Acute Flaccid Paralysis Accompanying West Nile Meningitis Ahmed ...

Does Academic Detailing Increase Use and Documentation of Clinical Decision Rules for
Pulmonary Embolism?
Grant, M, D.O., Patel, N, D.O., Horan, T, MSIV, MPH
St. Joseph's Regional Medical Center, Emergency Medicine Residency, Paterson, NJ
Introduction: The Well's Criteria for Pulmonary Embolus and the Pulmonary Embolism Rule Out
Criteria (PERC) are two clinical decision rules that have been prospectively validated to guide the
diagnostic work up of pulmonary embolism. Emergency Department physicians commonly do not
document the use of a clinical decision rule for the work-up of pulmonary embolism, whether they use
a rule or not, possibly leading to inappropriate ordering of diagnostic testing and exposing patients to
certain unnecessary risks such as contrast dye and radiation. We hypothesize that academic detailing
does increase documentation and use of clinical decision rules for pulmonary embolism in the
evaluation of patients in the emergency department.
Methods: A retrospective and prospective chart review was conducted over two three-month periods.
The study was performed at a single urban regional emergency medical center with over 140,000
visits/year and an emergency medicine residency training program. Charts included were all charts
with an order of D-dimer in the chart, any order of CT angiogram chest and charts with a final
diagnosis of pulmonary embolism. Exclusion criteria included patients who did not have the CT
angiogram chest done in the ED or had an order of D-dimer in the chart for evaluation of other
diagnoses rather than pulmonary embolism. In addition, the Well's score and PERC rule were
calculated for all charts, regardless if the clinical decision rules were documented in the charts.
Academic detailing was implemented through several mechanisms. A grand rounds lecture on clinical
decision rules for pulmonary embolism focusing on the Well's Criteria and the PERC rule was given to
attending physicians and residents. A diagnostic algorithm was also developed to help guide physician
diagnostic workup of pulmonary embolism. The PERC rule was also added to the electronic medical
record as the Well's Criteria was already available for use in the documentation system. The rates of
use and documentation of the Well's Criteria and the PERC rule were then analyzed pre and post
academic detailing.
Results: The total number of charts reviewed were 258 retrospectively and 316 prospectively.
Overall, ten charts had documentation retrospectively and 40 charts had documentation prospectively.
This was an increase from 4.03% documentation retrospectively to 14.49% prospectively. The odds
ratio was 3.59 (95% CI: 1.76 - 7.34, p