Implementing and supporting an electronic clinical decision support system (CDSS) in emergency departments to help physicians make decisions regarding site-of-care for patients with acute pulmonary embolism is a safe way to identify which patients can forgo hospitalization in favor of outpatient care, according to a study published in the Annals of Internal Medicine.
It is common for low-risk patients who present to the emergency department with acute pulmonary embolism to be hospitalized despite being eligible for outpatient care. Therefore, researchers conducted this controlled pragmatic trial (ClinicalTrials.gov Identifier: NCT03601676), which ran from January 2014 to April 2015, to evaluate the capability of an integrated CDSS to facilitate decision-making in these cases.
At month 9 of the 16-month study period, a multidimensional technology intervention was implemented at 10 of 21 community emergency departments within Kaiser Permanente Northern California, and the remaining 11 were used as concurrent controls
The study’s primary outcome was discharge from either a short-term outpatient observation unit (<24 hours) based in an emergency department or from the emergency department itself. Adverse outcomes evaluated included return visits for pulmonary embolism-related symptoms within 5 days and major hemorrhage, recurrent venous thromboembolism, and all-cause mortality within 30 days. Pre-post changes at intervention were compared using a difference-in-differences approach, with adjustments for clinical and demographic characteristics.
This study included 1703 patients with acute pulmonary embolism during the trial period (822 at control sites and 881 at intervention sites). Although the rate of adjusted home discharge did not change at the control sites after the month-9 intervention (15.1% preintervention to 14.5% postintervention; P =.88), the rate did increase at the intervention sites (17.4% preintervention to 28.0% postintervention), with a difference-in-differences comparison of 11.3 percentage points (95% CI, 3.0-19.5 percentage points; P =.007). The implementation of the CDSS was not associated with increases in return visits within 5 days, or major adverse outcomes within 30 days. Lack of random allocation was a limitation in this study.
Study investigators concluded that “[i]dentifying the most appropriate venue of care for patients with acute medical conditions is a key priority for transforming U.S. health care. The use of CDSSs to bring validated risk-stratiﬁcation tools to the [emergency department] bedside could help advance this agenda and could be expanded beyond [pulmonary embolism] to improve care and resource use for other clinical conditions.”
Vinson DR, Mark DG, Chettipally UK, et al. Increasing safe outpatient management of emergency department patients with pulmonary embolism: a controlled pragmatic trial [published online November 13, 2018]. Ann Intern Med. doi:10.7326/M18-1206