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.

Keywords: implementation science; pulmonary embolism (PE); quality improvement; vascular imaging/diagnostics.

背景：

美国血液学学会和美国急诊医师学院推荐使用经过验证的风险分层工具来评估疑似肺栓塞（PE）。

方法：

我们在紧急部门（ED）设计并实施了电子临床先验概率（PTP）工具。总共涉及美国三个卫生系统的38个急诊科（包括三级和区域急诊科）。我们分析了从2022年9月12日至2023年1月11日期间，在270,247次急诊访问中PTP使用的数据。我们考察了CT肺血管造影（CTPA）订单中记录的PTP分数的比例。每个站点选择了Wells评分的三等级版本进行实施，而第2个站点设计了一种结合了Wells、肺栓塞排除标准（PERC）和YEARS评分的方法。

结果：

在第3个站点，强制使用导致49%至53%的CTPA订单记录有PTP分数。而在可选使用PTP分数的第1和第2站点，CTPA订单中分别只有2-3%和1-3%记录了PTP分数。在第1站点，PTP使用的比例在整个研究期间略有上升，并且影像学上的PE检出率也有所增加（从3.4%到5.9%）。而在第2站点，影像学上的PE检出率为9%-10%，并且在整个研究期间保持相对稳定，PTP工具的使用情况相似。在第3个站点，整个研究期间影像学上的PE检出率同样保持相似水平（6-8%）。

结论：

在美国三个独立卫生系统中推荐使用的指南支持的PE先验概率评分并未提高影像学上的PE检出率。迫切需要涉及跨学科团队的新实施策略。

关键词：实施科学；肺栓塞（PE）；质量改进；血管成像/诊断。