Reassessment of Clinical Practices for Patients Presenting to the Emergency Department with Upper Gastrointestinal Bleeding
Project Lead: Dr. Eddy Lang
Other Team Members: Dr. Subrata Ghosh, Dr. Marilynne Hebert, Dr. Gilaad Kaplan, Dr. Sander Van Zanten, Dr. Kerri Novak, Dr. Michael Bullard, Dr. Andrew McRae
Acute upper gastrointestinal bleeding (UGIB) is a leading cause of emergency department visitation in Alberta, and a common condition for which red blood cell transfusions are administered. A recent systematic review found that more restrictive transfusion strategies were associated with lower rates of all-cause mortality, re-bleeding, and adverse events. Data from the Calgary region indicates that during 2013-2014, 29% of patients presenting with UGIB received packed red blood cell (RBC) transfusions and that 67% of these transfusions occurred above the new evidence-based thresholds of 70 g/L.
Inappropriate use of RBC transfusions is a patient safety concern, and has been identified as a priority by Choosing Wisely Canada. Their clinical recommendation is to not transfuse blood when effective and safer non-transfusion strategies are available, and to not transfuse more than one unit at a time in stable patients.
The Alberta Health Services Emergency Strategic Clinical Network is leading a province-wide quality-improvement initiative to improve the appropriateness of UGIB risk-stratification, management and disposition, including addressing the over-utilization of RBC transfusion of patients. Through the multidisciplinary development and implementation of an evidence-based clinical pathway, this initiative will help improve compliance with evidence-based guidelines, reduce the transfusion of hemodynamically stable patients, and improve patient outcomes. In line with the Choosing Wisely Canada campaign, this initiative aims to promote the avoidance of unnecessary treatments and procedures.
Improving the Stewardship of Diagnostic Imaging Resources in Alberta Emergency Departments
Project Lead: Dr. Eddy Lang
Other Team Members: Dr. James Andruchow, Dr. Andrew McRae, Dr. Grant Innes, Dr. Robert Sevick, Dr. Michael Bullard, Dr. Derek Emery, Dr. Brian Holroyd, Dr. Brian Rowe
Computed tomography (CT) utilization has increased dramatically as a result of availability, medico-legal pressures, and the perceived association of imaging with quality of care. Despite this trend, more is not always better when it comes to medical tests. CT exposes patients to radiation leading to consequent cancer risks and contributes to increased healthcare costs and length of stay.
In the case of mild traumatic brain injuries (MTBI), validated clinical decision rules can identify patients unlikely to benefit from a CT scan. The Canadian CT Head Rule (CCHR) is a check list of symptoms and risk factors to identify patients at very low-risk of adverse outcomes requiring treatment. Head-injured patients with no CCHR high-risk factors, have a probability of needing acute neurosurgical intervention of less than 1 in 7,000.
Despite widespread awareness of the CCHR, Alberta data indicate significant persistent practice variability between physicians. An analysis of 311 emergency physicians treating 20,797 patient encounters for head injury found that, while 40% of all patients received a CT scan, ordering rates by physician ranged between 5% and 90%.
The Alberta Health Services Emergency Strategic Clinical Network is leading a province-wide research and quality improvement initiative to address over-utilization and variation in CT ordering. The initiative focuses on engagement of physicians, decision support integrating the CCHR into physician workflow, performance monitoring and reporting, and engaging patients in shared decision-making.