Key findings from multisite implementation of electronic health record tools for clinical pretest probability of pulmonary embolism in the emergency department.

Background: The use of validated risk stratification tools for the workup of suspected pulmonary embolism (PE) is a recommendation of the American Society of Hematology and the American College of Emergency Physicians.

Methods: We designed and implemented electronic clinical pretest probability (PTP) tools for use in emergency departments (ED). Overall, 38 EDs (tertiary and regional EDs) in the United States were involved across three health systems. PTP use was analyzed between September 12, 2022 and January 11, 2023 in 270,247 ED visits. PTP use was examined in terms of the percentage of visits for which patients underwent computed tomography pulmonary angiography (CTPA). Each site chose the 3-tier Wells' score for implementation and Site 2 designed a combined Wells', pulmonary embolism rule-out criteria (PERC), and YEARS score.

Results: At Site 3, forced use resulted in documented PTP scores in 49-53% of ordered CTPAs. At Sites 1 and 2, where PTP scores were optional, documented PTP scores occurred in 2-3% and 1-3% of CTPA orders, respectively. At Site 1, the use of PTP increased slightly over the study period, with signs that PE yield on imaging was also increasing (3.4-5.9%). At Site 2, PE yield on imaging was 9-10%, and it remained similar, with similar use of PTP tools over the study period. PE yield (6-8%) on imaging also remained similar throughout the study at Site 3.

Conclusions: Guideline-endorsed PTP scores for PE at three independent health systems in the United States did not increase PE yield on imaging. Novel implementation strategies involving interdisciplinary teams are urgently needed.