143, median=159, Q3=179), a shift of approximately 10 mmHg between the groups. The logistic regression model was then fit separately to each group without the age:SBP interaction term. In the younger group, we found SBP to be highly significant (p<0.001), with an odds-ratio (OR) of 1.18 per 10 mmHg (95% CI: 1.10-1.29). In the older group, we found that SBP was not significant (p=0.91), with an OR of 1.00 per 10 mmHg (95% CI: 0.91-1.08). Age and sex were also significant risk factors in the younger group (each p<0.01), though not in the older group (both p>0.07). Conclusion: Our findings suggest that for ED patients suspected of ACVS, SBP is a clinically relevant predictor for younger patients, with higher SBP associated with an increased risk of ACVS, regardless of patient age and sex. SBP does not appear to be a strong predictor for patients over 70. ED physicians can leverage this finding by attributing greater importance to elevated SBP in younger patients than older patients when working toward a clinical suspicion of ACVS.

Introduction: The Prehospital Canadian Triage and Acuity Scale (Pre-CTAS) is based upon, and is consistent with, the CTAS (Canadian Triage and Acuity Scale). Paramedic-assigned Pre-CTAS scores using memory compared to Triage Nurse CTAS scores have previously demonstrated moderate inter-rater reliability. This is the first study to measure the effect of two different point-of-care decision support tools on the inter-rater reliability of paramedic assigned Pre-CTAS and Triage nurse CTAS scores. Methods: Paramedics were randomized to Pre-CTAS booklet or CTAS smartphone app during the one-year study period. Pre-CTAS scores assigned on arrival at hospital (AH) were compared with Triage Nurse CTAS scores and analyzed using Cohen’s Kappa. Paramedics were then surveyed to assess the perceived utility and satisfaction with the decision support tools. Results: For 1663 patient transports, the weighted kappa score for Paramedic AH vs. Triage Nurse CTAS was fair at 0.38 (95% CI 0.35-0.41). For patients whose initial on-scene and AH Pre-CTAS scores did not change (n= 1405, 85%), Paramedic-Triage Nurse agreement was moderate at 0.43 (95% CI 0.39-0.46). The survey revealed that tools, when employed, helped assign scores; however accessing the additional resource was cumbersome or time consuming, and scores were occasionally assigned post clinical encounter. Conclusion: Point-of-care external decision support tools did not affect Pre-CTAS and ED CTAS agreement. These tools may add complexity or be perceived to add time to documentation within the delivery of clinical care if not implemented with adequate support. Future research needs to evaluate the impact of clinical decision support embedded within an electronic patient care record consistent with many ED information systems.

Patients with suspected public health threats, such as Ebola, must be quickly identified and isolated on presentation to health care facilities. Patients can be screened by intake staff or other health care providers; however, perfect compliance is difficult to achieve. Well-designed, carefully placed clinical decision support (CDS) within the electronic health record can be a reliable partner in helping to rapidly identify, isolate, and care for patients with suspected Ebola infection and other emerging public health threats. We describe how different types of CDS can be applied in the clinical workflow and share how we implemented CDS to force Ebola screening upon patient presentation to our emergency department. (Disaster Med Public Health Preparedness. 2015;9:591–594)