A potentially life-threatening blood clot known as a pulmonary embolism can be hard to diagnose in the emergency room, since it often has common and unspecific symptoms like shortness of breath and chest pain. Typically, clinicians must rely on tests such as a computed tomography angiography (CTA), which uses a CT scan and an injection of special dye into the patient’s blood vessels.
But, as with any advanced imaging, these tests come with risks for the patient: increased exposure to radiation, increased risk for cancer, potential allergic reactions to the dye, or even dye leaks into the patients’ tissue. Plus, over-ordering CTA scans can bottleneck the emergency department, leaving both staff and patients waiting longer for care.
“More tests take more time, and you only have so many resources,” said Jean Lesko, MD, associate director of the White Plains Hospital emergency department. “And more importantly, to the patient, any CAT scan is a degree of radiation. You need to weigh the risks and benefits.”
A fellow with United Hospital Fund/Greater New York Hospital Association’s Clinical Quality Fellowship Program, Dr. Lesko noticed that the rate of these CTA tests had risen steadily at her emergency department. The hospital was now scanning more patients than its peers and finding fewer pulmonary embolism diagnoses than the national benchmark.
The data signaled an opportunity: find a way to safely decrease the number of unnecessary CTA tests.
To do so, Dr. Lesko and her team first analyzed more than 300 relevant cases from the last two months to understand how clinicians were deciding whether a CTA was necessary. They found that both the types of clinical decision tools used—and how well those decisions were documented—varied. The results helped them form a plan to streamline the process.
First, the team alerted clinicians of the ongoing review of CTA case files and educated them about the project's overall goals. The team also encouraged clinicians to all use a single validated and widely applicable clinical tool known as the YEARS Algorithm, which employs three distinct criteria to determine if a CTA is warranted.
Then, as the team reviewed cases each week, they would follow up with clinicians whose CTA scans were flagged as “avoidable” to either clarify the decision or provide a learning opportunity for future cases. The approach worked, Dr. Lesko said.
“Each week and each month, less and less cases were being flagged [as avoidable],” Dr. Lesko said.
Ultimately, the percentage of “avoidable” CTA scans decreased significantly, dropping to less than 5 percent of cases in the final weeks. Those numbers represent dozens of patients who avoided the test and its risks over the six months of the project.
Dr. Lesko noted that the Clinical Quality Fellowship program played an important role in her ongoing interest in quality improvement and in the project’s success, including when it came to securing buy-in from leadership. White Plains Hospital’s emergency department director and chief quality officer are also alumni of CQFP, she noted.
“We focus very much on quality here,” Dr. Lesko said. “CQFP was a very worthwhile program—it gave me a better understanding and I want to continue to focus [on quality].”
Started in 2009, the Clinical Quality Fellowship Program has trained more than 300 mid-career physicians, nurses, and physician assistants from over 50 health care facilities in the New York metropolitan area to become quality improvement and patient safety leaders in their organizations. The 15-month program graduates a new class of these change-makers on the front lines of health care each year.