'R/O path' - a quality assurance study of emergency department medical imaging requests during on-call hours.

Incidental Radiology Findings on Computed Tomography Studies in Emergency Department Patients: A Systematic Review and Meta-Analysis

Altered mental status (AMS) is a common presentation in the emergency department (ED). A previous study revealed 78% electroencephalogram (EEG) abnormalities, including nonconvulsive seizure (NCS; 5%), in ED patients with AMS. The objective of this study was to assess the impact of EEG on clinical management and outcomes of ED patients with AMS. This was a randomized controlled trial at two urban teaching hospitals. Adult patients (≥18 years old) with AMS were included. Excluded patients had immediately correctable AMS (e.g., hypoglycemia) or were admitted before enrollment. Patients were randomized to routine care (control) or routine care plus EEG (intervention). Research assistants used a scalp electrode set with a miniature, wireless EEG device (microEEG) to record standard 30-minute EEGs at presentation, and results were reported to the ED attending physician by an off-site epileptologist within 30 minutes. Primary outcomes included changes in ED management (differential diagnosis, diagnostic work-up, and treatment plan from enrollment to disposition) as determined by surveying the treating physicians. Secondary outcomes were length of ED and hospital stay, intensive care unit (ICU) requirement, and in-hospital mortality. A total of 149 patients were enrolled (76 control and 73 intervention). Patients in the two groups were comparable at baseline. EEG in the intervention group revealed abnormal findings in 93% (95% confidence interval [CI] = 85% to 97%), including NCS in 5% (95% CI = 2% to 13%). Using microEEG was associated with change in diagnostic work-up in 49% (95% CI = 38% to 60%) of cases and therapeutic plan in 42% (95% CI = 31% to 53%) of cases immediately after the release of EEG results. Changes in probabilities of differential diagnoses and the secondary outcomes were not statistically significant between the groups. An EEG can be obtained in the ED with minimal resources and can affect clinical management of AMS patients.

356 Frequency, Test Characteristics, and Patient Demographics Associated With Lab and Imaging Results Viewed in the Emergency Department During Encounters

Incidental findings on cone beam computed tomographic images: a Pandora's box?

ObjectiveTo investigate temporal changes in clinical reasoning quality of physicians who requested abdominal CT scans at a tertiary care center during on-call hours within a 15-year period.MethodsThis retrospective study included 531 patients who underwent abdominal CT at a tertiary care center during on-call hours on 36 randomly sampled unique calendar days in each of the years between 2005 and 2019. Clinical reasoning quality was expressed as a percentage (0–100%), taking into account the degree by which the differential diagnoses on the CT request form matched the CT diagnosis. Temporal changes in the quality of clinical reasoning and number of CT scans were assessed using Mann-Kendall tests. Associations between the quality of clinical reasoning with patient age and gender, requesting department, and time of CT scanning were determined with linear regression analyses.ResultsThe median annual clinical reasoning score was 14.7% (interquartile range: 12.2 to 16.0%; range: 7.7 to 34.6%). The quality of clinical reasoning significantly decreased between 2005 and 2019 (Mann-Kendall Tau of −0.390, p = 0.048), while the number of abdominal CT scans significantly increased (Mann-Kendall tau of 0.790, p < 0.001).ConclusionThe clinical reasoning quality of physicians who request abdominal CT scans during on-call hours has deteriorated over time. Clinical reasoning appears to be worse in younger patients.Key Points• In patients with suspected acute abdominal pathology who are scheduled to undergo CT scanning, referring physicians generally have difficulties in making an accurate pretest (differential) diagnosis.• Clinical reasoning quality of physicians who request acute abdominal CT scans has deteriorated over the years, while the number of CT scans has shown a significant increase.• Clinical reasoning quality appears to be worse in younger patients in this setting.

Introduction: Decision fatigue is a well-characterized phenomenon that has rarely been studied in the medical field. Emergency department (ED) physicians make many clinical decisions every shift. In this study, we examined ED physician decisions in computed tomography (CT) ordering, consultations, and discharges over time in an eight-hour shift. Methods: We performed a cohort study of adult patients presenting to two EDs of an academic, tertiary care hospital over a two-year period using the hospital administrative database. Patients triaged to the Urgent Care (minor acuity) area of the ED were excluded. Patients were analyzed based on the hour of the shift that they were initially assessed by an ED physician. For each hour, we evaluated the proportion of patients who had CTs, consultations, discharges, consultations not resulting in admission, returns within 72 hours of discharge, and median ED length of stay (LOS). Patients under the care of more than one ED physician (i.e. handovers) were analyzed as the time seen by the initial physician. Statistical significance of outcomes over time was assessed using random effects logistic regression. Results: 87,752 patients were included in the study period. 42,146 patients (48.0%) received consultations, of which, 29,347 (69.6%) were admitted. 45,470 patients (51.8%) were discharged without consultation, of which, 4102 (9.0%) returned within 72 hours. The median ED LOS for all non-consulted discharged patients was 4.9 hours. There was a statistically significant decline in the hourly rates of CT head and CT abdomen ordering as the shift progressed. CT head ordering declined significantly from 15.8% in the first hour to 12.2% in the last hour (p&lt;0.0001) while CT abdomen declined significantly from 9.6% to 7.6% (p&lt;0.0001). There were no significant differences in the hourly rates of consultations, consultations not resulting in admission, discharges, discharges returning within 72 hours, or ED LOS. Conclusion: ED physician decisions about patient disposition did not change in relation to hours into the shift. Interestingly, the rates of CT head and CT abdomen declined as the shift progressed. The lower CT ordering rates do not seem to be associated with any differences in patient disposition or ED LOS. In this large patient sample, we did not find evidence of decision fatigue among ED physicians.

Hepatic steatosis is a relatively common incidental finding on computed tomography (CT) studies performed for patients in the emergency department (ED). The aim of our survey was to explore the preferences and perspectives of emergency physicians regarding reporting of incidental findings with a focus on hepatic steatosis. A prospective web-based questionnaire was conducted and distributed electronically to emergency clinicians with anonymous collection of responses. A total of 236 responses were received. The true response rate could not be determined due to different methods of electronic distribution. However, there was an estimated representation of 8.3% for ED physicians and 2.5% for trainees. The median time spent on the survey was less than 3minutes. Seventy-seven per cent answered yes to giving an incidental finding more significance if mentioned in the conclusion section. More than half of respondents (60.2%) reported that they would like hepatic steatosis to be mentioned in a CT report while 30% reported that it was irrelevant in the emergency setting and 10% reported that they did not want it mentioned in the report. The majority (83.1%) reported that they would include this finding in the discharge summary for GP follow-up and less than half (44.1%) would mention it to patients. Our survey highlights the importance of clear communication between radiologists and ED physicians when incidental findings are encountered. Radiologists play an important role in alerting ED physicians and clinicians who have access to patients' radiology reports to the presence of incidental findings including hepatic steatosis.

Interpretation of Plain Chest Roentgenogram

To determine past 15-year trends in workload, negative findings, and incidental findings in acute neuroradiology during on-call hours at a European tertiary care center. This study analyzed a sample of 2494 CT and 264 MRI scans of the head and/or neck performed during on-call hours at a tertiary care center on random dates between 2009 and 2023. The workload significantly increased by 130% between 2009 and 2023 (Kendall tau of 0.76, p < 0.001), both due to an increased number and complexity of CT scans (80% and 50% increase, respectively). The workload for MRI remained stable (Kendall tau of 0.03, p = 0.869). The proportion of negative CT scans showed temporal stability (Kendall tau of 0.25, p = 0.139), at an average of 65%. The proportion of negative MRI scans showed an irregular but significant upward pattern over time, ending at 74% in 2023 (Kendall tau 0.42, p = 0.003). The percentage of CT scans with incidental findings exhibited a fluctuating yet significant upward trend over time, ending at 4% in 2023 (Kendall tau 0.62, p < 0.001), and was associated with increasing age (p = 0.010) and the use of a larger scan coverage (p < 0.001). No incidental findings were reported for MRI. The acute neuroradiology workload during on-call hours has considerably grown in the past 15 years, both due to a rise in the number and complexity of CT scans. Overuse of CT did not appear to increase, but MRI may be increasingly overutilized. The frequency of incidental findings on CT was non-negligible and increased. Question Both an increase in the number and complexity of CT scans has led to a 130% rise in acute neuroradiology workload during on-call hours over the past 15 years. Findings There are indications that MRI overuse may be increasing (but not CT), while the frequency of incidental findings on CT is also on the rise. Clinical relevance Policymakers should address the rising acute neuroradiology workload driven by CT and the potential overuse of MRI in this setting. Further investigation is needed into the consequences of the increase in incidental findings on CT.

The purpose of this study was to describe a new, broadly applicable radiology report categorization (RADCAT) system that was developed collaboratively between radiologists and emergency department (ED) physicians, and to establish its usability and performance by interobserver variation. In collaboration with our ED colleagues, we developed the RADCAT system for all imaging studies performed in our level-1 trauma center, including five categories that span the spectrum of normal through emergent life-threatening findings. During a pilot phase, four radiologists used the system real-time to categorize a minimum of 400 reports in the ED. From this pool of categorized studies, 58 reports were then selected semi-randomly, de-identified, stripped of their original categorization, and recategorized based on the narrative radiology report by 12 individual reviewers (6 radiologists, and 6 ED physicians). Interobserver variation between all reviewers, radiologists only, and ED physicians only was calculated using Cohen's Kappa statistic and Kendall's coefficient of concordance. Altogether, agreement among radiologists and ED physicians was substantial (κ=0.73, p<0.0001) and agreement for each category was substantial (all κ>0.60, p<0.0001). The lowest agreement was observed with RADCAT-3 (κ>0.61, p<0.0001) and the highest agreement with RADCAT-1 (κ>0.85, p<0.0001). A high trend in agreement was observed for radiologists and ED physicians and their combination (all W>0.90, p<0.0001). Our RADCAT system is understandable between radiologists and ED physicians for categorizing a wide range of imaging studies, and warrants further assessment and validation. Based upon these pilot results, we plan to adopt this RADCAT scheme and further assess its performance.

Introduction: Emergency Department (ED) Physicians typically consult with a specialist after pertinent results are gathered. In the case of acute stroke, delays in neurologist consultation equate to valuable time lost for treatment. When Telestroke went live in June 2015 at our 148-bed regional medical center, the physician norm was challenged because Telestroke protocol stipulates activation of the system before the CT scan. Despite education about the importance of calling early, ED physicians continued to activate Telestroke after gathering results. Hypothesis: Implementation of timely, structured feedback to ED physicians will change ED physician culture to reduce Door-to-Telestroke Activation (DTA) times. Methods: In February 2017, monthly feedback was initiated with ED physicians. Graphs showing current performance related to activation times were discussed, goals were reviewed, small improvements were acknowledged, and physicians were encouraged to share their successes. Using a prospective observational study design and a REDCap database, data from June 2015 to February 2017 were compared to data from March 2017 to July 2018. Results: From June 10, 2015 to July 18, 2018 Telestroke was activated 246 times in the ED. After the feedback initiation, the median DTA of 20 m (n=145) was significantly lower than the baseline median of 32 m (n=101, p&lt;0.0001) and the percentage of activations prior to the CT scan rose significantly from 20% to 46% (p=0.0003). Also, Door-to-Needle (DTN) time decreased to a median of 48 m (n=27), compared to the baseline of 56 m (n=19, p=0.15) and the percentage of ischemic stroke patients treated with IV Alteplase increased to 17.7% from 13.4%. Median Door-to-CT (DTCT) remained unchanged at 17 m both pre and post intervention, demonstrating consistent ED processes. Conclusions: Timely ED physician feedback led to faster Door-to-Telestroke Activation times. While statistically insignificant, post intervention DTN times rose from a baseline of 63% (n=19) to 81% (n=27, p=0.29) which met the primary Target: Stroke Phase II goal to treat 75% of patients within 60 minutes. Faster activation resulted in faster treatment and ultimately improved chances of a better outcome.

Prevalence and clinical significance of incidental findings in chest and abdominopelvic CT scans of trauma patients; A cross-sectional study

Effect of picture archiving and communication system on diagnosis accuracy in CT and radiography examinations in emergency departments

Over 50 million U.S. adults 65 years and older account for >20 million emergency departments (ED) visits each year. Increasing ED use by older adults is projected to exceed the capacity of U.S. EDs. The traditional ED model of care is ill-equipped to address the many complex care needs of older adults.

BackgroundSecondary triage protocols have been described in the literature as physiologic (first-tier) criteria and mechanism-related (second-tier) criteria to determine the level of trauma activation. There is debate as to the efficiency of triage decisions based on mechanism of injury which may result in overtriage and overuse of limited trauma resources. Our institution developed and implemented an advanced three-tier trauma alert system in which stable patients presenting with blunt traumatic mechanism of injury would be evaluated by the emergency department (ED) physician rather than the trauma surgeon. The American College of Surgeons Committee on Trauma (ACSCOT) requires that operational changes be monitored and evaluated for patient safety and performance. The primary aim of this study was to evaluate the process, as well as outcomes, of patient care pre and post implementation of the new triage protocol. The secondary aim was to determine predictor variables that were associated with ED dismissal.MethodsA retrospective blinded pre/post process change implementation explicit chart review was conducted to compare process and outcomes of minimally injured trauma patients who were field triaged by mechanism of injury. Generalized linear modeling was performed to determine which predictor variables were associated with ED dismissal.ResultsThere were no significant differences in minutes to physician evaluation, CT scan, OR/ICU disposition, readmission rates, safety or quality. Significant differences only occurred in time to chest x-ray, length of stay in ED, and ED dismissal rates. Trauma surgeon and ED physician patient groups did not differ on ISS, age, or sex. The only significant predictor for ED dismissal was treatment provider, with ED physicians 3.6 times more likely to dismiss the patient from the emergency department.ConclusionsED physicians provided compble care as measured by safety, timeliness, and quality in minimally-injured patients triaged to our trauma center based only on mechanism of injury. Moreover, ED physicians were more likely to dismiss patients from the ED. A three-tiered internal triaging protocol can redirect resource usage to reduce the burden on the trauma service. This may be increasingly beneficial in trauma models in which the trauma surgeons also serve as critical care intensivists.