Department Workflow Research Articles

Program evaluation and healthcare process improvement focused on complex wheelchair procurement

ABSTRACT The operations of a specialty wheelchair (WC) seating center can influence the evaluation to delivery timeframe in days for a complex rehab technology (CRT) WC. Operations at one facility improved due to departmental process improvement (PI) project with evaluation of the delivery workflow and implementation of changes. A retrospective chart audit gathered baseline data on the evaluation to delivery timeframe in days of a CRT WC for 50 individuals prior to PI changes. Standard departmental workflow collected 745 individuals’ post-PI changes. The interventions took place from March 25, 2017, to April 5, 2018, and included defining and educating stakeholders on their roles and expectations, revisions of the electronic medical record, weekly and quarterly meetings with supplier leadership, paperwork completion goals, and follow-up paperwork centralization. Mean pre- and post-intervention evaluation to delivery timeframes in days was significantly different (162.2 versus 127.4 days, p < 0.0001). Overall, a reduction in the mean evaluation to delivery timeframe in days of CRT WC by 21.5% or 34.8 days occurred. Systematic change takes time as well as the commitment of all key players. PI changes resulted in evaluation to delivery timeframe reduction for patients to receive their CRT WCs.

Effectiveness of an Artificial Intelligence Software for Limb Radiographic Fracture Recognition in an Emergency Department.

Objectives: To assess the impact of an Artificial Intelligence (AI) limb bone fracture diagnosis software (AIS) on emergency department (ED) workflow and diagnostic accuracy. Materials and Methods: A retrospective study was conducted in two phases-without AIS (Period 1: 1 January 2020-30 June 2020) and with AIS (Period 2: 1 January 2021-30 June 2021). Results: Among 3720 patients (1780 in Period 1; 1940 in Period 2), the discrepancy rate decreased by 17% (p = 0.04) after AIS implementation. Clinically relevant discrepancies showed no significant change (-1.8%, p = 0.99). The mean length of stay in the ED was reduced by 9 min (p = 0.03), and expert consultation rates decreased by 1% (p = 0.38). Conclusions: AIS implementation reduced the overall discrepancy rate and slightly decreased ED length of stay, although its impact on clinically relevant discrepancies remains inconclusive. Key Point: After AI software deployment, the rate of radiographic discrepancies decreased by 17% (p = 0.04) but this was not clinically relevant (-2%, p = 0.99). Length of patient stay in the emergency department decreased by 5% with AI (p = 0.03). Bone fracture AI software is effective, but its effectiveness remains to be demonstrated.

Integrating and Adopting AI in the Radiology Workflow: A Primer for Standards and Integrating the Healthcare Enterprise (IHE) Profiles.

The deployment of artificial intelligence (AI) solutions in radiology practice creates new demands on existing imaging workflow. Accommodating custom integrations creates a substantial operational and maintenance burden. These custom integrations also increase the likelihood of unanticipated problems. Standards-based interoperability facilitates AI integration with systems from different vendors into a single environment by enabling seamless exchange between information systems in the radiology workflow. Integrating the Healthcare Enterprise (IHE) is an initiative to improve how computer systems share information across health care domains, including radiology. IHE integrates existing standards-such as Digital Imaging and Communications in Medicine, Health Level Seven, and health care lexicons and ontologies (ie, LOINC, RadLex, SNOMED Clinical Terms)-by mapping data elements from one standard to another. IHE Radiology manages profiles (standards-based implementation guides) for departmental workflow and information sharing across care sites, including profiles for scaling AI processing traffic and integrating AI results. This review focuses on the need for standards-based interoperability to scale AI integration in radiology, including a brief review of recent IHE profiles that provide a framework for AI integration. This review also discusses challenges and additional considerations for AI integration, including technical, clinical, and policy perspectives.

Effect of Routine Child Physical Abuse Screening Tool on Emergency Department Efficiency.

Physical abuse is a significant cause of morbidity and mortality for children. Routine screening by emergency nurses has been proposed to improve recognition, but the effect on emergency department (ED) workflow has not yet been assessed. We sought to evaluate the feasibility of routine screening and its effect on length of stay in a network of general EDs. A 2-question child physical abuse screening tool was deployed for children <6 years old who presented for care in a system of 27 general EDs. Data were compared for the 6 months before and after screening was deployed (4/1/2019-10/2/2019 vs 10/3/2019-3/31/2020). The main outcome was ED length of stay in minutes. There were 14,133 eligible visits in the prescreening period and 16,993 in the screening period. Screening was completed for 13,404 visits (78.9%), with 116 (0.7%) screening positive. The mean ED length of stay was not significantly different in the prescreening (95.9 minutes) and screening periods (95.2 minutes; difference, 0.7 minutes; 95% CI, -1.5, 2.8). Among those who screened positive, 29% were reported to child protective services. On multivariable analysis, implementation of the screening tool did not impact overall ED length of stay. There were no significant differences in resource utilization between the prescreening and screening periods. Routine screening identifies children at high risk of physical abuse without increasing ED length of stay or resource utilization. Next steps will include determining rates of subsequent serious physical abuse in children with or without routine screening.

Exploring the implementation of role extension for Namibian radiographers: Perspectives on intravenous injection of contrast media

IntroductionRole extension to include intravenous (IV) injection of contrast media has been formally embraced by radiographers and their regulatory bodies in developed countries. The revised scope of practice, in our Namibian context, has formalised IV injection as an extended role for radiographers. This study aimed to explore the perspectives of radiographers regarding this new role of IV injection of contrast media. MethodsA qualitative design with a descriptive phenomenological approach was employed to collect data from 15 radiographers working in both public and private radiology facilities. Participants were purposively selected to participate in focus group discussions and individual interviews. An interview guide was used to facilitate the discussions and interviews, and a voice recorder was used for recording. Data were transcribed verbatim and analysed using Tesch's 8-step method. ResultsFrom the 15 participants, three themes were developed: enhanced service delivery with two subthemes (improved departmental workflow and patient care), training needs with two subthemes (inadequate contrast media reaction training and standardised training requirement), and medical-legal issues with two subthemes (regulatory blurriness and role conflict distress). ConclusionThe participants expressed mixed perceptions towards the IV injection role of radiographers, emphasising the benefits for the department and patients while raising concerns regarding standardisation of training and associated medico-legal issues. Furthermore, a large-scale evaluation is necessary to uncover the challenges and barriers to the successful adoption of this new role. Implications for practiceThe role extension for radiographers to include IV injections is a long-awaited development, but it should be accompanied by the necessary training and guidelines to fully realise its benefits.

Assessment of X-ray films and image quality in diagnostic radiology departments of teaching hospitals in Iraq

Background: Patients undergo repeated X-ray examinations after their initial X-ray radiographs are rejected due to poor image quality. Reject analysis in digital radiography (CR) helps guide the education and training of staff, influences department workflow, reduces patient dose and improves department efficiency. The role of reject analysis in providing relevant information that would help achieve a sound reduction in radiation exposure. Aims:To assess the reasons for X-ray film rejection and to analyze reasons for deletions to improve the radiological services. Methods: The data were collected from about 200 rejected films from different hospitals in Iraq from January 2021 to August 2021. The reject rate, reasons for rejection for individual radiographers, examination types and projections used a structured format on which investigators recorded relevant data for rejection. The results were then collected and entered into a database for analysis. Results: Reject rate and cause of rejection were measured across all plane X-ray examinations for the hospitals in Kirkuk General Hospital at 8.1%, Mosul General Hospital at 13.9% and Al-Jumhory Hospital at 6.4%. Study cases and (appointment) 16.1%, Mass & Kv with positioning error 3.7%. The examinations with the highest percentage of deleted images were the chest, lumber spine & knee joints, 13.2%, 3.2% and 1.7%, respectively. Conclusions: Creating awareness among the student reduces the overall reject rate. The outcome of this study can be used to set up training programs to improve radiological services and reduce unnecessary radiation exposure to patients.

Optimizing stress-only myocardial perfusion imaging: a clinical prediction model to improve patient selection.

Stress-only single photon emission computed tomography myocardial perfusion imaging (MPI) offers numerous advantages in terms of improved workflow, cost and radiation reduction but is currently not widely utilized due to challenges in selecting appropriate patients for this technique. Data from 5959 individuals were used to derive (N = 4018) and validate (N = 1941) a binomial logistic regression model to predict normal stress MPI studies (stress total perfusion deficit < 4%, ejection fraction ≥ 50%). Model performance was analyzed using receiver operator characteristic curves. A simplified point-scoring system was developed and its impact on imaging workflow was assessed. Significant predictors of abnormal vs. normal stress MPI included male sex, age > 65 years, cardiomyopathy, congestive heart failure, myocardial infarction, angina, and pharmacological stress. The final model and simplified scoring system were associated with areas under the curve of 0.81 (95% CI 0.79-0.83) and 0.80 (95% CI 0.79-0.82) in the validation group, respectively. Use of the scoring system was estimated to result in a decrease of 56.5% in the number of non-contributory imaging studies acquired with minimal patient rescheduling. A prediction tool derived from simple clinical information can identify candidates for stress-only MPI studies with a beneficial impact on departmental workflow.

Evaluation of Compressed SENSE on Image Quality and Reduction of MRI Acquisition Time: A Clinical Validation Study

To evaluate the effect of compressed SENSE (CS)in clinical settings on scan time reduction and image quality. Ninety-five magnetic resonance imaging (MRI) scans from different anatomical regions were acquired, consisting of a standard protocol sequence (SS) and sequence accelerated with CS. Anonymized paired sequences were randomly displayed and rated by six blinded subspecialty radiologists. Side-by-side evaluation on perceived sharpness, perceived signal-to-noise-ratio (SNR), lesion conspicuity, and artifacts were compared and scored on a five-point Likert scale, and individual image quality was evaluated on a four-point Likert scale. CS reduced overall scan time by 32% while maintaining acceptable MRI quality for all regions. The largest time savings were seen in the spine (mean = 68 seconds, 44% reduction) followed by the brain (mean = 86seconds, 37% reduction). The sequence with maximum time savings was intracranial 3D-time-of-flight magnetic resonance angiography (202seconds, 56% reduction). CS was mildly inferior to SS on perceived sharpness, perceived SNR, and lesion conspicuity (mean scores = 2.32-2.96, P<.001 [1:SS superior; 3: equivalent; 5: CS superior]). CS was equivalent to SS for joint and body scans on overall image quality (CS = 3.02-3.37, SS = 3.04-3.68, P>.05, [1: lowest quality and 4: highest quality]). The overall image quality of CS was slightly less for brain and spine scans (mean CS = 2.79-3.05, mean SS = 3.13-3.43, P=.021) but still diagnostic. Good overall clinical acceptance for CS (88%) was noted with full clinical acceptance for body scans (100%)and high acceptance for other regions (68%-95%). CS significantly reduced MR acquisition time while maintaining acceptable image quality. The implementation of CS may improve departmental workflows and enhance patient care.

Engaging Emergency Nurses in Strategies to Address the Social Determinants of Health

IntroductionFor patients with social needs, emergency departments can be an essential bridge between the health care system and the community. Emergency nurses’ knowledge of and engagement in this work need to be examined to ensure that efforts for social determinants of health screening and the resulting community connections are effective. However, there is limited research in this area of nursing practice. The purpose of this study is to describe emergency nurses’ knowledge about social needs in their community, assess their knowledge of existing community resources, and examine their perceived confidence to respond to the social needs of their patients. MethodsA cross-sectional survey was conducted with 243 nurses employed in a large regional health care system. Data were collected using an adapted 81-item social determinants of health survey instrument to measure knowledge of social determinants of health, confidence, and frequency of discussing social determinants of health with emergency department patients and awareness of social resources available in the community. Survey participants were asked about barriers to incorporating social determinants of health into their emergency department workflow and to provide general demographic information. Descriptive statistics were used to analyze study results. ResultsMost of the 243 emergency nurse participants believed that addressing social determinants of health was important and that emergency nurses should be involved in issues around social determinants of health. However, most nurses reported limited knowledge about social determinants of health and had very limited knowledge about the resources available in their community to help patients with needs related to food, housing, medical care, and transportation. Nurses reported that although they know that their patients are unlikely to ask for help with social needs during an emergency department visit, they are still unlikely to ask their patients about social needs owing to low confidence about having social needs conversations, limited time, and competing care priorities. Participants advocated for greater case manager presence. Feeling connected to the community was significantly correlated to increased knowledge, confidence, and likelihood to ask about social needs (P < .05). DiscussionThe emergency department is a logical place for screening for social determinants of health and connecting patients with social needs to community resources. Emergency nurses included in this study acknowledged that they want to address the social needs of their patients but reported that they lack knowledge about both social determinants of health and more importantly about the resources available to help patients with social needs. In general, they did not feel confident discussing social determinants of health with their patients in the emergency department and are unlikely to ask about social needs. Barriers to screening include time, competing care priorities, and lack of knowledge and support needed from case managers. Findings from this study have implications for supporting emergency nurses employed in institutions that seek to address social influences of health for the patients in their communities.

DICOM® integrated EEG data: A first clinical implementation of the new DICOM standard for neurophysiology data

ObjectiveDemonstrating a pilot implementation of the Digital Imaging and Communication in Medicine (DICOM) neurophysiology standard published in 2020. MethodsAn automated workflow for converting EEG data from a proprietary vendor EEG format to standardized and interoperable DICOM format was developed and tested. ResultsRetrieval of proprietary EEG data, associated videos, annotations and metadata from the vendor EEG archive and their subsequent conversion to DICOM EEG was possible without changes to the departmental workflow. To transfer DICOM EEG data to the central radiology DICOM archive, only minor extensions in the parameterization of the archive’s DICOM interfaces were necessary. Linkage with the electronic health record (EHR) and display in a DICOM EEG viewer could be demonstrated. A random sample of 88 DICOM EEG studies was compared to the original vendor files and EEG and video file sizes were comparable. ConclusionsStoring and reviewing EEG data in standardized DICOM format is feasible, facilitated by existing DICOM infrastructure, and therefore allows for vendor independent access to EEG data. SignificanceWe report the first implementation of the DICOM neurophysiology standard, thus promoting standardization in the field of neurophysiology as well as data exchange and access to legacy recordings in an interoperable vendor independent format.

1277-P: Prediction of HbA1c Test Eligibility in Emergency Department

Introduction: Diabetes screening using best practice advisory (BPA) alerts integrated into the emergency department (ED) workflow may efficiently identify at-risk patients disproportionally affected by diabetes. The objectives of this study were to 1) validate a BPA algorithm informed by the American Diabetes Association (ADA) screening criteria using elements from the electronic medical record (EMR) to identify eligible patients for hemoglobin A1c (HbA1c) testing, and 2) compare the characteristics of the ADA-based algorithm with one informed by the United States Preventative Services Task Force (USPSTF) recommendations. Methods: This cross-sectional study involved adults admitted to the University of Illinois Health ED in May 2021 with labs ordered (n=2963). Sensitivity, specificity, positive predictive value (PPV), and negative predictive values (NPV) estimated the BPA algorithm’s ability to correctly identify patients eligible for diabetes screening using manual EMR chart review as the reference standard. Receiver operator characteristic (ROC) curves and area under the curve (AUC) were calculated to compare ADA and USPSTF-informed algorithms. Results: The sensitivity, specificity, PPV, and NPV of the ADA model were 0.70 (95% CI: 0.66-0.75), 0.91 (0.90-0.92), 0.76 (0.73-0.79), and 0.88 (0.86-0.89), respectively. Compared to the ADA model, the USPSTF model’s sensitivity was worse (0.25 (0.22-0.27)) and specificity was slightly higher (0.94 (0.93-0.95)), though PPV remained similar (0.75 (0.71-0.79)) and NPV was lower (0.64 (0.62-0.66)). The ROC AUC for the ADA and USPSTF-based models were 0.91 (0.89-0.93) and 0.86 (0.84-0.89), respectively. Conclusion: Despite moderate to low sensitivity, the PPVs and large AUCs are acceptable due to the high prevalence of at-risk populations presenting to the ED. Findings suggest that a BPA algorithm informed by the ADA guideline is an adequate tool to identify eligible patients for diabetes screening in the ED, especially given its ease of workflow integration. Disclosure M.Smart: None. J.Lin: Research Support; Novo Nordisk, Xeris Pharmaceuticals, Inc. T.Lee: None. B.T.Layden: Consultant; Bayer Inc. Y.Eisenberg: None. K.K.Danielson: None. A.Kong: None. Funding Novo Nordisk (G2111)

Hacking Acute Care: A Qualitative Study on the Health Care Impacts of Ransomware Attacks Against Hospitals

Cyberattacks are an increasing threat to health care institutions which potentially impair patient outcomes. Current research is limited and focuses mainly on the technical consequences, whereas little is known about health care staff experiences and the effect on emergency care. This study aimed to explore the acute care effect of several large ransomware attacks against hospitals that occurred in Europe and the United States between 2017 and2022. This interview-based qualitative study assessed the experiences of emergency health care professionals and information technology (IT) staff and investigated the challenges during the acute and recovery phase of hospital ransomware attacks. The semistructured interview guideline was based on relevant literature and cybersecurity expert consultation. Transcripts were anonymized, and traceable information regarding participants and/or their organizations was removed for privacy purposes. Nine participants were interviewed, including emergency health care providers and IT-focused staff. Five themes were constructed from the data: effects and challenges regarding patient care continuity, challenges during the recovery process, personal effect on health care staff, preparedness and lessons identified, and future recommendations. According to the participants of this qualitative study, ransomware attacks have a significant effect on emergency department workflow, acute care delivery, and the personal well-being of health care providers. Preparedness for such incidents is limited, and many challenges are encountered during the acute and recovery phase of attacks. Although there was profound hesitancy among hospitals to participate in this study, the limited number of participants provided valuable information that can be used to develop response strategies for hospital ransomware attacks.

Increasing Understanding and Perceived Confidence of Nurses Working in an Emergency Department in Assessing Patients at Risk of Violent Behavior.

The aims of this quality improvement project were to improve understanding and perceived confidence in using a tool that assesses patients at risk of violence. The Brøset Violence Checklist is valid at assessing patients at risk of violence. Participants were given access to an e-learning module that demonstrated how to use the tool. Improvement in understanding and perceived confidence in using the tool were assessed preintervention and postintervention via an investigator-developed survey. Analysis of the data was conducted using descriptive statistics, and open-ended survey responses were analyzed using content analysis. Participants did not demonstrate an increase in understanding and perceived confidence after introduction of the e-learning module. Nurses reported that the Brøset Violence Checklist was easy to use, clear, reliable, and accurate and could be used to standardize assessments of at-risk patients. Emergency department nursing staff were educated in use of a risk assessment tool for identifying patients at risk of violence. This supported the implementation and integration of the tool into emergency department workflow.

Towards accurate and automatic emergency department workflow characterization using a real-time locating system

ABSTRACT This paper presents how patient throughput within an Emergency Department (ED) can be accurately and automatically characterized using a combination of data derived from a real-time location system (RTLS) and other traditional hospital IT systems such as Electronic Medical Records (EMR) and Laboratory Information Systems. Such insights can be used by a hospital to identify bottlenecks or inefficiencies and develop strategies to optimize and monitor patient flows. A descriptive, retrospective study was conducted among 1149 patients. Five KPIs, including time from arrival to triageand total length of stay, were used to evaluate ED timestamps to characterize the flow of the patient. A description of the techniques used to combine the various data sources to perform the accurate measurements is provided. The paper also describes the measurements obtained and indicates how real-time locating systems can contribute towards improving the quality of the timestamps generated compared to only using data from traditional hospital IT systems. A principial finding is that there is a large gap between the length of stay using only EMR data and the one computed combining EMR and RTLS data. Finally, the paper provides guidelines on how to deploy such a system effectively.

An evaluation of radiation therapy patient body mass index trends and potential impact on departmental resource planning.

Radiation therapy (RT) offers a less invasive management option for bariatric cancer patients. As the proportion of Australians categorised overweight or obese approaches 70%, it is not well understood how this growth will impact RT departments. The aim of this study was to evaluate the current and potential future body mass index (BMI) of RT patients at one centre, with the purpose of identifying variables that may impact resource planning decisions. De-identified demographic data including gender, age, diagnosis code, activity code and BMI were obtained from MOSAIQ® oncology information system for 5548 courses of RT commenced between 2017 and 2020, and retrospectively analysed. Descriptive statistics were used to summarise the data. Simple and multiple linear regression was used to analyse for statistically significant relationships between variables. Of all patient courses, 64% were overweight or obese. Average BMI increased over time by 0.3 kg/m2 per year. Courses related to the young and elderly had a lower average BMI. Breast, brain/skull, and pelvis/prostate treatment sites had a significant association with a higher average BMI. Thorax treatment sites had a lower average BMI, but this average is increasing at the fastest rate of all treatment sites. Prone breast courses had an average BMI 5.58 kg/m2 higher than IMRT/VMAT courses. Results demonstrate that patient BMI is increasing. Resources related to breast courses (breast board, prone board) and thorax courses (lung board) may experience increased strain in the future. Modifications to department workflow and scheduling are likely required. Further research into staffing implications is recommended.

Best Practices on Radiology Department Workflow: Tips from the Impact of the COVID-19 Lockdown on an Italian University Hospital.

Purpose: The workload of the radiology department (RD) of a university hospital in northern Italy dramatically changed during the COVID-19 outbreak. The restrictive measures of the COVID-19 pandemic lockdown influenced the use of radiological services and particularly in the emergency department (ED). Methods: Data on diagnostic services from March 2020 to May 2020 were retrospectively collected and analysed in aggregate form and compared with those of the same timeframe in the previous year. Data were sorted by patient type in the following categories: inpatients, outpatients, and ED patients; the latter divided in “traumatic” and “not traumatic” cases. Results: Compared to 2019, 6449 fewer patients (−32.6%) were assisted in the RD. This decrease was more pronounced for the emergency radiology unit (ERU) (−41%) compared to the general radiology unit (−25.7%). The proportion of investigations performed for trauma appeared to decrease significantly from 14.8% to 12.5% during the COVID-19 emergency (p < 0.001). Similarly, the proportion of assisted traumatic patients decreased from 16.6% to 12.5% (p < 0.001). The number of emergency patients assisted by the RD was significantly reduced from 45% during routine activity to 39.4% in the COVID-19 outbreak (p < 0.001). Conclusion: The COVID-19 outbreak had a tremendous impact on all radiology activities. We documented a drastic reduction in total imaging volume compared to 2019 because of both the pandemic and the lockdown. In this context, investigations performed for trauma showed a substantial decrease.

PACS downtime drill: testing departmental workflow with an enterprise imaging viewer and archive.

In today's workflow, radiologists rely on the picture archiving and communication system (PACS) to view images. Unplanned downtime causes significant delays in patient care and lengthy downtimes can have lasting effects on patient care and end-user confidence. The purpose of this manuscript is to describe the planning and implementation of a disaster drill where the departmental PACS was taken off-line and the hospital enterprise viewer was used for departmental image interpretation.

Developing and Demonstrating the Viability and Availability of the Multilevel Implementation Strategy for Syncope Optimal Care Through Engagement (MISSION) Syncope App: Evidence-Based Clinical Decision Support Tool.

BackgroundSyncope evaluation and management is associated with testing overuse and unnecessary hospitalizations. The 2017 American College of Cardiology/American Heart Association (ACC/AHA) Syncope Guideline aims to standardize clinical practice and reduce unnecessary services. The use of clinical decision support (CDS) tools offers the potential to successfully implement evidence-based clinical guidelines. However, CDS tools that provide an evidence-based differential diagnosis (DDx) of syncope at the point of care are currently lacking.ObjectiveWith input from diverse health systems, we developed and demonstrated the viability of a mobile app, the Multilevel Implementation Strategy for Syncope optImal care thrOugh eNgagement (MISSION) Syncope, as a CDS tool for syncope diagnosis and prognosis.MethodsDevelopment of the app had three main goals: (1) reliable generation of an accurate DDx, (2) incorporation of an evidence-based clinical risk tool for prognosis, and (3) user-based design and technical development. To generate a DDx that incorporated assessment recommendations, we reviewed guidelines and the literature to determine clinical assessment questions (variables) and likelihood ratios (LHRs) for each variable in predicting etiology. The creation and validation of the app diagnosis occurred through an iterative clinician review and application to actual clinical cases. The review of available risk score calculators focused on identifying an easily applied and valid evidence-based clinical risk stratification tool. The review and decision-making factors included characteristics of the original study, clinical variables, and validation studies. App design and development relied on user-centered design principles. We used observations of the emergency department workflow, storyboard demonstration, multiple mock review sessions, and beta-testing to optimize functionality and usability.ResultsThe MISSION Syncope app is consistent with guideline recommendations on evidence-based practice (EBP), and its user interface (UI) reflects steps in a real-world patient evaluation: assessment, DDx, risk stratification, and recommendations. The app provides flexible clinical decision making, while emphasizing a care continuum; it generates recommendations for diagnosis and prognosis based on user input. The DDx in the app is deemed a pragmatic model that more closely aligns with real-world clinical practice and was validated using actual clinical cases. The beta-testing of the app demonstrated well-accepted functionality and usability of this syncope CDS tool.ConclusionsThe MISSION Syncope app development integrated the current literature and clinical expertise to provide an evidence-based DDx, a prognosis using a validated scoring system, and recommendations based on clinical guidelines. This app demonstrates the importance of using research literature in the development of a CDS tool and applying clinical experience to fill the gaps in available research. It is essential for a successful app to be deliberate in pursuing a practical clinical model instead of striving for a perfect mathematical model, given available published evidence. This hybrid methodology can be applied to similar CDS tool development.

Ventilation-Perfusion Scan: A Primer for Practicing Radiologists.

Lung scintigraphy, or ventilation-perfusion (V/Q) scan, is one of the commonly performed studies in nuclear medicine. Owing to variability in clinical applications and different departmental workflows, many trainees are not comfortable interpreting the results of this study. This article provides a simplified overview of V/Q imaging, including a review of its technique, interpretation methods, and established and emerging clinical applications. The authors review the role of V/Q imaging in evaluation of acute and chronic pulmonary embolism, including the role of SPECT/CT and comparing V/Q scan with CT angiography. In addition, a variety of other applications of pulmonary scintigraphy are discussed, including congenital heart disease, pretreatment planning for lung cancer and emphysema, posttransplant imaging for bronchiolitis obliterans, and less common vascular and nonvascular pathologic conditions that may be detected with V/Q scan. This article will help radiologists and residents interpret the results of V/Q scans and understand the various potential clinical applications of this study. Online supplemental material is available for this article. ©RSNA, 2021.

"Friction by Definition": Conflict at Patient Handover Between Emergency and Internal Medicine Physicians at an Academic Medical Center.

IntroductionPatient handoffs from emergency physicians (EP) to internal medicine (IM) physicians may be complicated by conflict with the potential for adverse outcomes. The objective of this study was to identify the specific types of, and contributors to, conflict between EPs and IM physicians in this context.MethodsWe performed a qualitative focus group study using a constructivist grounded theory approach involving emergency medicine (EM) and IM residents and faculty at a large academic medical center. Focus groups assessed perspectives and experiences of EP/IM physician interactions related to patient handoffs. We interpreted data with the matrix analytic method.ResultsFrom May to December 2019, 24 residents (IM = 11, EM = 13) and 11 faculty (IM = 6, EM = 5) from the two departments participated in eight focus groups and two interviews. Two key themes emerged: 1) disagreements about disposition (ie, whether a patient needed to be admitted, should go to an intensive care unit, or required additional testing before transfer to the floor); and 2) contextual factors (ie, the request to discuss an admission being a primer for conflict; lack of knowledge of the other person and their workflow; high clinical workload and volume; and different interdepartmental perspectives on the benefits of a rapid emergency department workflow).ConclusionsCauses of conflict at patient handover between EPs and IM physicians are related primarily to disposition concerns and contextual factors. Using theoretical models of task, process, and relationship conflict, we suggest recommendations to improve the EM/IM interaction to potentially reduce conflict and advance patient care.