Reducing interruptions during duty radiology shifts, assessment of its benefits and review of factors affecting the radiology working environment

Operational challenges and collaborative solutions in radiology image interpretation: perspectives from imaging departments in a low-resource setting

INTRODUCTION

Medical imaging's critical role in diagnosis requires prompt and precise image interpretation. Numerous radiology departments, especially in low-resourced settings, encounter challenges such as a shortage of radiologists in their operational setup. This study explored the perceptions of radiographers and radiologists from low-resourced departments in a single country regarding operational challenges and potential solutions in image interpretation.

METHODS

A qualitative approach was utilised, involving heads of departments, senior radiographers, and radiologists with a minimum of 5 years of experience, from three major state referral hospitals. Face-to-face, semi-structured interviews were conducted in November 2022, using an interview guide that included questions on the challenges encountered during image interpretation and the proposed solutions. Data analysis was conducted using Atlas.ti version 9.0, following the four-step content analysis method. All participants willingly provided consent to participate in the study.

RESULTS

Ten participants, comprising two radiologists and eight radiographers participated in the study. The research identified three main themes: image interpretation pathways, image interpretation operational challenges and proposed solutions for image interpretation. In addition, a total of 10 subthemes were generated from the three main themes.

CONCLUSION

The study revealed critical challenges and the need to explore the formal inclusion of radiographers in image interpretation, as a way to improve efficiency. However, a comprehensive assessment of the image interpretation system, encompassing radiographers' knowledge and competence, is recommended for context-specific, empirical-based modifications to enhance service provision.

Sustainable reduction of phone-call interruptions by 35% in a medical imaging department using an automatic voicemail and custom call redirection system

BACKGROUND

Have you ever been in the trenches of a complicated study only to be interrupted by a not-so urgent phone-call? We were, repeatedly- unfortunately.

PURPOSE

To increase productivity of radiologists by quantifying the main source of interruptions (phone-calls) to the workflow of radiologists, and too assess the implemented solution.

MATERIALS AND METHODS

To filter calls to the radiology consultant on duty, we introduced an automatic voicemail and custom call redirection system. Thus, instead of directly speaking with radiology consultants, clinicians were to first categorize their request and dial accordingly: 1. Inpatient requests, 2. Outpatient requests, 3. Directly speak with the consultant radiologist. Inpatient requests (1) and outpatient requests (2) were forwarded to MRI technologists or clerks, respectively. Calls were monitored in 15-minute increments continuously for an entire year (March 2022 until and including March 2023). Subsequently, both the frequency and category of requests were assessed.

RESULTS

4803 calls were recorded in total: 3122 (65 %) were forwarded to a radiologist on duty. 870 (18.11 %) concerned inpatients, 274 (5.70 %) outpatients, 430 (8.95 %) dialed the wrong number, 107 (2.23 %) made no decision. Throughout the entire year the percentage of successfully avoided interruptions was relatively stable and fluctuated between low to high 30 % range (Mean per month 35 %, Median per month 34.45 %).

CONCLUSIONS

This is the first analysis of phone-call interruptions to consultant radiologists in an imaging department for 12 continuous months. More than 35 % of requests did not require the input of a specialist trained radiologist. Hence, installing an automated voicemail and custom call redirection system is a sustainable and simple solution to reduce phone-call interruptions by on average 35 % in radiology departments. This solution was well accepted by referring clinicians. The installation required a one-time investment of only 2h and did not cost any money.

Integrated Automatic Examination Assignment Reduces Radiologist Interruptions: A 2-Year Cohort Study of 232,022 Examinations

Radiology departments face challenges in delivering timely and accurate imaging reports, especially in high-volume, subspecialized settings. In this retrospective cohort study at a tertiary cancer center, we assessed the efficacy of an Automatic Assignment System (AAS) in improving radiology workflow efficiency by analyzing 232,022 CT examinations over a 12-month period post-implementation and compared it to a historical control period. The AAS was integrated with the hospital-wide scheduling system and set up to automatically prioritize and distribute unreported CT examinations to available radiologists based on upcoming patient appointments, coupled with an email notification system. Following this AAS implementation, despite a 9% rise in CT volume, coupled with a concurrent 8% increase in the number of available radiologists, the mean daily urgent radiology report requests (URR) significantly decreased by 60% (25 ± 12 to 10 ± 5, t = -17.6, p < 0.001), and URR during peak days (95th quantile) was reduced by 52.2% from 46 to 22 requests. Additionally, the mean turnaround time (TAT) for reporting was significantly reduced by 440 min for patients without immediate appointments and by 86 min for those with same-day appointments. Lastly, patient waiting time sampled in one of the outpatient clinics was not negatively affected. These results demonstrate that AAS can substantially decrease workflow interruptions and improve reporting efficiency.

Design and Perceived Value of a Novel Solution for Asynchronous Communication in Radiology

RATIONALE AND OBJECTIVES

Communication with and within the Radiology Department is typically initiated over phone, face-to-face or general-purpose chat, causing frequent interruptions, additional mental workload, workflow inefficiencies and diagnostic errors. We developed and evaluated a new communication solution that aims to reduce avoidable interruptions caused by technologist-radiologist communication.

MATERIALS AND METHODS

Following an iterative design process with future end users, a scalable web-based software solution, RadConnect, was developed enabling a chat-based communication workflow between a technologist and a radiologist. As a first experimental implementation, technologists can send categorized tickets to a radiology section account. Radiologists receive the tickets in a worklist that is prioritized by urgency. Consented radiologists and technologists performed scripted tasks in 2 hr sessions and completed a structured questionnaire on perceived value and comparison to standard communication modes.

RESULTS

Of 17 participants from three academic European institutes, 65% (11/17) believed they would use RadConnect frequently; 53% (9/17) believed that it reduces phone calls >80%; and 88% (15/17) believed it adds value compared to general-purpose enterprise chat applications.

DISCUSSION

Participants recognized the value of RadConnect especially its categorized tickets, prioritized worklist and role-based interaction model. Inter-institute differences in perceived value of RadConnect may have been caused by technologist-radiologist proximity and communication alternatives in the institutions.

CONCLUSION

Chat-based role-based communication might be a viable mode of communication between technologists and radiologists to reduce avoidable interruptions. Tailoring the chat solution to the needs of and tightly integrated with the radiology workflow is valued by future end users after exposure to the tool in a simulated environment.

Implementation of Medical Students as Radiology Reading Room Coordinators

OBJECTIVE

Effort has been made to minimize the burden of non-interpretive tasks (NITs), in particular by hiring and training non-radiologist support staff as reading room coordinators (RRCs). Our medical center recruited and trained senior medical students from our affiliated school of medicine to work alongside on-call radiology residents as RRCs.

METHODS

A 12-month Malpractice Carrier monetary grant was acquired to fund medical students at with the aim to reduce malpractice risk. After the first year, residents were surveyed regarding the impact of the RRCs on perceived on-call efficiency and morale. Furthermore, report turnaround times (TAT) on call shifts that were and were not accompanied by a RRC were compared.

RESULTS

89 % of residents strongly agreed that the RRC improved workflow efficiency, decreased distractions, and felt less stressed during the call shift when the RRC was on duty. 78 % strongly agreed to be more likely to contact a referring clinician when the RRC was able to help coordinate. The mean TAT in the presence of a RRC was 36.8 min, and the mean TAT in the absence of a RRC was 36.9 min DISCUSSION: After hiring medical students to assist on-call radiology residents with noninterpretive tasks, residents reported subjective indicators of program success, but average report turnaround time was unaffected. Nevertheless, we predict that this type of program will continue to grow among academic radiology departments, though additional research is required to evaluate national trends and impacts on radiologist productivity and well-being.

Simple changes to the reporting environment produce a large reduction in the frequency of interruptions to the reporting radiologist: an observational study

Background

Interruptions are a cause of discrepancy, errors, and potential safety incidents in radiology. The sources of radiological error are multifactorial and strategies to reduce error should include measures to reduce interruptions.

Purpose

To evaluate the effect of simple changes in the reporting environment on the frequency of interruptions to the reporting radiologist of a hospital radiology department.

Material and Methods

A prospective observational study was carried out. The number and type of potentially disruptive events (PDEs) to the radiologist reporting inpatient computed tomography (CT) scans were recorded during 20 separate 1-h observation periods during both pre- and post-intervention phases. The interventions were (i) relocation of the radiologist to a private, quiet room, and (ii) initial vetting of clinician enquiries via a separate duty radiologist

Results

After the intervention there was an 82% reduction in the number of frank interruptions (PDEs that require the radiologist to abandon the reporting task) from a median 6 events per hour to 1 (95% confidence interval [CI] = 4–6; P < 0.00001). The overall number of PDEs was reduced by 56% from a median 11 events per hour to 5 (95% CI = 4.5–11: P < 0.00001).

Conclusion

Relocation of inpatient CT reporting to a private, quiet room, coupled with vetting of clinician enquiries via the duty radiologist, resulted in a large reduction in the frequency of interruptions, a frequently cited avoidable source of radiological error.

Team Approach to Improving Radiologist Wellness: A Case-Based Methodology

Radiologist wellness is important on an individual and group/institutional level and helps to promote a strong and healthy working environment, which can improve radiologist retention and engagement. This paper will discuss case examples of radiologist wellness improvements in a single academic institution over a 3-year period using the DMAIC (Define, Measure, Analyze, Improve, and Control) model. Leveraging this framework led to the implementation of reading room assistants, reduction in work-related injuries by improvements in ergonomics, and the formation of a faculty mentorship program.

Workflow Interruptions and Effect on Study Interpretation Efficiency

BACKGROUND

Interruptions have been shown to adversely impact efficiency, accuracy, and patient safety.

OBJECTIVE

To analyze the frequency and types of interruptions and effect on report interpretation efficiency.

MATERIALS AND METHODS

A business process improvement team was consulted to make detailed recordings of the activities of the radiologists. Activities were categorized as interpreting studies, active interruptions initiated by the radiologist, and passive interruptions initiated by an external source.

RESULTS

Thirteen board-certified, pediatric radiologists were observed for 61 hours. Radiologists spent 52% of their time interpreting studies, 29% on active interruptions, and 18% on passive interruptions. Approximately 50% of non-interpretive time involved in-person conversations or consults and 16% involved phone calls of which 67% were incoming. The longest time period without an interruption was 20 minutes. 85% of the time, an interruption came within 3 minutes of beginning an interpretation and lasted 1 minute or less 70% of the time. Interruptions increased the time a radiologist needed to read a study by 1 minute for radiographs, 2 minutes for ultrasounds, 6 minutes for CTs, and 10 minutes for magnetic resonance imaging.

CONCLUSION

Total interruption time nearly equaled the total time interpreting studies for radiologists, and interruptions decreased efficiency and increased report interpretation times for all modalities studied. This study highlights the type and extent of interruptions in radiology and examines the effect on report interpretation times. With the frequency of interruptions and impact on efficiency, there is a need to dedicate resources to manage the radiologist workflow. Strategic interventions may ultimately improve outcomes, efficiency, and the overall work environment.

Mandating Limits on Workload, Duty, and Speed in Radiology

Research has not yet quantified the effects of workload or duty hours on the accuracy of radiologists. With the exception of a brief reduction in imaging studies during the 2020 peak of the COVID-19 pandemic, the workload of radiologists in the United States has seen relentless growth in recent years. One concern is that this increased demand could lead to reduced accuracy. Behavioral studies in species ranging from insects to humans have shown that decision speed is inversely correlated to decision accuracy. A potential solution is to institute workload and duty limits to optimize radiologist performance and patient safety. The concern, however, is that any prescribed mandated limits would be arbitrary and thus no more advantageous than allowing radiologists to self-regulate. Specific studies have been proposed to determine whether limits reduce error, and if so, to provide a principled basis for such limits. This could determine the precise susceptibility of individual radiologists to medical error as a function of speed during image viewing, the maximum number of studies that could be read during a work shift, and the appropriate shift duration as a function of time of day. Before principled recommendations for restrictions are made, however, it is important to understand how radiologists function both optimally and at the margins of adequate performance. This study examines the relationship between interpretation speed and error rates in radiology, the potential influence of artificial intelligence on reading speed and error rates, and the possible outcomes of imposed limits on both caseload and duty hours. This review concludes that the scientific evidence needed to make meaningful rules is lacking and notes that regulating workloads without scientific principles can be more harmful than not regulating at all.

Natural Language Processing for Imaging Protocol Assignment: Machine Learning for Multiclass Classification of Abdominal CT Protocols Using Indication Text Data

A correct protocol assignment is critical to high-quality imaging examinations, and its automation can be amenable to natural language processing (NLP). Assigning protocols for abdominal imaging CT scans is particularly challenging given the multiple organ specific indications and parameters. We compared conventional machine learning, deep learning, and automated machine learning builder workflows for this multiclass text classification task. A total of 94,501 CT studies performed over 4 years and their assigned protocols were obtained. Text data associated with each study including the ordering provider generated free text study indication and ICD codes were used for NLP analysis and protocol class prediction. The data was classified into one of 11 abdominal CT protocol classes before and after augmentations used to account for imbalances in the class sample sizes. Four machine learning (ML) algorithms, one deep learning algorithm, and an automated machine learning (AutoML) builder were used for the multilabel classification task: Random Forest (RF), Tree Ensemble (TE), Gradient Boosted Tree (GBT), multi-layer perceptron (MLP), Universal Language Model Fine-tuning (ULMFiT), and Google’s AutoML builder (Alphabet, Inc., Mountain View, CA), respectively. On the unbalanced dataset, the manually coded algorithms all performed similarly with F1 scores of 0.811 for RF, 0.813 for TE, 0.813 for GBT, 0.828 for MLP, and 0.847 for ULMFiT. The AutoML builder performed better with a F1 score of 0.854. On the balanced dataset, the tree ensemble machine learning algorithm performed the best with an F1 score of 0.803 and a Cohen’s kappa of 0.612. AutoML methods took a longer time for completion of NLP model training and evaluation, 4 h and 45 min compared to an average of 51 min for manual methods. Machine learning and natural language processing can be used for the complex multiclass classification task of abdominal imaging CT scan protocol assignment.

Performance of Pediatric Neuroradiologists Working from Home during a Pandemic at a Quaternary Pediatric Academic Hospital

BACKGROUND AND PURPOSE

As a result of the coronavirus disease 2019 (COVID-19) pandemic, many radiology departments shifted to working a portion of clinical assignments from home. To determine the effect of working from home on performance, productivity, quality, and safety, we evaluated turnaround time, volume of studies, and error rates on rotations worked from home compared with in the hospital.

MATERIALS AND METHODS

The number of studies interpreted per day for each neuroradiologist, turnaround times, and error rates reported to peer learning was identified from April 1, 2020, through September 30, 2020. For each neuroradiologist, mean turnaround times and volumes per day at home versus in the hospital were compared. Similar comparison was performed for STAT studies.

RESULTS

During the time period, 2597 CTs (1897 at home, 700 in the hospital) and 3685 MRIs (2601 at home, 1084 in the hospital) were read. By individual neuroradiologists, 57% (4/7) had shorter turnaround time at home and 57% (4/7) demonstrated an increase in the mean number of studies per day read at home. No statistically significant difference was noted in the neuroradiologists' performance while reading STAT studies. Reported error rates were not found to be higher at home, with statistically significantly lower rates when working at home (P = .018).

CONCLUSIONS

Variable productivity and performance of neuroradiologists when working from home versus in the hospital were found, being 57% faster and/or more productive while working at home without an increase in error rates. The decision to work at home versus in the hospital may best be based on local factors, balancing the variability among individual neuroradiologist's and the institution's needs, recognizing that working from home is not a one-size-fits-all phenomenon but requires adaptability for successful implementation.

Direct Access and Skill Mix Can Reduce Telephone Interruptions and Imaging Wait Times: Improving Radiology Service Effectiveness, Safety and Sustainability

Unnecessary telephone calls to reporting radiologists impede organizations' workflow and may be associated with a higher chance of errors in reports. We conducted a prospective study in two cycles, which identified vetting plain CT heads as the most common reason for these calls and vetting CT urinary tracts (KUB) was also frequent. Clear vetting and protocolling guidelines exist for both of these scans, which do not routinely require discussion with a radiologist. Therefore, our approach was to create new flow diagrams to allow radiographers to directly accept routine requests for plain CT head and CT KUB scans in- and out-of-hours. After this intervention, incoming calls to radiology for vetting CT heads decreased by 30% and for vetting CT KUBs by 100%. The average wait time between CT head request and scan completion was reduced by 40%. The number of CT head and CT KUB scans performed remained stable. In future, maximizing the benefit of direct access in-patient imaging pathways will rely on effective and sustained communication of the protocols to the junior clinical staff rotating through the organization, as they were responsible for requesting the vast majority of tests.

Improving Communication Between the Emergency Department and Radiology Department With a Novel Web-Based Tool in an Urban Academic Center

DESCRIPTION OF PROBLEM

Streamlining communication between radiology and referring services is vital to ensure appropriate care with minimal delays. Increased subspecialization has led to compartmentalization of the radiology department with many physicians working in disparate areas. At our hospital, we anecdotally noted that a significant portion of incoming phone calls were misdirected to the wrong workstations. This resulted in wasted time, unnecessary interruptions, and delays in care because the referring clinicians could not efficiently navigate the radiology department staffing structure. Our quality improvement project involved developing a web-based tool allowing the emergency department (ED) to more efficiently contact the appropriate radiology desk and reduce misdirected phone calls.

INSTITUTIONAL APPROACH EMPLOYED TO ADDRESS THE PROBLEM

Surveys were sent to radiology residents and ED providers (attendings, residents, physician assistants) to assess how often phone calls were misdirected to the wrong radiology station. Radiology residents were asked which stations received the most misdirected phone calls, and what station the caller was often looking for. ED providers were asked which stations they intended when they were told they called the wrong station, and a series of questions in the survey assessed their knowledge of commonly called radiology station (Plain Film, CT Body, Ultrasound, Neuoradiology, Pediatrics, and Overnight Desk). ED and radiology physicians worked together to design a simple, easily accessed web-based tool that allowed the ED clinicians to determine which station should be called during for each hour of the day, which integrated differences in staffing by radiology throughout the day. After the tool had been implemented for 8 months, surveys were again sent to radiology residents and ED clinicians asking the same questions as before to assess for any significant change in response. Additional questions were added to the ED survey to assess awareness of the new tool.

DESCRIPTION OF OUTCOMES IN CHANGE OF PRACTICE

An interactive, easily updated schedule with optimal contact numbers was made available through the ED intranet. The design allowed for easy modification of contact numbers over time to accommodate changes in coverage location or staffing models. Prior to implementation contact information was presented on a static screen, which was unable to be changed and included multiple incorrect and defunct numbers. Additionally, contact defaulted to a general radiology pager, which was carried by a resident only responsible for plain films for most of the day. Numbers included in the new intranet tool were all pertinent reading room stations, all scheduling desks, and all technologist workspaces. Different schedules were provided for weekdays and weekends. Initial survey results showed that prior to the intervention, 74% of radiology residents said they received misdirected phone calls at least twice a day, and 57.9% of ED respondents reached the wrong recipient at least once per day. Frequencies of misdirected calls dropped to 58.4% of radiology residents (P = 0.37) and 17.9% of ED respondents (P < 0.01) on follow-up surveys 8 months after the tool was established. After establishing the new tool, 82.1% of ED respondents were aware of the new intranet contact tool and were using it to contact radiology. On the series of questions assessing ED respondents' knowledge of radiology numbers, over 50% of respondents knew the correct answer or answered using the call sheet after implementation; this resulted in statistically significant increases in accuracy for Body, Neuroradiology, and Pediatric radiology stations. Furthermore, with the exception of ED plain films, there was a statistically significant reduction in number of responses who said the general radiology pager should be called for reads. Fifty percent of radiology residents believed there was a reduction in the number of misdirected phone calls from the ED with this tool.

CONCLUSION, LIMITATIONS, AND DESCRIPTIONS OF FUTURE DIRECTIONS

Our tool was successful in accomplishing multiple goals. First, over 80% of ED respondents adopted the new tool. Second, the number of misdirected phone calls based on the subjective perception of ED respondents and radiology residents was reduced. Third, we objectively improved the ED respondents' behavior pattern in contacting the radiology department by either calling the correct number using the call tool, and by reducing the number of respondents who use the pager. Going forward, we hope to be able to expand use of this tool throughout the hospital in order to provide more timely and efficient care with other services by streamlining access between referring services and the appropriate radiology recipients.

Evaluating Radiology Result Communication in the Emergency Department

PURPOSE

To assess the pattern of result communication that occurs between radiologists and referring physicians in the emergency department setting.

METHODS

An institutional review board-approved prospective study was performed at a large academic medical center with 24/7 emergency radiology cover. Emergency radiologists logged information regarding all result-reporting communication events that occurred over a 168-hour period.

RESULTS

A total of 286 independent result communication events occurred during the study period, the vast majority of which occurred via telephone (232/286). Emergency radiologists spent 10% of their working time communicating results. Similar amounts of time were spent discussing negative and positive cross-sectional imaging examinations. In a small minority of communication events, additional information was gathered through communication that resulted in a change of interpretation from a normal to an abnormal study.

CONCLUSIONS

Effective and efficient result communication is critical to care delivery in the emergency department setting. Discussion regarding abnormal cases, both in person and over the phone, is encouraged. However, in the emergency setting, time spent on routine direct communication of negative examination results in advance of the final report may lead to increased disruptions, longer turnaround times, and negatively impact patient care. In very few instances, does the additional information gained from the communication event result in a change of interpretation?

Effect of Analytics-Driven Worklists on Musculoskeletal MRI Interpretation Times in an Academic Setting

OBJECTIVE. The objective of this study was to determine how use of analytics-driven worklists for MRI based on relative individual interpretation time affects the overall group interpretation time in an academic musculoskeletal practice. SUBJECTS AND METHODS. In this prospective study, interpretation times for all MRI studies signed by three musculoskeletal fellowship-trained radiologists during 2016 were calculated from initial study view and report signing times. Custom worklists were made for each radiologist with body parts ordered from the fastest to the slowest based on relative interpretation time. These worklists were then used for a trial period of 7 consecutive days. The difference in mean interpretation times between the trial period and baseline and the differences in volume distribution were calculated. Changes in individual interpretation time were assessed by z-score with statistical significance set at ≤ 0.05. RESULTS. Across all readers, total interpretation time decreased by a mean of 29.5 minutes per day during the trial period. Only two types of studies were read with an individual interpretation time significantly different from baseline (wrist studies for reader 1 were 10 minutes slower [p = 0.01] and cervical spine studies for reader 3 were 9 minutes faster [p < 0.01]). Volume distributions changed across various body parts (-3% to 4% for reader 1, -13% to 14% for reader 2, and -24% to 10% for reader 3). CONCLUSION. Analytics-driven worklists for MRI may decrease overall group interpretation time without significant alteration in individual speed, though a change in volume distribution is required.