The Impact of Pop-Up Clinical Electronic Health Record Decision Tools on Ordering Pulmonary Embolism Studies in the Emergency Department.

BACKGROUND: Emergency physicians make time-sensitive care decisions for life threatening diagnoses and utilize evidence-based decision rules and testing with high sensitivity to ensure that critical diagnoses are not missed. Current literature suggests that there is over testing for pulmonary embolism in the emergency department. OBJECTIVES: This study aimed to determine whether the addition of a pop-up notification of the Modified Wells Criteria into the workflow would impact the number of total orders for computed tomography pulmonary angiography (CTPA) or the diagnostic yield of those studies. METHODS: This study was a retrospective observational study comparing CTPA utilization rates and diagnostic yield among physicians at a single academic emergency department in the 1 year prior and 1 year post implementation of an active electronic health recored (EHR) pop-up of Modified Well's scoring when ordering a CTPA. RESULTS: CTPA utilization rates were statistically equivalent, p <0.0001 within a 0.5% equivalence margin, during the pre and post intervention years. The observed difference was 0.1% (95% CI -0.02%, 0.21%). Despite proving equivalence in the rates of CTPA studies ordered, the diagnostic yield, however, was significantly different (p = 0.001), 32.35% in the pre-intervention year compared to 41.60% in the post-intervention year. CONCLUSION: There are many barriers to the implementation of successful EHR alerts. These findings support and validate previous studies that have shown a higher diagnostic yield of CT angiography for pulmonary embolism after implementation of active alerts integrated into the EHR with ordering studies. These tools are effective quality improvement initiatives, and their use should be encouraged.

Encephalitis with coinfection by Jamestown canyon virus (JCV) and varicella zoster virus (VZV).

We present the case of a 59-year-old Midwestern farmer who presented with altered mental status, dysarthria, urinary incontinence, and a right-sided L5 dermatomal rash; he had recently received a course of oral corticosteroids for treatment of radicular low back pain. Lumbar puncture revealed the presence of varicella zoster virus (VZV) and IgM antibodies against a California-group encephalitis virus, later confirmed as Jamestown Canyon virus (JCV). Unfortunately, the patient's health declined despite aggressive treatment, developing progressive subarachnoid hemorrhage. He died after withdrawal of supportive care following 3 weeks in the intensive care unit. To our knowledge, this is the first documented case of encephalitis associated with coinfection by VZV and JCV. While the relative contributions of these viral pathogens to the patient's illness are difficult to ascertain, the clinical features of this case are consistent with co-pathogenesis, possibly driven by antecedent corticosteroid use. This case highlights the emerging role of viral coinfections in the etiology of viral illnesses.