Emergency Diagnostic Imaging Research Articles

Quality Improvement: Achieving Zero HAIs for over 365 Days

In a 76-bed acute care hospital offering inpatient and outpatient services, a 31-bed emergency department, diagnostic imaging and cardiac catheterization, we have established a commitment of zero harm through executive leadership support, strategic initiatives, and continuous quality improvement. An opportunity was identified in 2021 to reduce the amount of Hospital Acquired Infections (HAI). In 2021 the hospital had 11 HAIs.

Justification and optimization of radiation exposures: a new framework to aggregate arbitrary detriments and benefits.

Myriad radiation effects, including benefits and detriments, complicate justifying and optimizing radiation exposures. The purpose of this study was to develop a comprehensive conceptual framework and corresponding quantitative methods to aggregate the detriments and benefits of radiation exposures to individuals, groups, and populations. In this study, concepts from the ICRP for low dose were integrated with clinical techniques focused on high dose to develop a comprehensive figure of merit (FOM) that takes into account arbitrary host- and exposure-related factors, endpoints, and time points. The study built on existing methods with three new capabilities: application to individuals, groups, and populations; extension to arbitrary numbers and types of endpoints; and inclusion of limitation, where relevant. The FOM was applied to three illustrative exposure situations: emergency response, diagnostic imaging, and cancer radiotherapy, to evaluate its utility in diverse settings. The example application to radiation protection revealed the FOM's utility in optimizing the benefits and risks to a population while keeping individual exposures below applicable regulatory limits. Examples in diagnostic imaging and cancer radiotherapy demonstrated the FOM's utility for guiding population- and patient-specific decisions in medical applications. The major finding of this work is that it is possible to quantitatively combine the benefits and detriments of any radiation exposure situation involving an individual or population to perform cost-effectiveness analyses using the ICRP key principles of radiation protection. This FOM fills a chronic gap in the application of radiation-protection theory, i.e., limitations of generalized frameworks to algorithmically justify and optimize radiation exposures. This new framework potentially enhances objective optimization and justification, especially in complex exposure situations.

Emergency Radiology During the COVID-19 Pandemic: The Canadian Association of Radiologists Recommendations for Practice.

Coronavirus Disease 2019 (COVID-19) is the disease caused by the novel coronavirus officially named the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), declared as a pandemic by the World Health Organization on March 11, 2020. The COVID-19 pandemic presents an unprecedented challenge to emergency radiology practice. The continuity of an effective emergency imaging service for both COVID-19 and non-COVID-19 patients is essential, while adhering to best infection control practices. Under the direction of the Board of the Canadian Association of Radiologists, this general guidance document has been synthesized by collaborative consensus of a group of emergency radiologists. These recommendations aim to assist radiologists involved in emergency diagnostic imaging to help mitigate the spread of COVID-19 and continue to add value to patient care in the emergency setting.

Optimizing Emergency Diagnostic Imaging in Patients with Pulmonary Embolism in the Emergency Room

Summary We performed a retrospective evaluation of the criteria for suspected pulmonary embolism (PE) and requests for computed tomography angiography (CTA) by the emergency room (ER) teams. Simultaneously, we tried to find irregularities in their work. Then we designed new behavioral protocols, and yearly we evaluated the effect on the workload of the computed tomography (CT) unit of the Roentgenology and Radiology at the University Hospital – Pleven and the total impact on the behavior of the teams in cases of suspected for PE. The data from before and after the intervention was evaluated. After the implementation of the protocols, matching the criteria of PE rule-out criteria (PERC), the number of D-dimer testing, echocardiography, and computed tomography pulmonary angiographies (CTPA) was significantly higher. We found that the number of patients urgently transported for primary thrombectomy had increased, and the reduction of PE mortality in the Emergency Unit proves the safety of our intervention. Overall, the intervention in the attitude of the ER teams has a significant positive effect on the management of patients with suspected PE.

P105: Transforming emergency stroke care through innovation: Canadas first stroke ambulance

Introduction: A two-year Stroke Ambulance (SA) pilot project was implemented at the University of Alberta Hospital (UAH) in February, 2017, the first in the world to utilize this specialized technology in a rural setting. The primary objective is to evaluate clinical and economic implications of timely SA assessment and treatment of hyperacute stroke patients who present to non-stroke centres in rural Alberta and might otherwise have received delayed treatment, or not at all, due to prolonged transfer times. Methods: A steering committee and seven working groups were established, with representation from Alberta Health Services (AHS) programs impacted, to ensure comprehensive project development and implementation. The SA portable CT scanner, point of care laboratory, and videoconference system facilitate diagnosis of stroke in the field. The multidisciplinary team includes a stroke fellow, advanced & primary care paramedics, registered nurse, CT technologist, and telestroke physician. When not dispatched, the team provides stroke expertise and patient care in the emergency department (ED) and diagnostic imaging. The service model includes suspected stroke patients presenting to non-stroke centres within a 250 Km radius of Edmonton (Phase I); patients presenting to Edmonton Zone (EZ) hospitals without CT capability and/or tPA protocols (Phase 2); and expedited transport from EZ hospitals to the UAH for urgent endovascular therapy (EVT) (Phase 3). A health economic analysis will compare stroke ambulance care with standard care. Results: The SA has responded to 54 dispatches, 13 patients thrombolyzed and 3 patients receiving EVT. Median rendezvous to CT time was 10 minutes, median rendezvous to tPA time was 21 minutes, and mean time from symptom onset to tPA was 180 minutes. There were no complications. After SA imaging and assessment, 18 patients were repatriated back to their local community hospital, avoiding unnecessary admission to tertiary care. Conclusion: Our preliminary experience demonstrates that the SA offers a novel approach to performing timely evaluation and treatment of suspected stroke from non-stroke centres and may serve as an excellent triage mechanism, reducing avoidable admissions to overcapacity tertiary care EDs. The SA team provides added value to the ED with stroke expertise and patient care. A comprehensive health economic analysis will determine cost-effectiveness and whether spread is feasible.

The association between pediatric chronic pain clinic attendance and health care utilization: A retrospective analysis

ABSTRACT Background Pediatric chronic pain is common, disabling, and costly. Children with chronic pain have high health care utilization in that they are seen by multiple health care providers, have frequent emergency room visits, and require many diagnostic tests. Pediatric health care utilization relating to direct health care services and associated costs of attendance at chronic pain clinics in Canada has not been well described. Aim The purpose of this project was to analyze the cost of physician services for individuals attending an interprofessional pediatric chronic pain clinic over an 8-year span including years before, during, and after treatment. Methods Physician claims were extracted from the Ontario Health Insurance Plan (OHIP) Claims History Database and retrospectively reviewed over 8 fiscal years for 100 new patients seen at the Chronic Pain Clinic at the Hospital for Sick Children. The utilization metrics analyzed included physician consultations and follow-up appointments, emergency room visits, lab tests, and diagnostic imaging. These data reflected 2 years prior to the first chronic pain clinic appointment, year of initial appointment, and five subsequent years. Results Health care utilization based on OHIP claims related to physician services and cost analysis showed an increase during the 2 years prior to first chronic pain clinic appointment, a decrease during the year of initial appointment, and a further decrease over the subsequent 5 years. Conclusions Further prospective research is required to establish whether attendance at the chronic pain clinic caused the reduction in health care services and costs and, if so, to identify the effective components of treatment.

P008: Implementation of a voluntary provincial knowledge translation intervention project to improve the appropriateness of CT imaging for patients with mild traumatic brain injury and suspected pulmonary embolism

Introduction: Utilization of CT imaging has risen dramatically with increases in availability, but without corresponding improvements in patient outcomes. Previous attempts to improve imaging appropriateness via guideline implementation have met with limited success, with commonly cited barriers including a lack of confidence in patient outcomes, medicolegal risk, and patient expectations. The objective of this project is to improve CT utilization and appropriateness by addressing common barriers through clinical decision support (CDS) embedded in clinical practice. Methods: This matched-pair cluster-randomized trial saw 12 Alberta EDs with CT scanners randomized to receive CDS for diagnostic imaging. After extensive site engagement to recruit emergency medicine and diagnostic imaging leadership and stakeholders and understand local contexts, half of the sites received CDS for mild traumatic brain injury (MTBI) based on the Canadian CT Head Rule, while the remainder received CDS for suspected pulmonary embolism (PE), including the Pulmonary Embolism Rule-out Criteria (PERC), Wells Score, age-adjusted D-dimer and CT pulmonary angiography (CTPA) use. Hardcopy CT order forms including quantitative decision support, source literature and patient handouts were developed and adapted and integrated into workflow as per local site preference. Regular physician and site report cards on CT utilization and CDS use were also provided. The primary outcome was diagnostic imaging utilization for patients with MTBI and suspected PE. Results: During the study period, 144 emergency physicians at 6 EDs saw 3,278 patients with MTBI and 146 emergency physicians at six matched comparison EDs saw 18,606 patients with suspected PE. Use of CDS was highly variable by site, ranging from 0% to 29% of CT orders for MTBI and from 13% to 75% of CTPA orders for suspected PE. Impact on CT utilization, appropriateness, diagnostic yield is currently under investigation, but is expected to be limited at many sites given the variable adoption of decision support. Conclusion: A comprehensive CDS intervention to improve evidence-based imaging has met with variable uptake. Meaningful and widespread sustained improvements in practice will likely require incentives, accountability measures and leadership authority to enforce change.

Abstract WP387: Outcomes of a Wake-up Stroke Protocol

Background: Patients who present with stroke symptoms upon awakening, often referred to as wake-up stroke (WUS), account for approximately 25% of acute ischemic strokes. In this group, onset time is unknown. Due to the unknown time of onset, patients with WUS are often excluded from consideration of aggressive stroke treatment and are generally treated with routine medical management only. However, through the use of advanced imaging and rapid interpretation of findings, we have found that selected WUS patients may benefit from endovascular stroke therapies. We identified the need for a standardized protocol to ensure that all WUS patients are urgently assessed as candidates for aggressive management. Purpose: The purpose of this project was to establish a standardized protocol, including a one-call alert system and pre-set orders for advanced diagnostic imaging, to be used in the quick determination of a treatment plan for patients presenting with WUS. Methods: A protocol was created by the stroke team. The stroke team responds to the one-call alert system, advanced diagnostics are rapidly performed, and a decision regarding endovascular treatment is made by the Interventional Radiologist. Education was provided to all major stakeholders including all Neurologists, Emergency Department Physicians and staff, Radiologists, Stroke Nurse Practitioners, Emergency Medical Providers, Diagnostic Imaging and Special Procedures staff. Wake-Up Stroke alert activations, procedures, and outcomes are monitored by the Stroke Coordinator. Results: Wake Up Stroke Protocol was published for use in February 2015. Within the 90-day period immediately following, 16 Stroke Alert activations were called for WUS patients. Eight of the 16 were deemed to be candidates for endovascular stroke therapy. Of the eight patients treated, the average improvement in NIHSS score is 5.5 points (range 0-14). Conclusion: In conclusion, the WUS Protocol is effective in the rapid identification of patients who could benefit from endovascular stroke therapies.

Developing a Research Agenda to Optimize Diagnostic Imaging in the Emergency Department: An Executive Summary of the 2015 Academic Emergency Medicine Consensus Conference.

The 2015 Academic Emergency Medicine (AEM) consensus conference, "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization," was held on May 12, 2015, with the goal of developing a high-priority research agenda on which to base future research. The specific aims of the conference were to: 1) understand the current state of evidence regarding emergency department (ED) diagnostic imaging utilization and identify key opportunities, limitations, and gaps in knowledge; 2) develop a consensus-driven research agenda emphasizing priorities and opportunities for research in ED diagnostic imaging; and 3) explore specific funding mechanisms available to facilitate research in ED diagnostic imaging. Over a 2-year period, the executive committee and other experts in the field convened regularly to identify specific areas in need of future research. Six content areas within emergency diagnostic imaging were identified prior to the conference and served as the breakout groups on which consensus was achieved: clinical decision rules; use of administrative data; patient-centered outcomes research; training, education, and competency; knowledge translation and barriers to imaging optimization; and comparative effectiveness research in alternatives to traditional computed tomography use. The executive committee invited key stakeholders to assist with planning and to participate in the consensus conference to generate a multidisciplinary agenda. There were 164 individuals involved in the conference spanning various specialties, including emergency medicine (EM), radiology, surgery, medical physics, and the decision sciences. This issue of AEM is dedicated to the proceedings of the 16th annual AEM consensus conference as well as original research related to emergency diagnostic imaging.

Optimizing Patient-centered Communication and Multidisciplinary Care Coordination in Emergency Diagnostic Imaging: A Research Agenda.

Patient-centered emergency diagnostic imaging relies on efficient communication and multispecialty care coordination to ensure optimal imaging utilization. The construct of the emergency diagnostic imaging care coordination cycle with three main phases (pretest, test, and posttest) provides a useful framework to evaluate care coordination in patient-centered emergency diagnostic imaging. This article summarizes findings reached during the patient-centered outcomes session of the 2015 Academic Emergency Medicine consensus conference "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization." The primary objective was to develop a research agenda focused on 1) defining component parts of the emergency diagnostic imaging care coordination process, 2) identifying gaps in communication that affect emergency diagnostic imaging, and 3) defining optimal methods of communication and multidisciplinary care coordination that ensure patient-centered emergency diagnostic imaging. Prioritized research questions provided the framework to define a research agenda for multidisciplinary care coordination in emergency diagnostic imaging.

Advancing Patient-centered Outcomes in Emergency Diagnostic Imaging: A Research Agenda.

Diagnostic imaging is integral to the evaluation of many emergency department (ED) patients. However, relatively little effort has been devoted to patient-centered outcomes research (PCOR) in emergency diagnostic imaging. This article provides background on this topic and the conclusions of the 2015 Academic Emergency Medicine consensus conference PCOR work group regarding "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization." The goal was to determine a prioritized research agenda to establish which outcomes related to emergency diagnostic imaging are most important to patients, caregivers, and other key stakeholders and which methods will most optimally engage patients in the decision to undergo imaging. Case vignettes are used to emphasize these concepts as they relate to a patient's decision to seek care at an ED and the care received there. The authors discuss applicable research methods and approaches such as shared decision-making that could facilitate better integration of patient-centered outcomes and patient-reported outcomes into decisions regarding emergency diagnostic imaging. Finally, based on a modified Delphi process involving members of the PCOR work group, prioritized research questions are proposed to advance the science of patient-centered outcomes in ED diagnostic imaging.

Funding Research in Emergency Diagnostic Imaging: Summary of a PanelDiscussion at the 2015 Academic Emergency Medicine Consensus Conference.

As part of the 2015 Academic Emergency Medicine consensus conference "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization," a panel of representatives from the National Institute of Health's Office of Emergency Care Research, the National Institute of Biomedical Imaging and Bioengineering, the Agency for Healthcare Research and Quality, and the Patient-Centered Outcomes Research Institute was assembled to discuss future opportunities for funding research in this particular area of interest. Representatives from these agencies and organizations discussed their missions and priorities and how they distribute funding. They also addressed questions on mechanisms for new and established researchers to secure future funding.

Optimizing Diagnostic Imaging in the Emergency Department

While emergency diagnostic imaging use has increased significantly, there is a lack of evidence for corresponding improvements in patient outcomes. Optimizing emergency department (ED) diagnostic imaging has the potential to improve the quality, safety, and outcomes of ED patients, but to date, there have not been any coordinated efforts to further our evidence-based knowledge in this area. The objective of this article is to discuss six aspects of diagnostic imaging to provide background information on the underlying framework for the 2015 Academic Emergency Medicine consensus conference, "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization." The consensus conference aims to generate a high priority research agenda for emergency diagnostic imaging that will inform the design of future investigations. The six components herein will serve as the group topics for the conference: 1) patient-centered outcomes research; 2) clinical decision rules; 3) training, education, and competency; 4) knowledge translation and barriers to image optimization; 5) use of administrative data; and 6) comparative effectiveness research: alternatives to traditional CT use.

2014 Canadian Stroke Congress Abstracts

d’Esterre, CD1, 3 Qazi, E1, 3 Patil, S1, 3 Almekhlafi, M3, 1 Lee, T2, 3 Demchuk, A1, 3 Goyal, M1, 3 Menon, B1, 3; 1. University of Calgary, Calgary, AB; 2. University of Western Ontario, London, ON; 3. Calgary Stroke Program, Calgary, AB Background : For ischemic stroke, CT Perfusion (CTP) may change thrombolytic/endovascular treatment decisions when compared to NCCT/CTA alone. Two distinct thresholds may be useful in this regard: separation of 1) non-salvageable tissue (infarct core) from salvageable electrically silent tissue (penumbra), and 2) penumbra from benign oligemia (hypoperfused, but will survive if clot persists). Methods : CTP (120s,8cm) was performed on 180 patients within 12hrs of ischemic stroke. Two patient cohorts were analyzed: (1) recanalization (TICI 2b,3) 6s. For group (2) CBF, CBV, and Tmax values were obtained from within the final infarct region, and total ipsilateral hemisphere, excluding infarction. CBF, CBV and Tmax were used in univariate regression models. Results : For group (1)[n=11], mean time from CTP to recanalization was 60±19min. CBF parameter (thresholds for gray and white matter 7.2 and 5.2 ml•min-1•(100g)-1) had the highest sensitivity (90.9%) and specificity (81.8%) for infarction. For group (2)[n=15], the Tmax parameter (thresholds for gray and white matter 11.3s and 11.8s) had the highest sensitivity (86.6%) and specificity (80.0%) for penumbra. Conclusion : Knowing the status of recanalization within 90mins of CTP allows for accurate delineation of infarct core, as …

Computer-aided simple triage

Computer-aided detection (CAD) established its role in medical imaging as second reader aimed to boost the diagnostic accuracy of human interpreter. As the diagnostic performance of CAD systems improves and more imaging modalities are covered, CAD steps forward to fill new, more demanding positions in medical practice. In this paper, we investigate how the introduction of CAD for emergency diagnostic imaging shifts the use case paradigm from second reader to initial interpreter and triage tool. We start from extracting common characteristics of exiting CAD systems and compare them to those for emergency diagnostic imaging modalities. Based on the deduced requirements, we define a new class of CAD systems-Computer-aided simple triage (CAST) and explore its properties, use case scenarios and clinical benefits. We also discuss the differences between the CAST, CAD, and automated computer diagnosis. A CAST system should serve as a simple triage tool performing a fully automatic analysis and providing initial classification at "per study" level. Positive studies are then immediately analyzed by expert reader, thus reducing delay for patients with critical conditions, while negative studies can be initially dealt with by less experienced staff. Automatic image quality and study complexity assessment can serve as reading prioritization key. CAST system should exhibit sufficiently high specificity, while not compromising the high sensitivity per study. CAST systems have a potential to become an "enabling technology" allowing introduction of advanced imaging techniques into the emergency workflow protocols by addressing the reader unavailability and reading prioritization problems.

Preliminary Radiology Resident Interpretations Versus Final Attending Radiologist Interpretations and the Impact on Patient Care in a Community Hospital

At academic institutions, overnight emergency radiology examinations are interpreted by the on-call radiology resident and are reviewed by an attending radiologist in the morning. The objective of our study was to determine the rate of discrepancies between the two interpretations and the possible effect, if any, on patient care. The preliminary reports for 11,908 emergency diagnostic imaging examinations interpreted after hours by residents over a 3-year period (January 2002-January 2005) were reviewed retrospectively for any discrepancy with the attending radiologist's final interpretation. A discrepancy was noted if verbal notification of the ordering physician was required. The medical charts of the cases for which there was a major discrepancy between the two interpretations were reviewed. The discrepancies were categorized as to the effect on patient morbidity. The resident discrepancy rates were also compared with RADPEER data from our institution. The overall major discrepancy rate was 2.6%. This rate is comparable to RADPEER data, which found a misinterpretation rate of 2.1%. The technique most commonly involved in cases with discrepant interpretations was contrast-enhanced CT of the abdomen and pelvis, with the most common diagnosis related to acute appendicitis (total of 21 cases). The rate of discrepancy was highest for residents who were in their third year of training. The indications for these examinations varied; however, the effect on patient management was no significant effect in 92.8%, some negative effect in 6.9%, and significant negative effect in 0.3%. The results of this investigation highlight the minimal discrepancy rate that occurs with overnight resident coverage. Thus, there is no detrimental effect on the quality of patient care from relying on preliminary interpretations made by radiology residents.

Identification of Root Causes for Emergency Diagnostic Imaging Delays at Three Canadian Hospitals

Diagnostic imaging of patients in the emergency department offers numerous opportunities for delay. In an era of ED overcrowding, it is important to identify causes of delay in caring for patients to minimize patient length of stay in the emergency department. This study was intended to: (1) identify each of the steps involved in completing emergency diagnostic imaging investigations; (2) identify points of delay in the process; (3) identify the root causes for delay; and (4) perform a barrier analysis to provide insight into the contribution of the work environment and existing processes to delays. This prospective, cross-sectional, modified time-in-motion study was conducted simultaneously at 3 urban emergency departments of a Canadian academic center over a 3-week period. Turnaround and process event times were recorded and a log transformation was performed to normalize the time data. Analysis of variance was used to examine individual time intervals between sites. Root cause and barrier analyses were conducted on the summary data. Analysis of 2297 cases revealed the mean turnaround time for one site was 50 minutes and significantly greater (P < .05) than the means of the other 2 sites (approximately 33 and 37 minutes, respectively). Root cause analysis identified 3 root causes of delay: (1) processing of radiograph request order by registered nurse; (2) transport times; and (3) radiology suite location. Barrier analysis indicated that current practices are responsible for the first 2 causes of delay. Both radiology and emergency department staffing considerations and workload contribute to delays in turnaround times of diagnostic imaging investigations.

Hepatic trauma: CT findings and considerations based on our experience in emergency diagnostic imaging

Abdominal blunt trauma represents the main cause of death in people of age less than 40 years; the liver injury occurs frequently, with an incidence varying from 3 to 10%. Isolated hepatic lesions are rare and in 77–90% of cases, lesions of other organs and viscera are involved. Right hepatic lobe is a frequent site of injury, because it is the more voluminous portion of liver parenchyma; posterior superior hepatic segments are proximal to fixed anatomical structures such as ribs and spine that may have an important role in determining of the lesion. The coronal ligaments’ insertion in this parenchymal region augments the effect of acceleration–deceleration mechanism. Associated lesions usually are homolateral costal fractures, laceration or contusion of the inferior right pulmonary lobe, haemothorax, pneumothorax, renal and/or adrenal lesions. Traumatic lesions of left hepatic lobe are rare and usually associated with direct impact on the superior abdomen, such as in car-crash when the wheel causes a compressive effect on thorax and abdomen. Associated lesions to left hepatic lobe injuries correlated to this mechanism are: sternal fractures, pancreatic, myocardial, gastrointestinal tract injuries. Lesions of the caudal lobe are extremely rare, usually not isolated and noted with other large parenchymal lesions. The Institution of Specialized Trauma Centers and the technical progress in imaging methodology developed in the last years a great reduction of mortality. New diagnostic methodologies allow a reduction of negatives laparotomies and allow the possibility of conservative treatment of numerous traumatic lesions; however, therapy depends from imaging findings and clinical conditions of the patient. Computed tomography (CT) certainly presents a large impact on diagnosis and management of patients with lesions from blunt abdominal traumas. It is important to establish a prognostic criteria allowing decisions for conservative or surgical treatment; CT findings and peritoneal fluid evaluation may be used to make a first differentiation of severity of lesions, but haemodynamic parameters may help the clinician to prefer a conservative treatment. In emergency based hospitals and also in our experience, positive benefits spring from diagnostic accuracy and consequent correct therapeutic management.