Computer Says: Discharge that Pulmonary Embolism!

We’ve learned a couple important things about pulmonary emboli for the past five or so years. First, we diagnose too many of them. Second, all pulmonary emboli do not need to be hospitalized. Knowing, as they say, is half the battle. That’s a start – but it’s not enough.

This study involves important thing number two above, the hospitalization of PE. Kaiser Permanente, in its endless quest for value, has already published several studies demonstrating the safety of discharging patients with PE. However, hidden in the descriptive statistics from those studies are the unfortunate still-low percentages of patients discharged.

In this prospective, multi-center, “convenience-assigned” trial, a computerized decision-support tool was rolled out to support risk-stratification for patients diagnosed with PE. Based on the pulmonary embolism severity index (PESI), patients scoring in class I or II were encouraged to be discharged, while those with higher scores were nudged towards hospitalization. In their pre-post design, little change occurred at the control hospitals, while the percentage of patients with PE discharged from the intervention hospitals jumped from 17.4% to 28.0%. No issues regarding untoward 5-day recidivism or 30-day adverse events were detected.

This is a great step forwards, and, frankly, one of the most prominent examples of decision-support being actually useful to implement practice change.   That said, in the intervention hospitals, there were “physician champions” associated with the roll-out of the CDS intervention, which almost certainly increased update.  Then, 41.2% of patients were PESI class I or II, so there’s even further room for improvement above these topline results – but this is an at least solid effort.

“Increasing Safe Outpatient Management of Emergency Department Patients With Pulmonary Embolism”

http://annals.org/aim/article-abstract/2714293/increasing-safe-outpatient-management-emergency-department-patients-pulmonary-embolism-controlled