LO83: Effectiveness of implementing evidence based interventions to reduce C-spine imaging in the emergency department: a systematic review

Abstract

Introduction: Diagnosing pulmonary embolism (PE) can be challenging because the signs and symptoms are often non-specific. Studies have shown that evidence-based diagnostic algorithms are not always adhered to in the Emergency Department (ED), which leads to unnecessary CT scanning. In 2013, the American College of Chest Physicians identified CT pulmonary angiography as one of the top five avoidable tests. One solution is to use a clinical prediction rule combined with the D-dimer, which safely reduces the use of CT scanning. The objective of this study was to compare the proportion of patients tested for PE in two emergency departments, who 1) had a CT-PE and 2) whose diagnosis of PE was missed. We compared these rates to those if the Wells rule and D-dimer had been applied as standard. Methods: This was a retrospective chart review of ED patients investigated for PE at two hospitals from April 2013 to March 2015 (24 months). Inclusion criteria were the ED physician ordered CT-PE, Ventilation-Perfusion (VQ) scan or D-dimer for investigation of PE. Patients under the age of 18 were excluded. PE was defined as CT/VQ diagnosis of acute PE or acute PE/DVT in 30-day follow-up. Trained researchers extracted anonymized data. The rate of CT/VQ imaging and the false-negative rates were calculated. The false-negative rate was calculated as the number of patients diagnosed with PE within 30 days as a proportion of those patients who did not have a CT/VQ scan at initial presentation. Results: There were 1,189 patients included in this study. 55/1,189 patients (4.6%; 95%CI 3.6-6.0%) were ultimately diagnosed with PE within 30 days. 397/1,189 patients (33.4%; 95%CI 30.8-36.1%) had CT/VQ scans for PE. 3 out of 792 who were not scanned had a missed PE resulting in a false-negative rate of 0.4% (95% CI 0.1-1.1%). 80 patients had an elevated D-dimer or high Wells score but were not imaged. Furthermore, 75 patients who did not have an elevated D-dimer nor a high Wells score were imaged. Had Wells rule/D-dimer been adhered to, 402/1,189 patients (33.8%; 95%CI 31.9-36.6%) would have undergone imaging and the false negative rate would be 0/727, 0% (95%CI 0.0-0.5%). Conclusion: If the Wells rule and D-dimer was used in all patients tested for PE, a similar proportion would have a CT scan but fewer PEs would be missed. Keywords: pulmonary embolism, D-dimer, diagnosis LO82The accuracy and prognostic value of point-of-care ultrasound for renal colic: a systematic review C. Wong, MD, P. Young, MD, M. Ross, MD, H. Lee Robertson, MLIS, E. Lang, MD, University of Calgary, Calgary, AB Introduction: Point-of-care ultrasound (POCUS) has been suggested as an initial investigation in the management of renal colic. Our objectives were: 1) to determine the accuracy of POCUS for the diagnosis of nephrolithiasis, and 2) to assess its prognostic value in the management of renal colic (PROSPERO: 42016035331). Methods: An electronic database search of MEDLINE, EMBASE, and PubMed was conducted utilizing subject headings, keywords, and synonyms that addr...

Review article: Best practice management of neck pain in the emergency department (part 6 of the musculoskeletal injuries rapid review series)

“…Reasons for deviating from the criteria may occur due to a variety of reasons, such as patient request or demand, medical malpractice fears or a physician's desire to document absence of an injury . However, interventions within the ED to improve compliance with the application of CDRs, such as regular education and teaching sessions, posters, policy change and ‘real‐time’ reminders on radiology referrals, can reduce inappropriate imaging …”

“…40,64 However, interventions within the ED to improve compliance with the application of CDRs, such as regular education and teaching sessions, posters, policy change and 'real-time' reminders on radiology referrals, can reduce inappropriate imaging. 29,65 Compared to 'assessment' and 'imaging', there was a paucity of high-level evidence on effective interventions for neck pain in the ED. Once red flags are screened and sinister pathologies diagnosed or excluded, there were few recommendations as to how to manage nonserious neck pain patients within the ED setting in terms of controlling their pain, exercise prescription, advice and education or other treatment modalities.…”