Optimizing diagnostic imaging in the emergency department

Trends in non-focal neurological chief complaints and CT angiography utilization among adults in the emergency department

Prudent imaging use is essential for cost reduction and efficient patient triage. Recent efforts have focused on head and neck CTA in patients with emergent concerns for non-focal neurological complaints, but have failed to demonstrate whether increases in utilization have resulted in better care. The objective of this study was to examine trends in head and neck CTA ordering and determine whether a correlation exists between imaging utilization and positivity rates. This is a single-center retrospective observational study at a quaternary referral center. This study includes patients presenting with headache and/or dizziness to the emergency department between January 2017 and December 2021. Patients who received a head and neck CTA were compared to those who did not. The main outcomes included annual head and neck CTA utilization and positivity rates, defined as the percent of scans with attributable acute pathologies. Among 24,892 emergency department visits, 2264 (9.1%) underwent head and neck CTA imaging. The percentage of patients who received a scan over the study period increased from 7.89% (422/5351) in 2017 to 13.24% (662/5001) in 2021, representing a 67.4% increase from baseline (OR, 1.14; 95% CI 1.11-1.18; P < .001). The positivity rate, or the percentage of scans ordered that revealed attributable acute pathology, dropped from 16.8% (71/422) in 2017 to 10.4% (69/662) in 2021 (OR, 0.86; 95% CI 0.79-0.94; P = .001), a 38% reduction in positive examinations. Throughout the study period, there was a 67.4% increase in head and neck CTA ordering with a concomitant 38.1% decrease in positivity rate.

Factors Associated with Overutilization of Computed Tomography of the Cervical Spine

Introduction: Despite the wide availability of clinical decision rules for imaging of the cervical spine after a traumatic injury (eg, NEXUS C-spine rule and Canadian C-spine rule), there is significant overutilization of computed tomography (CT) imaging in patients who are deemed to be at low risk for a clinically significant cervical spine injury by these clinical decision rules. The purpose of this study was to identify the major factors associated with the overuse of CT cervical spine imaging using a logistic regression model. Methods: This was a retrospective review of all adult patients who underwent CT cervical spine imaging for evaluation of a traumatic injury at a tertiary academic emergency department (ED) and three affiliate community EDs in January and February 2019. We performed multivariable logistic regression to identify factors associated with obtaining CT cervical spine imaging despite low-risk classification by the NEXUS C-spine Rule. Results: A total of 1,051 patients underwent CT cervical spine imaging for traumatic indications during the study period, and 889 patients were included in the analysis. Of these patients, 376 (42.3%) were negative by the NEXUS C-spine rule. Variables that were associated with increased likelihood of unnecessary imaging included age over 65, Emergency Severity Index (ESI) score 2 and 3, arrival as a walk-in, and anticoagulation status. Patients who presented to the tertiary academic ED had a significantly lower likelihood of unnecessary imaging. Twenty-one patients (2.4%) were found to have cervical spine fractures on imaging, two of whom were negative by the NEXUS C-spine rule, but neither had a clinically significant fracture. Conclusion: Cervical spine imaging is vastly overused in patients presenting to the ED with traumatic injuries, as adjudicated using the NEXUS C-spine rule as a reference standard. Older age, ESI level, arrival as a walk-in, and taking anticoagulation drugs were associated with overutilization of CT imaging. Conversely, presenting to the tertiary academic ED was associated with a lower likelihood of undergoing unnecessary imaging. This model can guide future interventions to optimize ED CT utilization and minimize unnecessary testing.

Utilizing Triage Data for Medical Imaging Studies in the Emergency Department

The use of radiological images is widespread in the emergency department (ED) as physicians commonly rely on them during initial evaluations to confirm diagnoses, contributing to prolonged waiting times. This study aimed to determine the relationship between commonly gathered triage data and the need for radiological imaging. Data were collected from electronic charts that contained routinely collected hospital data at the time of triage in the King Abdulaziz Medical City (KAMC) in Riyadh ED. The binary logistic regression results demonstrated a statistically significant relationship between age and radiological imaging ordered in the ED. Each one-unit increase in age corresponded to a 0.983-fold increase in the likelihood of ordering radiological imaging (odds ratio: 0.983, 95% confidence interval: 0.972-0.995, p = 0.004). In contrast, hypertension, diabetes, and heart failure were independent predictors of the need for radiological imaging in the ED (p >0.05). Patient data that are immediately available during ED triage can be used to predict the need for radiological imaging during ED visits. Such models can identify patients who may require radiological imaging during ED visits and expedite patient disposition.

Effect of the Extended Focused Assessment With Sonography for Trauma on the Screening Performance of the National Emergency X-Radiography Utilization Study Chest Decision Instrument

STUDY OBJECTIVE

Developed to decrease unnecessary thoracic computed tomography use in adult blunt trauma patients, the National Emergency X-Radiography Utilization Study (NEXUS) Chest clinical decision instrument does not include the extended Focused Assessment with Sonography in Trauma (eFAST). We assessed whether eFAST improves the NEXUS Chest clinical decision instrument's diagnostic performance and may replace the chest radiograph (CXR) as a predictor variable.

METHODS

We performed a secondary analysis of prospective data from 8 Level I trauma centers from 2011-2014. We compared performance of modified clinical decision instruments that (1) added eFAST as a predictor (eFAST-added clinical decision instrument), and (2) replaced CXR with eFAST (eFAST-replaced clinical decision instrument), in screening for blunt thoracic injuries.

RESULTS

One thousand nine hundred fifty-seven patients had documented computed tomography, CXR, clinical NEXUS criteria, and adequate eFAST; 624 (31.9%) patients had blunt thoracic injuries, and 126 (6.4%) had major injuries. Compared to the NEXUS Chest clinical decision instrument, the eFAST-added clinical decision instrument demonstrated unchanged screening performance for major injury (sensitivity 0.98 [0.94 to 1.00], specificity 0.28 [0.26 to 0.30]) or any injury (sensitivity 0.97 [0.95 to 0.98], specificity 0.21 [0.19 to 0.23]). The eFAST-replaced clinical decision instrument demonstrated unchanged sensitivity for major injury (sensitivity 0.93 [0.87 to 0.97], specificity 0.31 [0.29 to 0.34]) and decreased sensitivity for any injury (0.93 [0.91 to 0.951] versus 0.97 [0.953 to 0.98]).

CONCLUSION

In our secondary analysis, adding eFAST as a predictor variable did not improve the diagnostic screening performance of the original NEXUS Chest clinical decision instrument; eFAST cannot replace the CXR criterion of the NEXUS Chest clinical decision instrument.

Factors Contributing to Computed Tomography Trauma Scan Times at a Tertiary Center: Improving Emergency Department Trauma Imaging Workflow Through Targeted Interventions

PURPOSES

The aims of the study are to identify factors contributing to computed tomography (CT) trauma scan turnaround time variation and to evaluate the effects of an automated intervention on time metrics.

METHODS

Throughput metrics were captured via picture archiving and communication system from January 1, 2018, to December 16, 2019, and included 17,709 CT trauma scans from our institution. Initial data showed that imaging technologist variation played a significant role in trauma imaging turnaround time. In December 2019, we implemented a 2-pronged intervention: (1) educational intervention to techs and (2) modified trauma CT abdomen/pelvis to autogenerate and autosend reformats to picture archiving and communication system. A total of 13,169 trauma CT scans were evaluated from the postintervention period taking place from January 2020 to March 2021. Throughput metrics such as last image to first report interval and emergency department length of stay were captured and compared with performing technologist, time of day, and weekday versus weekend scans.

RESULTS

Substantial variability among trauma CT scans was observed. For CT trauma abdomen/pelvis, the interval from last image to initial report decreased from 26.4 to 24.0 minutes (P = 0.001) while the interval between first and last image time decreased from 11.4 to 4.2 minutes (P < 0.001). Emergency department length of stay also decreased from 3.9 to 3.7 hours (P < 0.0001) in the postintervention period. Variation among imaging technologist was statistically significant and became less significant after intervention (P = 0.09, P = 0.54).

CONCLUSIONS

Factors such as imaging technologist variability, time of day, and day of the week of trauma scans played a significant role in CT trauma turnaround time variability. Automation interventions can help with efficiency in image turnaround time.

Utilization of an Internal Medicine Triaging Resident in the Emergency Department Reduces Preventable Admissions and Improves Trainee Experiences

OBJECTIVE

Increasing patient care requirements and suboptimal communication between emergency department (ED) and Internal Medicine (IM) services may lead to inefficient hospital utilization, lapses in transitions of care, and reduced trainee satisfaction in the inpatient setting. Furthermore, a lack of triaging roles for IM trainees has been a common limitation in graduate medical education. We aimed to demonstrate that the addition of an IM triaging resident (TR) in the ED may represent an innovative solution to these problems.

METHODS

A single-center pilot study was performed. An IM trainee served as the TR at a tertiary Veterans Affairs hospital for 2 weeks. The TR evaluated medical patients in a parallel manner with ED physicians and assisted in the initial management, disposition, and transitions of care under the supervision of an IM attending physician. Hospital utilization and patient safety were tracked using electronic records, and trainee satisfaction was measured using daily surveys administered to IM resident teams.

RESULTS

Of the 62 cases evaluated by the TR for medical admission, 26 (42%) represented preventable admissions; 12 (46%) of those patients were discharged from the ED, representing a 19% overall reduction. There were statistically significant improvements in trainee experiences relating to patient flow (P < 0.01) and initial patient management (P < 0.02), and our intervention did not have a negative impact on ED performance metrics or patient safety.

CONCLUSIONS

Expansion of this model in select integrated health systems may improve graduate medical education and healthcare system performance. Future iterations of this study can aim to improve transitions of care between ambulatory and inpatient providers and limit the overuse of antimicrobial agents, radiography, and consultative services.

Interpretation of Emergency CT Scans of the Head in Trauma: Neurosurgeon vs Radiologist

BACKGROUND

Traumatic brain injury (TBI) is a major cause of mortality and morbidity across all ages in all countries. Management of the patient with TBI is time critical. Emergency computed tomography (CT) scans of the head are often assessed by neurosurgeons and patient management plans are implemented before the final radiological report is released in hospitals, particularly where there is a shortage of radiologists in LMIC. The aims of this study were to identify discrepancies in the interpretation of CT scans of the head in patients with isolated head injury between the neurosurgeon and radiologist and to assess if these differences impacted patient management.

METHODS

This 6-month long prospective observational study was performed at a tertiary hospital in South Africa. The study population comprised 347 patients with isolated head injury who had a CT scan of the head performed on admission. The neurosurgeons' initial CT scan interpretation and the final radiological report were compared.

RESULTS

Out of 347 CT head scans, the neurosurgeons correctly interpreted 318 cases. Of the 29 incorrectly interpreted cases, there were 17 false negatives and 12 cases with mismatching abnormalities. The concordance rate was 91.64% (95% CI 88.73-94.55) with a kappa of 0.78. An accuracy rate of 95.33% (95% CI 92.63-97.26) was achieved by the neurosurgeon. No patient was negatively impacted by any neurosurgical error in misinterpretation.

CONCLUSIONS

In the interpretation of CT head scans in trauma, there is good neurosurgical and radiological interobserver agreement without negative patient impact. The neurosurgeons' interpretation of CT scans of the head in TBI is safe especially when radiology reports are not timeously available.

Radiation risk issues in recurrent imaging

Millions of patients benefit from medical imaging every single day. However, we have entered an unprecedented era in imaging practices wherein 1 out of 125 patients can be exposed to effective dose >50 mSv from a single CT exam and 3 out of 10,000 patients undergoing CT exams could potentially receive cumulative effective doses > 100 mSv in a single day. Recurrent imaging with CT, fluoroscopically guided interventions, and hybrid imaging modalities such as positron emission tomography/computed tomography (PET/CT) is more prevalent today than ever before. Presently, we do not know the cumulative doses that patients may be receiving across all imaging modalities combined. Furthermore, patients with diseases with longer life expectancies are being exposed to high doses of radiation enabling radiation effects to manifest over a longer time period. The emphasis in the past on improving justification of imaging and optimization of technique and practice has proved useful. While that must continue, the current situation requires imaging device manufacturers to urgently develop imaging technologies that are safer for patients as high doses have been observed in patients where imaging has been justified through clinical decision-support and optimized by keeping doses below the national benchmark doses. There is a need to have a critical look at the fundamental principles of radiation protection as cumulative doses are likely to increase in the coming years.

Reducing time to X-ray in emergency department ambulatory patients: a quality improvement project

This quality improvement project began when physicians and nurses at our hospital observed patients waiting for excessive periods of time for a porter to escort patients from the emergency department (ED) to medical imaging (MI). However, certain patients may not need staff escort and are able to ambulate from ED to MI by themselves. This would reduce waiting time from when the X-ray is ordered to X-ray being done, which may reduce overall ED length of stay and improve patients’ experience.

Our project aim is to decrease the time to X-ray by 50% within 6 months by having appropriate ambulatory patients walk from the ED to the X-ray department without a porter. To achieve our goal, several strategies were employed. First, brainstorm sessions were held to better understand the barriers and ways to implement the new process. Second, a patient survey was conducted to understand their thoughts on the change idea. Third, data were collected to assess the inefficiency problem on the number of times non-porter staff escorted patients due to porters being unavailable. A total of 14 PDSA (Plan-Do-Study-Act) cycles were completed between December 2018 and May 2019. A human factor specialist was consulted to examine the process for safety and optimisation of the patient journey.

In our PDSA cycles, self-ambulatory patients were compared with ambulatory patients who required an escort. An improvement was found from time to X-ray of 28 min (11 min vs 39 min). The new self-ambulatory process was implemented in June 2019 on a daily basis.

Does shifting to professional emergency department staffing affect the decision for chest radiography?

BACKGROUND

The study aims to determine whether shifting to professional emergency department (ED) teams leads to a higher rate of radiologic workup.

METHODS

We retrospectively analyzed a total of 2,000 patients presenting to the ED of a tertiary teaching hospital in two time periods: group 1 (G1) comprised 1,000 consecutive patients enrolled from December 21, 2012 to January 5, 2013 (all patients were examined by an internal medicine specialist); group 2 (G2) comprised 1,000 consecutive patients enrolled from December 21, 2018 to January 3, 2019 (all patients were examined by an emergency physician).

RESULTS

The chest X-ray (CXR) was performed in 40.6% of all patients. There was no difference in the frequency of CXR (38.9% in G1 vs. 42.3% in G2, P=0.152). More CXRs were performed in G2 patients older than 65 years, in female patients older than 65 years, in patients presenting during the evening and night shifts or off-hours, in patients with a history of malignancy, in patients with gastrointestinal bleeding, and in patients with bradycardia, but fewer in patients presenting with arrhythmia. No difference in the rates of pathological CXR was found (47.3% in G1 vs. 52.2% in G2, P=0.186). Compared with G2, higher sensitivity and specificity were obtained for the binary logistic regression model predicting pathological findings in G1.

CONCLUSIONS

Shifting to professional ED teams does not increase radiologic workup. By implementing deliberate usage of ultrasound, some self-governing procedures, case-oriented investigations, and center-specific recommendations, unnecessary radiologic workup can be avoided. Professional ED teams could lead to a higher standard of emergency care.

Patient Race/Ethnicity and Diagnostic Imaging Utilization in the Emergency Department: A Systematic Review

PURPOSE

Diagnostic imaging often is a critical contributor to clinical decision making in the emergency department (ED). Racial and ethnic disparities are widely reported in many aspects of health care, and several recent studies have reported a link between patient race/ethnicity and receipt of imaging in the ED.

METHODS

The authors conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, searching three databases (PubMed, Embase, and the Cochrane Library) through July 2020 using keywords related to diagnostic imaging, race/ethnicity, and the ED setting, including both adult and pediatric populations and excluding studies that did not control for the important confounders of disease severity and insurance status.

RESULTS

The search strategy identified 7,313 articles, of which 5,668 underwent title and abstract screening and 238 full-text review, leaving 42 articles meeting the inclusion criteria. Studies were predominately conducted in the United States (41), split between adult (13) and pediatric (17) populations or both (12), and spread across a variety of topics, mostly focusing on specific anatomic regions or disease processes. Most studies (30 of 42 [71.4%]) reported an association between Black, African American, Hispanic, or nonwhite race/ethnicity and decreased receipt of imaging.

CONCLUSIONS

Despite heterogeneity among studies, patient race/ethnicity is linked with receipt of diagnostic imaging in the ED. The strength and directionality of this association may differ by specific subpopulation and disease process, and more efforts to understand potential underlying factors are needed.

The practice of emergency radiology throughout Europe: a survey from the European Society of Emergency Radiology on volume, staffing, equipment, and scheduling

OBJECTIVES

To obtain information from radiology departments throughout Europe regarding the practice of emergency radiology METHODS: A survey which comprised of 24 questions was developed and made available online. The questionnaire was sent to 1097 chairs of radiology departments throughout Europe using the ESR database. All data were collected and analyzed using IBM SPSS Statistics software, version 20 (IBM).

RESULTS

A total of 1097 radiologists were asked to participate, 109 responded to our survey. The response rate was 10%. From our survey, 71.6% of the hospitals had more than 500 beds. Ninety-eight percent of hospitals have an active teaching affiliation. In large trauma centers, emergency radiology was considered a dedicated section. Fifty-three percent of institutions have dedicated emergency radiology sections. Less than 30% had all imaging modalities available. Seventy-nine percent of institutions have 24/7 coverage by staff radiologists. Emergency radiologists interpret cross-sectional body imaging, US scans, and basic CT/MRI neuroimaging in more than 50% of responding institutions. Cardiac imaging examinations/procedures are usually performed by cardiologist in 53% of institutions, while non-cardiac vascular procedures are largely performed and interpreted by interventional radiologists. Most people consider the European Diploma in Emergency Radiology an essential tool to advance the education and the dissemination of information within the specialty of emergency radiology.

CONCLUSION

Emergency radiologists have an active role in the emergency medical team. Indeed, based upon our survey, they have to interact with emergency physicians and surgeons in the management of critically ill patients. A broad skillset from ultrasonography and basic neuroimaging is required.

KEY POINTS

• At most major trauma centers in Europe, emergency imaging is currently performed by all radiologists in specific units who are designated in the emergency department. • Radiologists in the emergency section at present have a broad skillset, which includes cross-sectional body imaging, ultrasonography, and basic neuroimaging of the brain and spine. • A dedicated curriculum that certifies a subspecialty in emergency radiology with a diploma offered by the European Society of Emergency Radiology demonstrates a great interest by the vast majority of the respondents.

Musculoskeletal Radiology Reports: Overlooked or Valuable?

The electronic medical record (EMR) can reveal preferences of clinicians regarding imaging services. We sought to evaluate viewing habits for reports and images of musculoskeletal (MSK) studies by ordering clinicians. We hypothesized that MSK reports are important to clinical management, especially for advanced imaging modalities. We tracked the image and report access of all MSK studies ordered in September 2016 over 8 months using logs of the EMR (Epic Systems, Verona, WI), and by an independent analysis of the institutional PACS (Picture Archiving and Communication Systems) (Carestream Health, Rochester, NY). The time stamps were extracted for when images and reports were viewed. We categorized MSK studies by modality and provider department. We also compared the rates of viewing reports and images among different modalities and departments using the chi-square test. Of the 8143 viewed MSK studies, 7842 (96.3%) reports (with/without images) and 3916 (48.1%) imaging data (with/without reports) were viewed. Viewing reports alone occurred in 4227 (51.9%) studies. CT and MRI reports alone views occurred more often in comparison to radiographs ([482/706; 68.3%] for CT and [981/1713; 57.3%] for MRI vs. [2764/5724; 48.3%] for radiography, p < 0.001). Orthopedists ordered the highest number of MSK studies and viewed reports 99.2% (3216/3242) of the time, including a 54.6% (1770/3242) rate of viewing reports alone and a 44.6% (1446/3242) rate of viewing both reports and images. They viewed images without reports in 0.8% (27/3242) of cases. MSK reports were viewed significantly more frequently than the images across all modalities and all relevant specialties.

Low-Value Back Imaging in the Care of Medicare Beneficiaries: A Comparison of Nurse Practitioners and Physician Assistants

Little is known about practice pattern differences between nurse practitioners (NPs) and physician assistants (PAs). We compared the rates of low-value back images ordered by NPs and PAs. For this comparison, we used 2012-2013 Medicare Part B claims for all beneficiaries in 18 hospital referral regions and a measure of low-value back imaging from the Choosing Wisely recommendations. Models included a random clinician effect and fixed effects for beneficiary age, disability, Elixhauser comorbidities, clinician type, the emergency department setting, and region. NPs (N = 234) order low-value back images significantly less than PAs (N = 204) (NPs 25.5% vs. PAs 39.2%, p < .0001). Controlling for relevant factors, NPs are 10.0 percentage points (p < .0001) less likely to order a low-value back image than PAs. NPs and PAs have distinct patterns of low-value back imaging, which is likely a reflection of their different practice settings.

Awareness of Risks Associated with the Use of Plain X-Ray, Computed Tomography, and Magnetic Resonance Imaging Among Emergency Physicians and Comparison with that of Other Physicians: A Survey from Turkey

BACKGROUND Increased use of radiological imaging in all departments of medicine, especially in the Emergency Department, requires that physicians have a high level of knowledge regarding commonly used imaging methods and high awareness of the risks of examinations. MATERIAL AND METHODS The physicians were divided into 5 groups according to their specialties as emergency medicine physicians (EMPs), physicians from any specialty of internal sciences, physicians from any specialty of surgical sciences, general practitioners (GPs), and radiologists. A total of 700 physicians answered the questionnaire via email. RESULTS 15.7% of EMPs reported that they did not routinely perform any risk assessment before requesting computed tomography (CT); the rate was 17.9% for direct radiography and 29.3% for magnetic resonance imaging (MRI). The proportions of physicians who do not routinely perform risk assessments for direct radiography, CT, and MRI were as follows: 16.4%, 8.6%, and 19.3% in physicians from medical sciences, respectively; 25%, 22.9%, and 35% in physicians from surgical sciences, respectively; 24.3%, 14.3%, and 37.1% in GPs, respectively; and 27.1%, 22.1% and 37.1% in radiologists, respectively. In all radiological examinations, 1.4% of EMPs and ≤1.4% of other physicians routinely explain the risks associated with the imaging method to the patients, and discuss the risks and benefits of the imaging with the patients. CONCLUSIONS All physicians, including EMPs, need to undergo urgent training to increase their knowledge on risks of imaging methods and discussion of existing risks with patients.

An impact analysis of the NEXUS Chest CT clinical decision rule

BACKGROUND

The NEXUS Chest CT clinical decision rules (CDRs) have been proposed to safely guide selective chest CT use in blunt trauma evaluation. We conducted a cost-effectiveness analysis of the NEXUS Chest CT CDR to determine its impact on missed injuries, cost, and radiation exposure.

METHODS

We constructed a decision model comparing two strategies: implementation of the NEXUS Chest CDR vs. usual care in the evaluation of adults with blunt trauma. We derived probabilities, clinical outcomes, effective radiation dose (ERD) from the NEXUS Chest CT validation cohort and costs from the Charge-master at the primary study site. Our primary outcomes were cost and effective radiation dose (ERD) per missed clinically significant injury (CSI).

RESULTS

Using a hypothetical cohort of 1000 adults with blunt chest trauma in each arm, the base case model projected that the implementation of the CDR would result in 161 fewer chest CTs, 0.08 additional missed CSIs, a cost savings of $136,432 and a decrease in 1435 mSv, as compared to Usual Care. To detect one additional CSI, the Usual Care strategy would require 2015 more chest CTs with a cost of $1.8 million and 17,934 mSv more radiation.

CONCLUSIONS

Compared to usual care, implementation of the NEXUS Chest CT Major CDR in the evaluation of adults with blunt trauma would greatly reduce CT associated costs and radiation exposure with a slight increased risk of missed CSIs.

Evaluation of a new goal-directed training curriculum for point-of-care ultrasound in the emergency department: impact on physician self-confidence and ultrasound skills

Purpose

Developing countries need effective and efficient training curriculum for the point-of-care ultrasound (POCUS) in the emergency department (ED). We have developed a new goal-directed training curriculum focusing on critical POCUS procedures used in ED.

Methods

To evaluate the impact of the new POCUS curriculum on ED physicians’ performance/self-confidence, we carried out a quasi-experimental trial at ED training center of Peking Union Medical College Hospital, in which we trained two groups of physicians using either traditional curriculum or the new goal-directed curriculum. We measured the confidence in performing Focused Assessment with Sonography in Trauma, thoracic, vascular, ultrasound-guided puncture, echocardiography and undifferentiated shock diagnostic ultrasound at baseline, training completion and 1 month after training. We also measured the performance skills at the time of training completion. The relative value of the new curriculum was evaluated by differences in the confidence and performance measurements, with control for baseline measurements and confounding characteristics in univariate analyses and multivariate linear regression models.

Results

After training, both groups of trainees reported significantly increased self-confidence in performing POCUS as compared with baseline. Trainees with the new curriculum had statistically significant higher self-confidence increase and performance scores (p < 0.05), e.g., increase in confidence for diagnosis of undifferentiated shock at training completion = 3.14 vs. 1.85, 1 month after training = 2.22 vs. 1.56, for new and traditional curriculum, respectively. The new curriculum also resulted in a higher number of shock POCUS done within 1 month after training: 1.73 vs. 0, and higher overall performance scores: 165 vs. 113. The findings were robust when controlling for imbalanced baseline characteristics in multivariate regression models.

Conclusion

We conclude that a goal-directed, intensive but brief ED POCUS curriculum significantly increases trainee self-confidence, performance, and promote trainees to perform more procedures.

Visceral artery aneurysms: evolving interdisciplinary management and future role of the abdominal surgeon

Background

Visceral artery aneurysms (VAA) are rare vascular lesions. Clinically silent VAA are increasingly detected by cross-sectional imaging but some lesions are at risk for rupture with severe bleeding. The aim of the present study was to evaluate the trends in the interdisciplinary management at a tertiary center.

Methods

Patients who underwent treatment for VAA at University Hospital of Bonn between 2005 and 2018 were enrolled in this retrospective study. Demographic, clinical, VAA-specific data as well as information on therapy, early and long-term outcome were collected and statistically analyzed.

Results

Forty-two consecutive patients, 19 females and 23 males with a median age of 59 years (range 30–91 years), were diagnosed with 56 VAA. The majority were true aneurysms (N = 32; 57%), whereas 43% (N = 24) were pseudoaneurysms. The most common localization was the splenic artery (N = 18; 32%) and the average diameter was 3 cm (range 1–5 cm). Twenty-five patients (59.5%) had VAA-related symptoms such as chronic abdominal pain and hemorrhage at primary diagnosis, while the diagnosis was incidental in 17 patients (40.5%). Eleven patients (26%) underwent open surgery whereas 29 patients (69%) received an endovascular treatment. Patients with pseudoaneurysms were significantly older (P = 0.003), suffered more often from associated symptoms (P < 0.001) and required more emergency interventions (P < 0.0001) compared to those with true VAA. In the last years, the number and proportion of true VAA increased significantly (P < 0.001) while a significantly larger proportion could be managed interventionally (P = 0.017).

Conclusions

VAA are increasingly detected on imaging with lesions presenting very heterogeneously. Due to the risk of lethal rupture and in the absence of reliable prognostic markers, all the patients with VAA should be offered definite treatment. Localization, anatomy and the end-organ perfusion after intervention or operation are the most important aspects to consider when planning a treatment for VAA. For this reason, a multidisciplinary evaluation of every individual patient is necessary for an optimized outcome.

Improving Emergency Department Flow: Reducing Turnaround Time for Emergent CT Scans

Emergency departments across the U.S. are more congested than ever, and there is a pressing need to create capacity by improving patient flow. The long turnaround time of imaging tests, such as computed tomography (CT) scans, are a major reason for delays in treatment and disposition. Over an eight-month pre-intervention period during which 10,063 CT scans were ordered in our emergency department, the average time from a CT order to the availability of the radiologist's final report was 5.9 hours (median=4.2 hours). We created a multi-disciplinary team of physicians, nurses, technicians, transporters, informaticians, and engineers to identify barriers and implement technical as well as human-factors solutions. In the corresponding eight-month period after the implementation of the intervention bundle, there was a 1.2 hour reduction in CT turnaround time, despite a 13.8% increase in the number of CT scans ordered (p<0.0001).

Reduced Computed Tomography Use in the Emergency Department Evaluation of Headache Was Not Followed by Increased Death or Missed Diagnosis

Introduction

This study investigated whether a 9.6% decrease in the use of head computed tomography (HCT) for patients presenting to the emergency department (ED) with a chief complaint of headache was followed by an increase in proportions of death or missed intracranial diagnosis during the 22.5-month period following each index ED visit.

Methods

We reviewed the electronic medical records of all patients sampled during a quality improvement effort in which the aforementioned decrease in HCT use had been observed. We reviewed notes from the ED, neurology, neurosurgery, and primary care services, as well as all brain imaging results to determine if death occurred or if an intracranial condition was discovered in the 22.5 months after each index ED visit. An independent, blinded reviewer reviewed each case where an intracranial condition was diagnosed after ED discharge to determine whether the condition was reasonably likely to have been related to the index ED visit’s presentation, thereby representing a missed diagnosis.

Results

Of the 582 separate index ED visits sampled, we observed a total of nine deaths and 10 missed intracranial diagnoses. There was no difference in the proportion of death (p = 0.337) or missed intracranial diagnosis (p = 0.312) observed after a 9.6% reduction in HCT use. Among patients who subsequently had visits for headache or brain imaging, we found that these patients were significantly more likely to have not had a HCT done during the index ED visit (59.2% vs. 49.6% (p = 0.031) and 37.1% vs. 26% (p = 0.006), respectively).

Conclusion

Our study adds to the compelling evidence that there is opportunity to safely decrease CT imaging for ED patients. To determine the cost effectiveness of such reductions further research is needed to measure what patients and their healthcare providers do after discharge from the ED when unnecessary testing is withheld.

Impact on patient management of the implementation of a magnetic resonance imaging dedicated to neurological emergencies

RATIONALE, AIMS AND OBJECTIVES

Neurological emergencies consumed a high amount of resources in emergency department (ED). We aimed to study the effect of the implementation of a magnetic resonance imaging (MRI) dedicated to emergencies on the management of patients admitted in ED for neurological emergencies.

METHODS

We enrolled consecutive patients who underwent computed tomography and/or MRI for neurological disorders categorized as the suspicion of stroke and other reasons, over 2 periods that differed according to the priority access to computed tomography in the first period versus priority access to MRI in the second one. Criteria used to evaluate the effectiveness of the management were door-to-imaging time, ED length of stay, diagnostic performance, patient orientation, and length of hospitalization stay.

RESULTS

When priority access to MRI, the door-to-imaging time was 31 minutes longer (P = .005) for patients suspected of stroke or transient ischaemic attack (TIA) and 70 minutes for the others (P < .001). The ED length of stay was 42 minutes shorter (P = .013) for stroke/TIA patients and 26 minutes longer (P = .029) for other patients. The proportion of patients with stroke mimics (no stroke amongst suspected stroke/TIA) increased (16.7% vs 25.6%, P = .017) as well as discharged patients (21.6% vs 29.6%, P = .002). The proportion of patients with stroke/TIA amongst other reasons of admission remained unchanged (P = .114). The median length of hospitalization stay decreased from 9 to 7 days for the stroke/TIA patients (P = .042).

CONCLUSIONS

The implementation of a MRI optimized the quality of care and diagnostic accuracy for patients admitted in ED with a better identification of stroke mimics, avoiding unnecessarily hospitalizations. The management of stroke-TIA patients was not modified, but their length of hospital stay reduced.

Improving Emergency Department radiology transportation time: a successful implementation of lean methodology

Background

Emergency Department overcrowding has become a global problem and a growing safety and quality concern. Radiology and laboratory turnaround time, ED boarding and increased ED visits are some of the factors that contribute to ED overcrowding. Lean methods have been used in the ED to address multiple flow challenges from improving door-to-doctor time to reducing length of stay. The objective of this study is to determine the effectiveness of using Lean management methods on improving Emergency Department transportation times for plain radiography.

Methods

We performed a before and after study at an academic urban Emergency Department with 49,000 annual visits after implementing a Lean driven intervention. The primary outcome was mean radiology transportation turnaround time (TAT). Secondary outcomes included overall study turnaround time from order processing to preliminary report time as well as ED length of stay. All ED patients undergoing plain radiography 6 months pre-intervention were compared to all ED patients undergoing plain radiography 6 months post-intervention after a 1 month washout period.

Results

Post intervention there was a statistically significant decrease in the mean transportation TAT (mean ± SD: 9.87 min ± 15.05 versus 22.89 min ± 22.05, respectively, p-value <0.0001). In addition, it was found that 71.6% of patients in the post-intervention had transportation TAT ≤ 10 min, as compared to 32.3% in the pre-intervention period, p-value <0.0001, with narrower interquartile ranges in the post-intervention period. Similarly, the “study processing to preliminary report time” and the length of stay were lower in the post-intervention as compared to the pre-intervention, (52.50 min ± 35.43 versus 54.04 min ± 34.72, p-value = 0.02 and 3.65 h ± 5.17 versus 4.57 h ± 10.43, p < 0.0001, respectively), in spite of an increase in the time it took to elease a preliminary report in the post-intervention period.

Conclusion

Using Lean change management techniques can be effective in reducing transportation time to plain radiography in the Emergency Department as well as improving process reliability.

Effect of spinal immobilisation devices on radiation exposure in conventional radiography and computed tomography

Trauma patients at risk for, or suspected of, spinal injury are frequently transported to hospital using full spinal immobilisation. At the emergency department, immobilisation is often maintained until radiological work-up is completed. In this study, we examined how these devices influence radiation exposure and noise, as a proxy for objective image quality. Conventional radiographs (CR) and computer tomography (CT) scans were made using a phantom immobilised on two types of spineboard and a vacuum mattress and using two types of headblocks. Images were compared for radiation transmission and quantitative image noise. In CR, up to 23 % and, in CT, up to 11 % of radiation were blocked by the devices. Without compensation for the decreased transmission, noise increased by up to 16 % in CT, depending on the device used. Removing the headblocks led to a statistically significant improvement in transmission with automatic exposure control (AEC) enabled. Physicians should make an informed decision whether the increased radiation exposure outweighs the risk of missing a clinically significant injury by not making a CR or CT scan. Manufacturers of immobilisation devices should take radiological properties of their devices into account in the development and production process.

Research Challenges and Opportunities for Clinically Oriented Academic Radiology Departments

Between 2004 and 2012, US funding for the biomedical sciences decreased to historic lows. Health-related research was crippled by receiving only 1/20th of overall federal scientific funding. Despite the current funding climate, there is increased pressure on academic radiology programs to establish productive research programs. Whereas larger programs have resources that can be utilized at their institutions, small to medium-sized programs often struggle with lack of infrastructure and support. To address these concerns, the Association of University Radiologists' Radiology Research Alliance developed a task force to explore any untapped research productivity potential in these smaller radiology departments. We conducted an online survey of faculty at smaller clinically funded programs and found that while they were interested in doing research and felt it was important to the success of the field, barriers such as lack of resources and time were proving difficult to overcome. One potential solution proposed by this task force is a collaborative structured research model in which multiple participants from multiple institutions come together in well-defined roles that allow for an equitable distribution of research tasks and pooling of resources and expertise. Under this model, smaller programs will have an opportunity to share their unique perspective on how to address research topics and make a measureable impact on the field of radiology as a whole. Through a health services focus, projects are more likely to succeed in the context of limited funding and infrastructure while simultaneously providing value to the field.

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 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 use 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 before 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 the planning and to participate in the consensus conference to generate a multidisciplinary agenda. There were a total of 164 individuals involved in the conference and spanned various specialties, including general emergency medicine, pediatric emergency medicine, radiology, surgery, medical physics, and the decision sciences.

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.