P136: A quality improvement initiative to optimize appropriate testing for venous thromboembolism in the emergency department

Abstract

Introduction: Venous thromboembolism (VTE) is a common diagnostic consideration among patients presenting to the emergency department (ED) and often requires the use of diagnostic testing. A normal d-dimer (DD) blood test can exclude VTE and eliminate the need for costly imaging and the associated contrast medium and radiation exposure. The purpose of this quality improvement initiative was to increase the use of DD testing for patients with a low and intermediate clinical pretest probability of VTE, increase the use of ventilation perfusion scans (VQ) as an alternative to CT pulmonary angiogram (CTPA) and decrease the use of CTPA and venous doppler ultrasound (VDUS) at St. Michael’s hospital. Methods: A multispecialty team developed an ED specific algorithm set for appropriate VTE testing that were posted on the ED online portal along with a poster in each zone of the ED after an ED launch campaign with request for feedback. A run chart was used to track DD, CTPA, VQ and VDUS utilization. Two-sided T-test comparison was conducted to compare pre- and post-implementation utilization. Results: Physician feedback was positive regarding the use of: DD in VTE intermediate risk patients and the VTE algorithm set. Feedback was negative for DD turnaround time. We found a significant increase in DD use (77 tests per month to 93; p=0.013), but no significant change in the use of CTPA (27.3 per month to 30; p=0.38), VDUS, or VQ. Number of monthly ED visits remained constant. Conclusion: This intervention increased DD utilization, but measuring appropriateness will require prospective collection of clinical pre-test probability. Integrated risk stratification and decision aids into computer physician order entry may be necessary to track and improve appropriateness.