Barriers and Facilitators to Reducing Unnecessary Admission from the Emergency Department for Low-Risk Pulmonary Embolism

From the 2021 HVPAA National Conference

Hannah Lahti (University of Michigan), Tony Cuttitta, Colin Greineder, Shawna Smith, Keith Kocher, Eve Kerr, Geoff Barnes

Background

Approximately 250,000 people are diagnosed with pulmonary embolisms (PE) annually, predominantly in Emergency Departments (ED). Evidence-based guidelines recommend outpatient management for up to 50% of patients with low-risk acute PE. However, multi-center studies confirm our academic medical center’s finding that fewer than 5% of all patients with acute PE are actually discharged from the ED. Admission for low-risk PE patients leads to unnecessary healthcare costs and exposure to risks associated with admission. Identifying barriers to outpatient management and potential implementation strategies are important for improving high-value care.

Objective

To identify barriers and facilitators to outpatient management of acute low-risk PE, as well as barriers and facilitators to the potential implementation of an alert in the electronic health record (EHR) to notify providers which low-risk PE patients may be candidates for discharge.

Methods

An interview guide to assess barriers and facilitators to discharge for patients with low-risk PE as well as a potential EHR intervention was designed using constructs from the Tailored Implementation in Chronic Diseases framework. Using convenience sampling, two qualitative analysts conducted eight interviews with ED clinicians at one academic medical center, including four residents, three physician assistants, and one attending physician. After an initial check for consistency, transcripts were independently summarized by two analysts, and rapid qualitative analysis was used to identify barriers and facilitators to guideline adherence and intervention implementation.

Results

While providers varied in their awareness of the recommendation, there was general agreement with the recommendation to discharge low-risk PE patients and/or belief in increasing the number of low-risk PE patients discharged. Providers noted that the primary barriers to discharging patients with low-risk PE included safety concerns, access to medication, and fears about prompt outpatient follow-up. When asked about a potential EHR alert to notify the provider which patients could be considered for discharge, alert fatigue was a commonly cited barrier among physicians but not physician assistants. Potential facilitators to guideline adherence endorsed by participants included the use of institutional data to track positive and negative outcomes (e.g. adverse events), as well as the provision of evidence-based guidelines to support decision-making.

Conclusions

Reducing admissions for low-risk PE should address the patient need for reliable medication access and prompt outpatient follow-up. Barriers to the implementation of an EHR intervention may include alert fatigue. Potential facilitators to reducing admissions for low-risk PE include the possibility to track data and provide evidence-based guidelines to providers.

Clinical Implications

Although literature suggests that many patients with low-risk PE can be managed without hospitalization, provider practice is not consistently concordant with guidelines. This lack of adherence to guidelines may lead to increased healthcare costs and exposure to risks. Important barriers prevent clinicians from following this high-value, evidence-based practice. Addressing these barriers to discharge, including medication access and concerns about outpatient follow-up, as well as providing institutional data on patient outcomes and evidence-based guidelines for discharge, may be helpful in future quality improvement efforts to reduce admissions for low-risk PE.

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