Emergency Department CT Research Articles

SP7.5 - Time to CT for Acute General Surgery and Trauma in patients undergoing emergency laparotomy. A major trauma centre experience

Abstract Introduction In our institution separate care pathways exist for patients presenting with major trauma and acute abdomen (AA). Trauma patients activate a Consultant led trauma team attendance on arrival and CT imaging within 30 minutes where indicated. Our acute abdomen pathway attracts ST3+ general surgical review within 2 hours of emergency department referral and CT within a further 1 hour. We aimed to compare the two laparotomy cohorts with respect to clinical outcomes. Methods A retrospective analysis was performed on patients that underwent an emergency laparotomy following CT at our institution between December 2020 and February 2022. Patients were identified from the NELA and TARN databases. Results 66 trauma and 64 AA patients were identified. The mean time to CT in trauma was 56.1 minutes ± 24.8 and in AA 390.7 minutes ± 306.1 (p<0.001). There was no difference in length of ITU stay (mean days 3.1 ± 8.1 vs 4.2 ±9.8 p=0.260) or hospital stay (mean days 13.7 ± 19.2 vs 13.8 ±11.7 p=0.494). no correlation between time to CT and length of hospital stay (r=0.233 p=0.97) or ITU stay (r=0.224 p=0.964) in trauma patients or AA (r=0.217 p=0.58 and -0.001 p=0.562 respectively for hospital and ITU stays) was detected. However, there was a trend towards lower mortality in the trauma cohort (3% vs 7.8% p=0.227). Conclusion Trauma patients were scanned quicker than acute abdomen presentations likely due to greater personnel resource and better care pathways. This was associated with a trend towards lower mortality because of earlier pathology detection and Consultant directed care from hospital arrival.

PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study

Cervical spine injuries in children are uncommon but potentially devastating; however, indiscriminate neck imaging after trauma unnecessarily exposes children to ionising radiation. The aim of this study was to derive and validate a paediatric clinical prediction rule that can be incorporated into an algorithm to guide radiographic screening for cervical spine injury among children in the emergency department. In this prospective observational cohort study, we screened children aged 0-17 years presenting with known or suspected blunt trauma at 18 specialised children's emergency departments in hospitals in the USA affiliated with the Pediatric Emergency Care Applied Research Network (PECARN). Injured children were eligible for enrolment into derivation or validation cohorts by fulfilling one of the following criteria: transported from the scene of injury to the emergency department by emergency medical services; evaluated by a trauma team; and undergone neck imaging for concern for cervical spine injury either at or before arriving at the PECARN-affiliated emergency department. Children presenting with solely penetrating trauma were excluded. Before viewing an enrolled child's neck imaging results, the attending emergency department clinician completed a clinical examination and prospectively documented cervical spine injury risk factors in an electronic questionnaire. Cervical spine injuries were determined by imaging reports and telephone follow-up with guardians within 21-28 days of the emergency room encounter, and cervical spine injury was confirmed by a paediatric neurosurgeon. Factors associated with a high risk of cervical spine injury (>10%) were identified by bivariable Poisson regression with robust error estimates, and factors associated with non-negligible risk were identified by classification and regression tree (CART) analysis. Variables were combined in the cervical spine injury prediction rule. The primary outcome of interest was cervical spine injury within 28 days of initial trauma warranting inpatient observation or surgical intervention. Rule performance measures were calculated for both derivation and validation cohorts. A clinical care algorithm for determining which risk factors warrant radiographic screening for cervical spine injury after blunt trauma was applied to the study population to estimate the potential effect on reducing CT and x-ray use in the paediatric emergency department. This study is registered with ClinicalTrials.gov, NCT05049330. Nine emergency departments participated in the derivation cohort, and nine participated in the validation cohort. In total, 22 430 children presenting with known or suspected blunt trauma were enrolled (11 857 children in the derivation cohort; 10 573 in the validation cohort). 433 (1·9%) of the total population had confirmed cervical spine injuries. The following factors were associated with a high risk of cervical spine injury: altered mental status (Glasgow Coma Scale [GCS] score of 3-8 or unresponsive on the Alert, Verbal, Pain, Unresponsive scale [AVPU] of consciousness); abnormal airway, breathing, or circulation findings; and focal neurological deficits including paresthesia, numbness, or weakness. Of 928 in the derivation cohort presenting with at least one of these risk factors, 118 (12·7%) had cervical spine injury (risk ratio 8·9 [95% CI 7·1-11·2]). The following factors were associated with non-negligible risk of cervical spine injury by CART analysis: neck pain; altered mental status (GCS score of 9-14; verbal or pain on the AVPU; or other signs of altered mental status); substantial head injury; substantial torso injury; and midline neck tenderness. The high-risk and CART-derived factors combined and applied to the validation cohort performed with 94·3% (95% CI 90·7-97·9) sensitivity, 60·4% (59·4-61·3) specificity, and 99·9% (99·8-100·0) negative predictive value. Had the algorithm been applied to all participants to guide the use of imaging, we estimated the number of children having CT might have decreased from 3856 (17·2%) to 1549 (6·9%) of 22 430 children without increasing the number of children getting plain x-rays. Incorporated into a clinical algorithm, the cervical spine injury prediction rule showed strong potential for aiding clinicians in determining which children arriving in the emergency department after blunt trauma should undergo radiographic neck imaging for potential cervical spine injury. Implementation of the clinical algorithm could decrease use of unnecessary radiographic testing in the emergency department and eliminate high-risk radiation exposure. Future work should validate the prediction rule and care algorithm in more general settings such as community emergency departments. The Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Health Resources and Services Administration of the US Department of Health and Human Services in the Maternal and Child Health Bureau under the Emergency Medical Services for Children programme.

Emergency department CT examinations demonstrate no evidence of early viral circulation at the start of the COVID-19 pandemic—a multicentre epidemiological study

BackgroundBiological studies suggested that the COVID-19 outbreak in France occurred before the first official diagnosis on January 24, 2020. We investigated this controversial topic using a large collection of chest CTs performed throughout French emergency departments within 6 months before the 1st lockdown.ResultsOverall, 49,311 consecutive patients (median age: 60 years, 23,636/49,311 [47.9%] women) with available chest CT images and reports from 61 emergency departments between September 1, 2020, and March 16, 2020 (day before the 1st French lockdown), were retrospectively included in this multicentre study. In the macroscopic analysis of reports automatically (labelled for presence of ground glass opacities [GGOs], reticulations, and bilateral and subpleural abnormalities), we found a significant breakpoint on February 17, 2020, for the weekly time series with 1, 2 and ≥ 3 of these 4 radiological features, with 146/49,311 (0.3%) patients showing bilateral abnormalities and ground glass opacities (GGOs) from that day. According to radiologists, 22/146 (15.1%) CT images showed typical characteristics of COVID-19, including 4/146 (2.7%) before February 2020. According to hospital records, one patient remained without microbial diagnosis, two patients had proven influenza A and one patient had concomitant influenza A and mycoplasma infection.ConclusionThese results suggest that SARS-CoV-2 was not circulating in the areas covered by the 61 emergency departments involved in our study before the official beginning of the COVID-19 outbreak in France. In emergency patients, the strong resemblance among mycoplasma, influenza A and SARS-CoV-2 lung infections on chest CT and the nonspecificity of CT patterns in low prevalence periods is stressed.Critical relevance statementWe proposed here an innovative approach to revisit a controversial ‘real’ start of the COVID-19 pandemic in France based on (1) a population-level approach combining text mining, time series analysis and an epidemiological dataset and (2) a patient-level approach with careful retrospective reading of chest CT scans complemented by analysis of samples performed contemporarily to the chest CT. We showed no evidence that SARS-CoV-2 was actively circulating in France before February 2020.Graphical

Emergency department referrals for CT imaging of extremity soft tissue infection: before and during the COVID-19 pandemic.

To evaluate the incidence and spectrum of findings in patients referred for CT imaging of extremity soft tissue infection in the adult emergency department (ED) setting before and during the COVID-19 pandemic. Two hundred thirteen CT exams in the pre-COVID cohort (February 1, 2018-January 31, 2020) and 383 CT exams in the COVID cohort (February 1, 2020-January 31, 2022) were evaluated in this multicentre, retrospective study. Demographic information and clinical histories were collected, along with regional data on COVID-19 hospitalizations and deaths. Comparable age and sex distribution was found in the pre-COVID (average age of 53.5 years; male: female ratio of 71:29) and COVID (average age of 54.6 years; male: female ratio of 69:31) cohorts. The frequency of reported clinical risk factors (diabetes mellitus, injected drug use, prior surgery, animal bite) was not significantly different between the two cohorts. Findings of simultaneous involvement of both superficial and deep soft tissue infection on CT imaging were significantly higher in the COVID cohort (53.4%) than in the pre-COVID cohort (33.7%). CT findings of phlegmon (49.1% vs 22.1%), ulcers (48.8% vs 30%), osteomyelitis (21.7% vs 13.1%), as well as localized (18.8% vs 11.7%) and extensive (3.7% vs 2.3%) soft tissue gas were significantly more common in the COVID cohort than in the pre-COVID cohort. During the COVID-19 pandemic, the number of ED CT exams for the evaluation of extremity soft tissue infection increased, with this imaging also showing more advanced disease. Pandemic-related modifications to human behaviour and re-distribution of healthcare resources may underlie these observed changes. This multi-centre study shows an increase in extremity soft tissue infection presenting to the ED during the pandemic. This finding is important for future pandemic preparations, as it can aid in the decision-making process around resource allocation.

Deferral of Estimated Glomerular Filtration Rate Testing Before Contrast-Enhanced CT in Low-Risk Emergency Department Patients: Assessment of Safety and Impact on Throughput

ObjectiveTo assess the safety and utility of deferring estimated glomerular filtration rate (eGFR) testing before contrast-enhanced CT (CECT) in low-risk emergency department (ED) patients. MethodsA new question was added to CECT order screens, allowing ordering ED providers to defer eGFR testing in patients deemed low risk for contrast-induced acute kidney injury (AKI). Low risk was defined as no known chronic kidney disease (CKD) or risk factors for AKI or CKD. Patients on chronic dialysis were deemed low risk. The project included three phases: baseline, pilot (optional order question), and full implementation (required order question). Outcomes were operational throughput metrics of CECT order to protocol (O to P) and order to begin (O to B) times. As a balancing safety measure, the proportion of patients deemed to be “low risk” and subsequently found to have eGFR value less than 30 mL/min/1.73 m2 was reported. ResultsA total of 16,446 CECT studies were included from four EDs. In the pilot phase, provider engagement rates with the question were low (5%-14%). After full implementation, median O to P time improved from 23.93 min at baseline to 13.02 (P < .0001) and median O to B time improved from 80.34 min to 76.48 (P = .0002). In 0.3% (2 of 646) studies, CECT was completed in patients categorized as low risk by the ED provider with subsequently resulted eGFR <30 mL/min/1.73 m2. DiscussionUpfront clinical risk assessment for AKI and CKD by ED providers can be used to safely defer eGFR testing and improve operational performance for patients requiring CECT.

Safety and Feasibility of an Emergency Department-to-Outpatient Pathway for Patients With TIA and Nondisabling Stroke.

Evaluation of transient ischemic attack/nondisabling ischemic strokes (TIA/NDS) in the emergency department (ED) contributes to capacity issues and increasing health care expenditures, especially high-cost duplicative imaging. As an institutional quality improvement project, we developed a novel pathway to evaluate patients with TIA/NDS in the ED using a core set of laboratory tests and CT-based neuroimaging. Patients identified as 'low risk' through a safety checklist were discharged and scheduled for prompt outpatient tests and stroke clinic follow-up. In this prespecified analysis designed to assess feasibility and safety, we abstracted data from patients consecutively enrolled in the first 6 months. We compared data from 106 patients with TIA/NDS enrolled in the new pathway from April through September 2020 (age 67.9 years, 45% female), against 55 unmatched historical controls with TIA encountered from April 2016 through March 2017 (age 68.3 years, 47% female). Both groups had similar median NIHSS scores (pathway and control 0) and ABCD2 scores (pathway and control 3). Pathway-enrolled patients had a 44% decrease in mean ED length of stay (pathway 13.7 hours, control 24.4 hours, p < 0.001) and decreased utilization of ED MRI-based imaging (pathway 63%, control 91%, p < 0.001) and duplicative ED CT plus MRI-based brain and/or vascular imaging (pathway 35%, control 53%, p = 0.04). Among pathway-enrolled patients, 89% were evaluated in our stroke clinic within a median of 5 business days; only 5.5% were lost to follow-up. Both groups had similar 90-day rates of ED revisits (pathway 21%, control 18%, p = 0.84) and recurrent TIA/ischemic stroke (pathway 1%, control 2%, p = 1.0). Recurrent ischemic events among pathway-enrolled patients were attributed to errors in following the safety checklist before discharge. Our TIA/NDS pathway, implemented during the initial outbreak of COVID-19, seems feasible and safe, with significant positive impact on ED throughput and ED-based high-cost duplicative imaging. The safety checklist and option of virtual telehealth follow-up are novel features. Broader adoption of such pathways has important implications for value-based health care.

Coronary CTA for Acute Chest Pain in the Emergency Department: Comparison of 64-Detector-Row Single-Source and Third-Generation Dual-Source Scanners.

BACKGROUND. When coronary CTA is performed in the emergency department (ED), the use of a contemporary scanner with improved temporal resolution may eliminate the need to administer β-blockers for heart rate (HR) control, thereby expediting workup. OBJECTIVE. The purpose of this study was to compare ED length of stay (LOS), image quality, frequency of nondiagnostic examinations, and other clinical outcomes between patients undergoing coronary CTA in the ED on a single-source CT (SSCT) scanner with HR control versus on a dual-source CT (DSCT) scanner without HR control. METHODS. This retrospective study included 509 patients (283 men, 226 women; mean age, 52.1 ± 15.1 [SD] years) at low to intermediate risk for acute coronary syndrome who underwent coronary CTA for acute chest pain during off-hours in a single ED from March 1, 2020, to April 25, 2022. A total of 205 patients initially underwent CTA using a 64-detector-row SSCT scanner with HR control (oral β-blocker administration if HR was > 65 beats/min); after scanner replacement on April 26, 2021, 304 patients underwent CTA using a third-generation DSCT without HR control. Groups were compared in terms of ED LOS and CT completion time (defined as time from ordering CTA to completion of acquisition) using propensity score matching and additional endpoints including image quality and nondiagnostic examinations based on radiology reports. RESULTS. The DSCT group, compared with the SSCT group, showed no significant difference in median ED LOS (505 vs 457 minutes, respectively; p = .37) but showed shorter median CT completion time (95 vs 117 minutes, p < .001); on the basis of a mediation analysis, 89% of the reduction in CT completion time for DSCT was attributed to the absence of HR control. The DSCT group, compared with the SSCT group, showed higher frequency of examinations with good or excellent image quality (87.8% vs 60.0%, p < .001) and lower frequency of nondiagnostic examinations (1.6% vs 6.3%, p = .01) but showed no significant difference in frequencies of emergent cardiology consultation, invasive angiography, ED disposition, or coronary revascularization (all p > .05). No patient in either group experienced 30-day all-cause mortality or a major adverse cardiovascular event. CONCLUSION. The use of a DSCT scanner for coronary CTA can eliminate the need for β-blocker administration for HR control while decreasing nondiagnostic examinations. CLINICAL IMPACT. A DSCT scanner can expedite clinical processes in the ED.

Expediting emergent MRI in acute ischemic stroke by extending CT scout image: a simple intervention to decrease time to treatment (P11-5.010)

<h3>Objective:</h3> We revised our acute stroke CT protocol to reduce time to MRI in acute ischemic stroke. <h3>Background:</h3> “Time is brain” in acute stroke. Patients requiring emergent MR imaging in the emergency department prior to thrombolytic treatment (e.g. wake-up strokes, iodinated contrast allergy, assessment of DWI/FLAIR mismatch) must undergo the MRI safety screen for implantable devices and foreign metallic bodies. Patient factors including neurologic deficits, language barrier, or lack of information on implantable devices make the screening process time-consuming. If patients cannot complete the safety checklist, radiographic clearance with chest and abdomen x-rays is pursued which delays time to treatment. <h3>Design/Methods:</h3> We revised our CT acute stroke radiology protocol to include scout images from the head to the femur to screen for foreign bodies, implantable devices or metallic objects. Standard CTA head and neck scout images previously only extended to the mid-chest. The new protocol obviates need for MRI screening checklist in emergent situations and allows to proceed directly from CT to MRI with the assistance of the radiologist interpreting the scout image. <h3>Results:</h3> Our multidisciplinary stroke team has implemented this change in our emergency department CT acute stroke protocol. The difference in additional radiation exposure is minimal to non-significant; the estimated total radiation dose of the topogram for the head, neck, chest, abdomen, and pelvic regions is approximately 0.24mSv (of which only the abdomen and pelvis are additional in this protocol). In comparison, the radiation dose of a standard abdomen/pelvis radiograph is 0.7mSv. Data collection is ongoing to measure impact on door to needle time. <h3>Conclusions:</h3> Revision of the CT stroke protocol to extend the CT scout from the head to the femur can expedite clearance for emergent MRI in patients who are candidates for thrombolysis or thrombectomy at no significant expense or radiation. This has potential to reduce time to acute stroke treatment. <b>Disclosure:</b> Dr. Aghajan has nothing to disclose. Dr. Gupta has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for •

Abstract Number ‐ 252: High Mortality in Patients with Spontaneous Intracerebral Hemorrhage Experiencing Neurological Decline on Mobile Stroke Unit

Introduction Spontaneous intracranial hemorrhage (ICH) is associated with significant morbidity and mortality. Mobile Stroke Unit (MSU) provides a unique opportunity to assess patients in the hyperacute phase of ICH to track outcomes. Methods Methods: We conducted a retrospective review of patients with spontaneous ICH diagnosed on two different MSUs in the United States. Patients were divided into three groups based on symptom onset/last known well (LKW): Group 1: 0–1 hours from LKW, Group 2: 1–2 hours from LKW, and Group 3: 2–4 hours from LKW. We compared neurological decline (ND) rates between MSU and Emergency Department (ED) arrival for patients in the three groups. Neurological decline was defined as a decrease in GCS by ≥ 2 points or an increase in NIHSS ≥ 4 points between MSU and ED examination. χ2 test was used to compare the proportion of patients who experience ND between MSU and ED transport. We also assessed and compared pre‐defined factors that could be associated with ND in the three groups. CT scans done on MSU were compared to those done on ED arrival. Results Results: Fifty‐fourpatients met the study criteria. The mean age was 62, and 69% were male. Median MSU NIHSS was 18, and median ED NIHSS was 19. The mean MSU GCS was 14, and ED GCS was 12. The mean hematoma volume on the MSU CT head was 21 cc and 24 cc on the ED CT head. Mean MSU MAP was 136, and MAP on ED arrival was 120. Thirty‐three percent (18/54) of patients experienced ND between MSU and ED transport. Forty percent (n = 10/25) patients in group 1, 22% (n = 4/18) in group 2 and 36%(n = 4/11) in group 3 had ND (chi‐square 0.45). Overall, patients with ND experienced significantly high mortality (OR 5.091, p = 0.029, CI 1.24‐20.78). On univariate analysis, variables significantly associated with ND were MSU NIHSS, hematoma volume, and presence of hydrocephalus on MSU CT scan. No variables were significant to predict ND on multivariate analysis (Hematoma Expansion OR 1.028, CI 0.99‐1.05; Hydrocephalus OR 3.70 CI 0.67‐20.43) Conclusions Conclusion: One‐thirdof ICH patients experience neurological decline between MSU and ED transport within four hours of symptom onset and are at a significantly higher risk of mortality. Higher ND rates are likely due to earlier diagnosis of ICH on MSU. Due to the smaller sample size, we did not find significant variables associated with ND. However, various ways of providing rapid medical and surgical treatment to these patients should be explored in future studies to assess the effect on functional outcomes.

Effect of an ultrasound-first clinical decision tool in emergency department patients with suspected nephrolithiasis: A randomized trial

IntroductionPreviously, we found that the use of ultrasonography for patients with suspected nephrolithiasis resulted in similar outcomes and less radiation exposure vs. CT scan. In this study, we evaluated the implementation of an ultrasound-first clinical decision support (CDS) tool in patients with suspected nephrolithiasis. MethodsThis randomized trial was conducted at an academic emergency department (ED). We implemented the ultrasound-first CDS tool, deployed when an ED provider placed a CT order for suspected nephrolithiasis. Providers were randomized to receiving the CDS tool vs. usual care. The primary outcome was receipt of CT during the index ED visit. Secondary outcomes included radiation dose and ED revisit. Results64 ED Providers and 254 patients with suspected nephrolithiasis were enrolled from January 2019 through Dec 2020. The US-First CDS tool was deployed for 128 patients and was not deployed for 126 patients. 86.7% of patients in the CDS arm received a CT vs. 94.4% in the usual care arm, resulting in an absolute risk difference of −7.7% (−14.8 to −0.6%). Mean radiation dose in the CDS arm was 6.8 mSv (95% CI 5.7–7.9 mSv) vs. 6.1 mSv (95% CI 5.1–7.1 mSv) in the usual care arm. The CDS arm did not result in increased ED revisits, CT scans, or hospitalizations at 7 or 30 days. Conclusions and relevanceImplementation of the US-first CDS tool resulted in lower CT use for ED patients with suspected nephrolithiasis. The use of this decision support may improve the evaluation of a common problem in the ED.Trial Registration:ClinicalTrials.gov#NCT03461536

Mitigation Tactics Discovered During COVID-19 with Long-Term Report Turnaround Time and Burnout Reduction Benefits

Rationales and ObjectivesThe purpose is to describe a hybrid teleradiology solution utilized in an academic medical center and its outcomes on radiology report turnaround time (RTAT) and physician wellness.Materials and MethodsDuring coronavirus disease 2019, we utilized an alternating teleradiology solution with procedural and education attendings working in the hospital and other faculty remote to keep the worklist clean. RTAT data was collected for remote vs. in house emergency department (ED) and inpatient cases over a 6-month period. Pre and post implementation burnout surveys were administered.ResultsRTAT significantly improved for ED and inpatient MR and CT, and inpatient US and radiographs when interpreted remotely compared to in-hospital. Physician wellness scores improved and open-ended comments reflected positive feedback about the hybrid work solution. 74% enjoyed the autonomy and flexibility, and 51% said the solution positively influences my desire to remain in my current institution and improves their clinical and/or academic productivity.ConclusionHybrid work from home solutions allow faculty autonomy and flexibility with work-life balance, improving wellness. It is important to alternate the at-home faculty to maintain interdepartmental relations, particularly for junior faculty, and prevent isolation. The hybrid solution also demonstrated improved patient care metrics, possibly due to decreased distractions at home compared to the reading room.

Impact of Rapid Testing for Gonorrhea and Chlamydia in an Urban Pediatric Emergency Department

PurposeTo determine the impact of rapid testing for gonorrhea (NG) and chlamydia (CT) on accuracy of treatment in adolescents in the pediatric emergency department (ED). MethodsRetrospective study of adolescents tested for NG and CT in the pediatric ED before and after implementation of rapid testing. Treatment during initial visit, availability of test results prior to discharge, and number of follow-up phone calls made with test results were compared. Appropriate treatment was defined per Centers for Disease Control and Prevention 2015 guidelines as monotherapy for CT and dual therapy for NG. Descriptive statistics were used to compare groups. ResultsRapid testing improved treatment accuracy with 522 (79.3%) patients treated appropriately in the rapid testing group compared to 478 (64.7%) patients in the batched testing group (p < .001). Inaccurate treatment was more common in the batch testing group among those who tested negative (p < .001). Among those who tested positive for NG and/or CT, phone calls were made to 54 (47.8%) patients in the rapid testing group and 129 (84.3%) patients in the batched testing group to discuss positive test results (p < .001). ConclusionCompared to batched testing, rapid testing is associated with improved accuracy of treatment of NG and CT in the pediatric ED setting. Additionally, rapid testing is associated with decreased number of phone calls to discuss positive test results.

COVID-19 CT Scan Lung Segmentation: How We Do It.

The National Health Systems have been severely stressed out by the COVID-19 pandemic because 14% of patients require hospitalization and oxygen support, and 5% require admission to an Intensive Care Unit (ICU). Relationship between COVID-19 prognosis and the extent of alterations on chest CT obtained by both visual and software-based quantification that expresses objective evaluations of the percentage of ventilated lung parenchyma compared to the affected one has been proven. While commercial applications for automatic medical image computing and visualization are expensive and limited in their spread, the open-source systems are characterized by not enough standardization and time-consuming troubles. We analyzed chest CT exams on 246 patients suspected of COVID-19 performed in the Emergency Department CT room. The lung parenchyma segmentation was obtained by a threshold-based method using the open-source 3D Slicer software and software tools called “Segment Editor” and “Segment Quantification.” For the three main characteristics analyzed on lungs affected by COVID-19 pneumonia, a specifical densitometry value range was defined: from − 950 to − 700 HU for well-aerated parenchyma; from − 700 to − 250 HU for interstitial lung disease; from − 250 to 250 HU for parenchymal consolidation. For the well-aerated parenchyma and the interstitial alterations, the procedure was semi-automatic with low time consumption, whereas consolidations’ analysis needed manual interventions by the operator. After the chest CT, 13% of the sample was admitted to intensive care, while 34% of them to the sub-intensive care. In patients moved to intensive care, the parenchyma analysis reported a higher crazy paving presentation. The quantitative analysis of the alterations affecting the lung parenchyma of patients with COVID-19 pneumonia can be performed by threshold method segmentation on 3D Slicer. The segmentation could have an important role in the quantification in different COVID-19 pneumonia presentations, allowing to help the clinician in the correct management of patients.

Revisiting racial disparities in ED CT utilization during the Affordable Care Act era: 2009–2018 data from the NHAMCS

To examine the trends in CT utilization in the emergency department (ED) for different racial and ethnic groups, factors that may affect utilization, and the effects of increased insurance coverage since passage of the Affordable Care Act in 2010. Data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for the years 2009-2018 were used for the analysis. The NHAMCS is a cross-sectional survey which has random and systematical samples of more than 200,000 visits to over 250 hospital EDs in the USA. Patient demographic characteristics, source of payment/insurance, clinical presentation, and disposition from the ED were recorded. Descriptive statistics and multivariate logistic regression were performed. Between 2009 and 2018, the rate of uninsured patients in the ED decreased from 18.1% to as low as 9.9%, but this was not associated with a decrease in the disparity in CT utilization between non-Hispanic Black and non-Hispanic White patients. CT use rate increased 38% over the study period. Factors strongly associated with CT utilization include age, source of payment, triage category, disposition from the ED, and residence. After controlling for these factors, non-Hispanic White patients were 21% more likely to undergo CT than non-Hispanic Black patients, though no disparity was seen for Hispanic or Asian/other groups. Despite increased insurance coverage over the sample period, racial disparities between non-Hispanic Black and non-Hispanic White patients persist in CT utilization, though no disparity was seen for Hispanic or Asian/other patients. The source of this disparity remains unclear and is likely multifactorial.

Automated tracking of emergency department abdominal CT findings during the COVID-19 pandemic using natural language processing.

PurposeDuring the COVID-19 pandemic, emergency department (ED) volumes have fluctuated. We hypothesized that natural language processing (NLP) models could quantify changes in detection of acute abdominal pathology (acute appendicitis (AA), acute diverticulitis (AD), or bowel obstruction (BO)) on CT reports.MethodsThis retrospective study included 22,182 radiology reports from CT abdomen/pelvis studies performed at an urban ED between January 1, 2018 to August 14, 2020. Using a subset of 2448 manually annotated reports, we trained random forest NLP models to classify the presence of AA, AD, and BO in report impressions. Performance was assessed using 5-fold cross validation. The NLP classifiers were then applied to all reports.ResultsThe NLP classifiers for AA, AD, and BO demonstrated cross-validation classification accuracies between 0.97 and 0.99 and F1-scores between 0.86 and 0.91. When applied to all CT reports, the estimated numbers of AA, AD, and BO cases decreased 43–57% in April 2020 (first regional peak of COVID-19 cases) compared to 2018–2019. However, the number of abdominal pathologies detected rebounded in May–July 2020, with increases above historical averages for AD. The proportions of CT studies with these pathologies did not significantly increase during the pandemic period.ConclusionDramatic decreases in numbers of acute abdominal pathologies detected by ED CT studies were observed early on during the COVID-19 pandemic, though these numbers rapidly rebounded. The proportions of CT cases with these pathologies did not increase, which suggests patients deferred care during the first pandemic peak. NLP can help automatically track findings in ED radiology reporting.

Trends in Use of Diagnostic Imaging for Abdominal Pain in U.S. Emergency Departments

OBJECTIVE. CT has excellent accuracy for appendicitis but is associated with risks. Research and educational campaigns have been conducted to implement an ultrasound-first strategy for children but not for adults. The purpose of this study was to measure the use of CT and ultrasound in emergency department (ED) visits for abdominal pain and appendicitis to examine the impact of these efforts. MATERIALS AND METHODS. We analyzed data from the National Hospital Ambulatory Medical Care Survey (1997-2016). Use of CT and ultrasound was measured over time in visits for abdominal pain and visits in which appendicitis was diagnosed. Predictors of CT use were identified by means of regression analysis. RESULTS. For children, CT use increased from 1.2% (95% CI, 0.6-2.5%) in 1997, peaked in 2010 at 16.6% (95% CI, 13.8-19.6%), and decreased slightly in 2016. In adults, CT use increased steadily from 3.9% in 1997 (95% CI, 3.1-4.8%) to 37.8% (95% CI, 35.5-41.0%) in 2016. CT use increased for both pediatric and adult ED visits with a diagnosis of appendicitis, from 5.2% (95% CI, 0.7-29.5%) to 71.0% (95% CI, 43.1-88.8%) for children and 7.2% (95% CI, 2.7-17.6%) to 83.3% (95% CI, 64.1-93.3%) for adults. Children with abdominal pain and a diagnosis of appendicitis evaluated in a pediatric ED were at decreased odds (pain odds ratio, 0.6 [95% CI, 0.3-0.9]; appendicitis odds ratio, 0.2 [95% CI, 0.0-0.7]) of receiving CT than were those evaluated in general EDs. CONCLUSION. CT use has decreased in the evaluation of abdominal pain in children, perhaps because of research findings and efforts to implement an ultrasound-first strategy for suspected appendicitis. In contrast, CT use has continued to increase among adults with abdominal pain in EDs.

Impact of the COVID-19 pandemic on emergency department CT for suspected diverticulitis.

PurposeThis study examined the impact of the COVID-19 pandemic on emergency department CT use for acute nontraumatic abdominal pain, to better understand why imaging volume so drastically decreased during the COVID-19 pandemic.MethodsThis was a retrospective review of emergency imaging volumes from January 5 to May 30, 2020. Weekly volume data were collected for total imaging studies, abdominopelvic CT, and abdominopelvic CTs positive for common causes of acute nontraumatic abdominal pain. Two emergency radiology attendings scored all diverticulitis cases independently, and weekly volume data for uncomplicated and complicated diverticulitis cases was also collected. Volume data prior to and during the COVID-19 pandemic was compared, using 2019 volumes as a control.ResultsDuring the COVID-19 pandemic, overall emergency imaging volume decreased 30% compared to 2019 (p = 0.002). While the number of emergency abdominopelvic CTs positive for appendicitis and small bowel obstruction did not significantly change during the COVID-19 pandemic, the number of cases of diverticulitis decreased significantly compared to 2019 (p = 0.001). This reduction can be specifically attributed to decreased uncomplicated diverticulitis cases, as the number of uncomplicated diverticulitis cases dropped significantly (p = 0.002) while there was no significant difference in the number of complicated diverticulitis cases (p = 0.09).ConclusionsReduced emergency abdominopelvic CT volume during the COVID-19 pandemic can partially be explained by decreased imaging of lower acuity patients. This data may help formulate future strategies for imaging resource utilization with an improved understanding of the relationship between perceived imaging risk and symptom acuity.

Diagnostic Utility of CT and Fluoroscopic Esophagography for Suspected Esophageal Perforation in the Emergency Department.

OBJECTIVE. We evaluated the diagnostic utility of CT in emergency department (ED) patients with suspected esophageal perforation and assessed whether subsequent fluoroscopic esophagography is necessary. MATERIALS AND METHODS. This retrospective study included consecutive adult patients presenting to an urban academic tertiary care ED from January 1, 2000, to August 31, 2017, who underwent CT and fluoroscopic esophagography within 1 calendar day (< 27 hours) of each other for suspected esophageal perforation. The use of oral or IV contrast material and the CT findings (i.e., pneumomediastinum, pleural effusion, pneumothorax, unexplained mediastinal fluid or stranding, esophageal wall air or frank esophageal wall disruption, or extraluminal oral contrast material) were documented. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Surgical or procedural intervention results or clinical follow-up results were the reference standard. RESULTS. One hundred three patients met the inclusion criteria. Sensitivity, specificity, PPV, and NPV for diagnosing esophageal perforation were 100.0%, 79.8%, 32.1%, and 100.0%, respectively, with CT and 77.8%, 98.9%, 87.5%, and 97.9% with fluoroscopic esophagography. Combining CT and fluoroscopic esophagography did not improve sensitivity, specificity, PPV, or NPV relative to using CT alone. The true-positive esophageal perforation rate was 8.7% for CT and 6.8% for fluoroscopic esophagography. When CT showed only pneumomediastinum (n = 51) or no pneumomediastinum (n = 14), the NPV of CT was 100.0%. CT with oral contrast material had a PPV of 38.5%, whereas CT without oral contrast material had a PPV of 26.7%. CONCLUSION. CT has a high NPV similar to that of fluoroscopic esophagography and has greater sensitivity than fluoroscopic esophagography for diagnosing suspected esophageal perforation. Fluoroscopic esophagrams do not provide additional information that changes clinical management beyond the information that CT provides. In ED patients with suspected esophageal perforation, CT with oral contrast material should be considered the initial imaging examination and can obviate fluoroscopic esophagography.

213 Variables Associated With Gonorrhea And Chlamydia in the Emergency Department

Gonorrhea (NG) and chlamydia (CT) are frequently diagnosed sexually transmitted infections (STIs) in the emergency department (ED). Results of nucleic acid amplification tests (NAATs) are not available at the time of the clinical encounter requiring providers to decide whether to treat the patient in the ED or wait for the NAAT results to come back. Not treating the patient in the ED risks the ED not being able to reconnect with the patient for treatment if the NAAT is positive. Clinical gestalt about who has a STI is poor leading clinicians to significantly over-treat patients for STIs when none exists as well as miss those with the disease. The objectives of our study were to determine the variables associated with NG and CT infection in the ED. We reviewed 17,358 female and 1,119 male encounters where testing was performed for NG and/or CT in EDs in northeast Ohio between 2012 and 2017. We performed Chi-square analysis or t-tests using data obtained at triage including demographic information, mechanism of ED arrival, ED disposition, ED length of stay, pain level, ICD-9 and ICD-10 codes, and the vaginal wet prep, STI testing, urinalysis, and urine culture results to identify the independent variables associated with having NG and/or CT. An alpha 0.05 was sent for statistical significance. In our cohort 9.8% (1703) of females and 6.9% (759) of males were positive for NG and/or CT by NAAT. The following variables were significantly associated being infected for NG and/or CT in females: younger age, black race, unmarried, Medicaid insurance, higher emergency severity index (ESI), no primary care physician, pregnant, infected with Trichomonas vaginalis, lack of yeast but the presence of clue cells on vaginal wet prep. Additionally, on urinalysis there were positive associations between leukocyte esterase, white blood cell (WBCs), WBC clumps, nitrite, protein, urine red blood cells (RBCs), amorphous crystals, and not having glucose in the urine. For men the following variables were significantly associated with being infected with NG and/or CT: younger age, black race, unmarried, higher ESI, WBC on penile wet prep, and on urinalysis: higher WBCs, positive leukocyte esterase, WBC clumps, mucus, proteinuria, urine bacteria, urine RBCs, urobilinogen, and lack of glucose. Univariate analysis shows multiple independent variables significantly associated with both NG and/or CT infection in males and females in the ED. Clinicians’ decisions regarding treatment for STIs in the ED inherently rely on a form of Bayesian analysis because definitive test results are not available at the time of the clinical encounter. No validated clinical decision rules regarding treatment of STI in the ED have yet been developed. The independent variables identified in our analysis can be utilized for future multivariate analysis to help create clinical decision tools to aid clinicians caring for persons being evaluated for STIs.

Increasing Use, Geographic Variation, and Disparities in Emergency Department CT for Suspected Urolithiasis

PurposeThe aim of this study was to examine changing characteristics of utilization and potential disparities in US emergency department (ED) patients undergoing CT of the abdomen and pelvis (CTAP) for suspected urolithiasis. MethodsA retrospective study was conducted among all patients from 2006 to 2015 with a primary diagnosis of suspected urolithiasis within the Nationwide Emergency Department Sample, the largest publicly available all-payer ED database in the United States. The annual numbers of ED visits for suspected urolithiasis and associated CTAP examinations per visit were determined. The compound annual growth rate for CTAP was calculated. Using multivariate logistic regression analyses, patient demographics and payer and hospital characteristics were evaluated as potential independent predictors of utilization. ResultsNationwide, the number of ED visits per year for suspected urolithiasis increased from 1,057,119 in 2006 to 1,246,041 in 2014 (relative +17.9%), whereas the annual use of CTAP increased from 24.6% to 49.4% per visit (relative +100.8%; CAGR +8.0%). Multivariate analysis showed higher CTAP use associated with higher patient household income ZIP code quartile (odds ratio [OR] for wealthiest/poorest, 1.48), private payer (ORs, 1.21 versus Medicare and 1.22 versus Medicaid), Northeast geographic region (ORs, 5.07 versus Midwest, 4.16 versus West, and 1.77 versus South), hospital urban status (OR, 1.42), and nonteaching hospitals (OR, 1.20) (P < .05 for all). ConclusionsThe relative use of CTAP in ED patients presenting with suspected urolithiasis doubled between 2006 and 2014 and showed marked geographic variation. Among ED patients with suspected urolithiasis, CTAP was more frequent in patients from higher household income ZIP codes, with private insurance, in the Northeast, and at urban and nonteaching hospitals.