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Orso D, Furlanis G, Romanelli A, Gheller F, Tecchiolli M, Cominotto F. Risk Factors Analysis for 90-Day Mortality of Adult Patients with Mild Traumatic Brain Injury in an Italian Emergency Department. Geriatrics (Basel) 2024; 9:23. [PMID: 38525740 PMCID: PMC10961819 DOI: 10.3390/geriatrics9020023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 02/16/2024] [Accepted: 02/21/2024] [Indexed: 03/26/2024] Open
Abstract
Purpose: The most prominent risk factors for mortality after mild traumatic brain injury (TBI) have not been established. This study aimed to establish risk factors related to 90-day mortality after a traumatic event. Methods: A retrospective cohort study on adult patients entering the Emergency Department of the University Hospital of Trieste for mild TBI from 1 January 2020 to 31 December 2020 was conducted. Results: The final population was 1221 patients (median age of 78 years). The 90-day mortality rate was 7% (90 patients). In the Cox regression model (likelihood ratio 110.9; p < 2 × 10-16), the variables that significantly correlated to 90-day mortality were age (less than 75 years old is a protective factor, HR 0.29 [95%CI 0.16-0.54]; p < 0.001); chronic liver disease (HR 4.59 [95%CI 2.56-8.24], p < 0.001); cognitive impairment (HR 2.76 [95%CI 1.78-4.27], p < 0.001); intracerebral haemorrhage (HR 15.38 [95%CI 6.13-38.63], p < 0.001); and hospitalization (HR 2.56 [95%CI 1.67-3.92], p < 0.001). Cardiovascular disease (47% vs. 11%; p < 0.001) and cognitive impairment (36% vs. 10%; p < 0.001) were more prevalent in patients over 75 years of age than the rest of the population. Conclusions: In our cohort of patients with mild TBI, 90-day mortality was low but not negligible. The risk factors associated with 90-day mortality included age, history of chronic liver disease, and cognitive impairment, as well as evidence of intracerebral hemorrhage and hospitalization. The mortality of the sub-population of older patients was likely to be linked to cardiovascular comorbidities and neurodegenerative diseases.
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Affiliation(s)
- Daniele Orso
- Department of Anesthesia and Intensive Care, ASUFC University Hospital of Udine, Via Pozzuolo 330, 33100 Udine, Italy
| | - Giulia Furlanis
- Department of Emergency Medicine, ASUGI University Hospital of Trieste, 34100 Trieste, Italy; (G.F.); (F.C.)
| | - Alice Romanelli
- Department of Emergency Medicine, ASUGI University Hospital of Trieste, 34100 Trieste, Italy; (G.F.); (F.C.)
| | - Federica Gheller
- Department of Emergency Medicine, ASUGI University Hospital of Trieste, 34100 Trieste, Italy; (G.F.); (F.C.)
| | - Marzia Tecchiolli
- Department of Emergency Medicine, ASUGI University Hospital of Trieste, 34100 Trieste, Italy; (G.F.); (F.C.)
| | - Franco Cominotto
- Department of Emergency Medicine, ASUGI University Hospital of Trieste, 34100 Trieste, Italy; (G.F.); (F.C.)
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Knox JA, Kumar V, Conrad MB, Nanavati S, Moore T, Wilson M. Synergy in IR-Hybrid CT/C-arm in the setting of critical trauma. Emerg Radiol 2022; 29:605-609. [PMID: 35106683 PMCID: PMC9123063 DOI: 10.1007/s10140-022-02015-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/03/2022] [Indexed: 11/24/2022]
Abstract
Access to multi-detector computed tomography (MDCT) scanning for interventional procedures can prove to be logistically challenging as resources are often in different areas within the hospital. At some institutions, interventional radiology suites have moved to the operating room, separate from the diagnostic radiology department. At these institutions, complex interventional procedures requiring both fluoroscopy and MDCT may pose logistical challenges, especially as they pertain to timely patient transfers. Hybrid CT/fluoroscopy suite provides rapid, reliable MDCT assessment of trauma patients before and after emergent surgery, as well as access to the entire spectrum of emergent image-guided interventions in the same suite.
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Affiliation(s)
- Joseph A Knox
- San Francisco Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, 94110, USA
| | - Vishal Kumar
- San Francisco Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, 94110, USA. .,San Francisco General Hospital, San Francisco, CA, 94001, USA.
| | - Miles B Conrad
- San Francisco Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, 94110, USA.,San Francisco General Hospital, San Francisco, CA, 94001, USA
| | - Sujal Nanavati
- San Francisco Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, 94110, USA.,San Francisco General Hospital, San Francisco, CA, 94001, USA
| | - Teri Moore
- San Francisco General Hospital, San Francisco, CA, 94001, USA
| | - Mark Wilson
- San Francisco Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, 94110, USA.,San Francisco General Hospital, San Francisco, CA, 94001, USA
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3
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Hocking KC, Wright CR, Alhun U, Hughes F, Balian VJ, Kabuli MAK, Tse G, McGonnell M, Chopra A, Kotnis N, Connelly D, Alabed S. Acute haemorrhage rate in 28,000 Out-of-Hours CT heads. Br J Radiol 2022; 95:20210580. [PMID: 34928168 PMCID: PMC8822576 DOI: 10.1259/bjr.20210580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVES The aim of this paper is to assess the acute haemorrhage rate in patients who had CT head investigation out-of-hours with and without trauma and compare the rates of haemorrhage between warfarin and DOACs, at a busy teritary teaching hospital. METHODS All CT heads performed between January 2008 and December 2019 were identified from the radiology information system (RIS) at Sheffield Teaching Hospitals (STH), with the requesting information being available from January 2015. The clinical information was assessed for the mention of trauma or anticoagulation, and the reports were categorised into acute and non-acute findings. RESULTS Between 2008 and 2019 the number of scans increased by 63%, with scans performed out of hours increasing by 278%. Between 2015 and 2019, the incidence of acute ICH was similar over the 5-year period, averaging at 6.9% and ranging from 6.1 to 7.6%. The rate of detection of acute haemorrhage following trauma was greater in those not anticoagulated (6.8%), compared with patients on anticoagulants such as warfarin (5.2%) or DOACs (2.8%). CONCLUSIONS Over 12 years, there has been a significant increase in the number of CT heads performed at STH. The rate of ICH has remained steady over the last 5 years indicating a justified increase in imaging demand. However, the incidence of ICH in patients prescribed DOACs is lower than the general population and those on warfarin. ADVANCES IN KNOWLEDGE This finding in a large centre should prompt discussion of the risk of bleeding with DOACs in relation to CT head imaging guidelines.
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Affiliation(s)
| | | | - Utku Alhun
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Frances Hughes
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Vartan J Balian
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - George Tse
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Maria McGonnell
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Annu Chopra
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Nikhil Kotnis
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Daniel Connelly
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Samer Alabed
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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4
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Ha NT, Abdullah L, Bulsara M, Celenza A, Doust J, Fatovich D, McRobbie D, Mountain D, O’Leary P, Slavotinek J, Wright C, Youens D, Moorin R. The use of computed tomography in the management of injury in tertiary emergency departments in Western Australia: Evidence of overtesting? Acad Emerg Med 2022; 29:193-205. [PMID: 34480498 DOI: 10.1111/acem.14385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/29/2021] [Accepted: 09/01/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study investigated trends in computed tomography (CT) utilization across different triage categories of injury presentations to tertiary emergency departments (EDs) and associations with diagnostic yield measured by injury severity, hospitalization and length of stay (LOS), and mortality. METHODS A total of 411,155 injury-related ED presentations extracted from linked records from Western Australia from 2004 to 2015 were included in the retrospective study. The use of CT scanning and diagnostic yield measured by rate of diagnosis with severe injury, hospitalizations and LOS, and mortality were captured annually for injury-related ED presentations. Multivariable regression models were used to calculate the annual adjusted rate of CT scanning for injury presentations and hospitalizations across triage categories, diagnosis with severe injury, LOS, and mortality. The significance of changes observed was compared among patients with CT imaging relative to those without CT. RESULTS While the number of ED presentations with injury increased by 65% from 2004 to 2015, the use of CT scanning in these presentations increased by 176%. The largest increase in CT use was among ED presentations triaged as semi-/nonurgent (+256%). Injury presentations with CT, compared to those without, had a higher rate of diagnosis with moderate/severe injury and hospitalization but no difference in LOS and mortality. The probability/rate observed in the outcomes of interest had a greater decrease over time in those with CT scanning compared with those without CT scanning across triage categories. CONCLUSIONS The reduction in diagnostic yield in terms of injury severity and hospitalization found in our study might indicate a shift toward overtesting using CT in ED for injury or a higher use of CT to assist in the management of injuries. This helps health care policymakers consider whether the current increase in CT use meets the desired levels of quality and efficient care.
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Affiliation(s)
- Ninh T. Ha
- Health Economics and Data Analytics Curtin School of Population Health Faculty of Health Sciences Curtin University Perth Western Australia Australia
| | - Lana Abdullah
- Health Economics and Data Analytics Curtin School of Population Health Faculty of Health Sciences Curtin University Perth Western Australia Australia
| | - Max Bulsara
- Institute for Health Research University of Notre Dame Fremantle Western Australia Australia
- Centre for Health Services Research School of Population and Global Health The University of Western Australia Perth Western Australia Australia
| | - Antonio Celenza
- Department of Emergency Medicine Sir Charles Gairdner Hospital Nedlands Western Australia Australia
- Division of Emergency Medicine Medical School University of Western Australia Perth Western Australia Australia
| | - Jenny Doust
- Centre for Longitudinal and Life Course Research Faculty of Medicine University of Queensland Brisbane Queensland Australia
| | - Daniel Fatovich
- Division of Emergency Medicine Medical School University of Western Australia Perth Western Australia Australia
- Emergency Department Royal Perth Hospital Perth Western Australia Australia
- Centre for Clinical Research in Emergency Medicine Harry Perkins Institute of Medical Research Perth Western Australia Australia
| | - Donald McRobbie
- School of Physical Sciences University of Adelaide Adelaide South Australia Australia
| | - David Mountain
- Department of Emergency Medicine Sir Charles Gairdner Hospital Nedlands Western Australia Australia
- Division of Emergency Medicine Medical School University of Western Australia Perth Western Australia Australia
- Curtin University Medical School Faculty of Health Sciences Curtin University Perth Western Australia Australia
| | - Peter O’Leary
- Health Economics and Data Analytics Curtin School of Population Health Faculty of Health Sciences Curtin University Perth Western Australia Australia
- Obstetrics and Gynaecology Medical School Faculty of Health and Medical Sciences The University of Western Australia Perth Western Australia Australia
- PathWest Laboratory Medicine QE2 Medical Centre Nedlands Western Australia Australia
| | - John Slavotinek
- SA Medical Imaging SA Health and College of Medicine and Public Health Flinders University Adelaide South Australia Australia
| | - Cameron Wright
- Health Economics and Data Analytics Curtin School of Population Health Faculty of Health Sciences Curtin University Perth Western Australia Australia
- Fiona Stanley Hospital Murdoch Western Australia Australia
- Division of Internal Medicine Medical School Faculty of Health and Medical Sciences University of Western Australia Perth Western Australia Australia
- School of Medicine College of Health and Medicine University of Tasmania Hobart Tasmania Australia
| | - David Youens
- Health Economics and Data Analytics Curtin School of Population Health Faculty of Health Sciences Curtin University Perth Western Australia Australia
| | - Rachael Moorin
- Health Economics and Data Analytics Curtin School of Population Health Faculty of Health Sciences Curtin University Perth Western Australia Australia
- Centre for Health Services Research School of Population and Global Health The University of Western Australia Perth Western Australia Australia
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5
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Screening performance of the chest X-ray in adult blunt trauma evaluation: Is it effective and what does it miss? Am J Emerg Med 2021; 49:310-314. [PMID: 34182276 DOI: 10.1016/j.ajem.2021.06.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 05/14/2021] [Accepted: 06/08/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Although chest x-ray (CXR) is often used as a screening tool for thoracic injury in adult blunt trauma assessment, its screening performance is unclear. Using chest CT as the referent standard, we sought to determine the screening performance of CXR for injury. METHODS We analyzed data from the NEXUS Chest CT study, in which we prospectively enrolled blunt trauma patients older than 14 years who received chest imaging as part of their evaluation at nine level I trauma centers. For this analysis, we included patients who had both CXR and chest CT. We used CT as the referent standard and categorized injuries as clinically major or minor according to an a priori expert panel classification. RESULTS Of 11,477 patients enrolled, 4501 had both CXR and chest CT; 1496 (33.2%) were found to have injury, of which 256 (17%) were classified as major injury. CXR missed injuries in 818 patients (54.7%), of which 63 (7.7%) were classified as major injuries. For injuries of major clinical significance, CXR had a sensitivity of 75.4% (95% confidence interval [CI] 69.6-80.4%), specificity of 86.2% (95% CI 85.1-87.2%), negative predictive value of 98.3 (95%CI 97.9-98.6%), and positive predictive value of 24.7 (95%CI 22.9-26.7%). For any injury CXR had a sensitivity of 45.3% (95% CI 42.8-47.9%), specificity of 96.6% (95% CI 95.9-97.2%), negative predictive value of 78% (95% CI 77.2-78.8%), and positive predictive value of 86.9% (95% CI 84.5-89.0%). The most common missed major injuries were pneumothorax (30/185; 16.2%), spinal fractures (19/39; 48.7%), and hemothorax (8/70; 11.4%). The most common missed minor injuries were rib fractures (381/836; 45.6%), pulmonary contusion (203/462; 43.9%), and sternal fractures (153/229; 66.8%). CONCLUSIONS When used alone, without other trauma screening criteria, CXR has poor screening performance for blunt thoracic injury.
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Kornblith AE, Graf J, Addo N, Newton C, Callcut R, Grupp‐Phelan J, Jaffe DM. The Utility of Focused Assessment With Sonography for Trauma Enhanced Physical Examination in Children With Blunt Torso Trauma. Acad Emerg Med 2020; 27:866-875. [PMID: 32159909 DOI: 10.1111/acem.13959] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 02/02/2020] [Accepted: 03/10/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Computed tomography (CT), the reference standard for diagnosis of intraabdominal injury (IAI), carries risk including ionizing radiation. CT-sparing clinical decision rules for children have relied heavily on physical examination, but they did not include focused assessment with sonography for trauma (FAST), which has emerged into widespread use during the past decade. We sought to determine the independent associations of physical examination, laboratory studies, and FAST with identification of IAI in children and to compare the test characteristics of these diagnostic variables. We hypothesized that FAST may add incremental utility to a physical examination alone to more accurately identify children who could forgo CT scan. METHODS We reviewed a large trauma database of all children with blunt torso trauma presenting to a freestanding pediatric emergency department during a 20-month period. We used logistic regression to evaluate the association of FAST, physical examination, and selected laboratory data with IAI in children, and we compared the test characteristics of these variables. RESULTS Among 354 children, 50 (14%) had IAI. Positive FAST (odds ratio [OR] = 14.8, 95% confidence interval [CI] = 7.5 to 30.8) and positive physical examination (OR = 15.2, 95% CI = 7.7 to 31.7) were identified as independent predictors for IAI. Physical examination and FAST each had sensitivities of 74% (95% CI = 60% to 85%). Combining FAST and physical examination as FAST-enhanced physical examination (exFAST) improved sensitivity and negative predictive value (NPV) over either test alone (sensitivity = 88%, 95% CI = 76% to 96%) and NPV of 97.3% (95% CI = 94.5% to 98.7%). CONCLUSIONS In children, FAST and physical examinations each predicted the identification of IAI. However, the combination of the two (exFAST) had greater sensitivity and NPV than either physical examination or FAST alone. This supports the use of exFAST in refining clinical predication rules in children with blunt torso trauma.
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Affiliation(s)
- Aaron E. Kornblith
- From the Department of Emergency Medicine and PediatricsUniversity of California San Francisco CA
| | | | - Newton Addo
- the Department of Emergency MedicineUniversity of California San Francisco CA
| | | | - Rachael Callcut
- and the Department of Surgery University of California San Francisco CA
| | - Jacqueline Grupp‐Phelan
- From the Department of Emergency Medicine and PediatricsUniversity of California San Francisco CA
| | - David M. Jaffe
- the Department of Emergency MedicineUniversity of California San Francisco CA
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7
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Lai WA, Liu PH, Tsai MJ, Huang YC. Frequency, Recognition, and Potential Risk Factors of Incidental Findings on Trauma Computed Tomography Scans: A Cross-Sectional Study at an Urban Level One Trauma Center. J Acute Med 2020; 10:106-114. [PMID: 33209569 DOI: 10.6705/j.jacme.202009_10(3).0002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Background Computed tomography (CT) use in injured patients has continuously increased in the past decades. We designed and undertook this study to evaluate the frequency, and potential risks of incidental findings (IFs), and how they were processed in trauma patients receiving CT scans. Methods We retrospectively reviewed CT scans, official CT reports, and basic demographics in trauma patients who received CT scans at our emergency department in 2016. Scans with IFs prompted a detailed review of medical records to determine clinical significance and how they were processed. IFs were classified into three categories: category I (potentially severe condition, in-time management required), category II (not urgent, follow-up needed), and category III (of minor concern). Multivariable logistic regression models were fitted to determine patient characteristics associated with IFs. Results In the 4,092 scans enrolled, IFs were identified in 649 (15.9%). There were 13 (2.0%) category I, 306 (47.2%) category II, and 330 (50.8%) category III IFs. Patients with IFs were older than those without. No sex-based difference was found. Most (61.5%) of the scans were performed for the head; however, the abdomen had the highest IF prevalence (26.2%). Documentation about IFs was poor; 31% of category I, 91.9% of category II, and 97.0% of category III have no related record. Old age remains the risk predicting the presence of IFs, and every year of increasing age was independently associated with a higher prevalence of IFs (OR: 1.019; 95% CI: 1.015-1.024). Conclusions IFs are common in trauma CT scans; however, recognition and management remain poor. Abdomen and chest scans, and CT in older patients should remind us of increasing risks of IFs.
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Affiliation(s)
- Wei-An Lai
- Ditmanson Medical Foundation Chia-Yi Christian Hospital Department of Emergency Medicine Chiayi City Taiwan
| | - Pang-Hsu Liu
- Ditmanson Medical Foundation Chia-Yi Christian Hospital Department of Emergency Medicine Chiayi City Taiwan
| | - Ming-Jen Tsai
- Ditmanson Medical Foundation Chia-Yi Christian Hospital Department of Emergency Medicine Chiayi City Taiwan
| | - Ying Chieh Huang
- Ditmanson Medical Foundation Chia-Yi Christian Hospital Department of Emergency Medicine Chiayi City Taiwan.,Kaohsiung Medical University Department of Emergency Medicine, Medical Center and School of Medicine Kaohsiung Taiwan
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Pines JM, Zocchi MS, De Maio VJ, Carlson JN, Bedolla J, Venkat A. The Effect of Operational Stressors on Emergency Department Clinician Scheduling and Patient Throughput. Ann Emerg Med 2020; 76:646-658. [PMID: 32331842 DOI: 10.1016/j.annemergmed.2020.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 01/15/2020] [Accepted: 02/04/2020] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVE We assess the effect of emergency department (ED) operational stressors on clinician scheduling and throughput. METHODS We evaluated 2014 to 2018 data from a national ED group. Operational stressors included measures of workload, patient acuity, and complexity. We used multilevel linear regression to estimate the effect of operational stressors, temporal factors, and facility characteristics on ED clinician scheduling; patient throughput, measured as shift-level patient departures per corrected clinician hour; and length of stay. RESULTS In greater than 14 million ED visits across 359 facility-years, the mean of patient departures per corrected clinician hour was 2.23 (95% confidence interval [CI] 2.15 to 2.31). Temporal and facility effects had the greatest influence on patient departures per hour (eg, -0.55 [95% CI -0.75 to -0.36] in 7 am to 3 pm shifts versus midnight to 7 am on Mondays, 0.25 [95% CI 0.03 to 0.47]) in teaching versus nonteaching hospitals, and 0.43 (95% CI 0.24 to 0.61) in larger EDs (30,000 to 59,999 ED visits/year) versus smaller EDs. Operational stressors had significant but small effects on patient departures per hour (eg, length of stay [per-minute increase] 0.002 [95% CI 0.0019 to 0.0023] and percentage admitted [per 1% increase] -0.003 [95% CI -0.004 to -0.001]). Weekday nights, particularly Mondays, had the highest proportion of shifts with increasing length of stay compared with previous years in the same ED. CONCLUSION ED operational stressors had minimal influence on patient throughput when included in adjusted ED clinician scheduling models, whereas temporal and facility factors were more influential. Therefore, incorporating operational stressors into ED clinician scheduling is less likely to balance workloads than accounting for temporal and facility-level factors alone. Length of stay on some shifts, particularly Monday nights, became increasingly long, suggesting they require additional resources.
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Affiliation(s)
- Jesse M Pines
- US Acute Care Solutions, Canton, OH; Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, PA
| | - Mark S Zocchi
- Heller School for Social Policy and Management, Brandeis University, Waltham, MA
| | - Valerie J De Maio
- US Acute Care Solutions, Canton, OH; Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC
| | - Jestin N Carlson
- US Acute Care Solutions, Canton, OH; Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, PA
| | - John Bedolla
- US Acute Care Solutions, Canton, OH; Dell Medical School, University of Texas, Austin, TX
| | - Arvind Venkat
- US Acute Care Solutions, Canton, OH; Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, PA.
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Callen AL, Chow DS, Chen YA, Richelle HR, Pao J, Bardis M, Weinberg BD, Hess CP, Sugrue LP. Predictive Value of Noncontrast Head CT with Negative Findings in the Emergency Department Setting. AJNR Am J Neuroradiol 2020; 41:213-218. [PMID: 31974080 DOI: 10.3174/ajnr.a6408] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 12/06/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE Noncontrast head CTs are routinely acquired for patients with neurologic symptoms in the emergency department setting. Anecdotally, noncontrast head CTs performed in patients with prior negative findings with the same clinical indication are of low diagnostic yield. We hypothesized that the rate of acute findings in noncontrast head CTs performed in patients with a preceding study with negative findings would be lower compared with patients being imaged for the first time. MATERIALS AND METHODS We retrospectively evaluated patients in the emergency department setting who underwent noncontrast head CTs at our institution during a 4-year period, recording whether the patient had undergone a prior noncontrast head CT, the clinical indication for the examination, and the examination outcome. Positive findings on examinations were defined as those that showed any intracranial abnormality that would necessitate a change in acute management, such as acute hemorrhage, hydrocephalus, herniation, or interval worsening of a prior finding. RESULTS During the study period, 8160 patients in the emergency department setting underwent a total of 9593 noncontrast head CTs; 88.2% (7198/8160) had a single examination, and 11.8% (962/8160) had at least 1 repeat examination. The baseline positive rate of the "nonrepeat" group was 4.3% (308/7198). The 911 patients in the "repeat" group with negative findings on a baseline/first CT had a total of 1359 repeat noncontrast head CTs during the study period. The rate of positive findings for these repeat examinations was 1.8% (25/1359), significantly lower than the 4.3% baseline rate (P < .001). Of the repeat examinations that had positive findings, 80% (20/25) had a study indication that was discordant with that of the prior examination, compared with only 44% (593/1334) of the repeat examinations that had negative findings (P < .001). CONCLUSIONS In a retrospective observational study based on approximately 10,000 examinations, we found that serial noncontrast head CT examinations in patients with prior negative findings with the same study indication are less likely to have positive findings compared with first-time examinations or examinations with a new indication. This finding suggests a negative predictive value of a prior noncontrast head CT examination with negative findings with the same clinical indication.
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Affiliation(s)
- A L Callen
- From the Neuroradiology Section (A.L.C., C.P.H., L.P.S.), Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - D S Chow
- Neuroradiology Section (D.S.C., H.R.R., J.P., M.B.), Department of Radiology, University of California, Irvine, Irvine, California
| | - Y A Chen
- Trillium Health Partners (Y.A.C.), University of Toronto, Toronto, Ontario, Canada
| | - H R Richelle
- Neuroradiology Section (D.S.C., H.R.R., J.P., M.B.), Department of Radiology, University of California, Irvine, Irvine, California
| | - J Pao
- Neuroradiology Section (D.S.C., H.R.R., J.P., M.B.), Department of Radiology, University of California, Irvine, Irvine, California
| | - M Bardis
- Neuroradiology Section (D.S.C., H.R.R., J.P., M.B.), Department of Radiology, University of California, Irvine, Irvine, California
| | - B D Weinberg
- Radiology and Imaging Sciences (B.D.W.), Emory University, Atlanta, Georgia
| | - C P Hess
- From the Neuroradiology Section (A.L.C., C.P.H., L.P.S.), Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - L P Sugrue
- From the Neuroradiology Section (A.L.C., C.P.H., L.P.S.), Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
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10
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Kline JA, Garrett JS, Sarmiento EJ, Strachan CC, Courtney DM. Over-Testing for Suspected Pulmonary Embolism in American Emergency Departments: The Continuing Epidemic. Circ Cardiovasc Qual Outcomes 2020; 13:e005753. [PMID: 31957477 DOI: 10.1161/circoutcomes.119.005753] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND No recent data have investigated rates of diagnostic testing for pulmonary embolism (PE) in US emergency departments (EDs), and no data have examined computed tomographic pulmonary angiography (CTPA) rates in subgroups at high risk for adverse imaging outcomes, including young women and children. We hypothesized that over-testing for PE remains a problem. METHODS AND RESULTS We used electronic health record and billing data for 16 EDs in Indiana and 11 hospitals in the Dallas-Fort Worth area from 2016 to 2019 to locate ED patients who had any of the following: D-dimer, CTPA, scintillation ventilation perfusion lung scanning or formal pulmonary angiography. The primary outcomes were ED encounter volume-adjusted CTPA rate, PE yield rate with subgroup reporting for children (<18 years) and women under 45 years. We also examined the most frequent diagnoses. From a total visit volume of 1 828 010 patient encounters, 97 125 (5.3% of the total volume) had a diagnostic test for PE, including 25 870 patients who had CTPA order without D-dimer (59% of all tests for PE). The yield rate for PE from CTPA scans was 1.3% (1.1%-1.5%) in Indiana and 4.8% (4.2%-5.1%) in Dallas-Fort Worth (pooled rate 3.1%). Linear regression showed that increased D-dimer ordering correlated with increased PE yield rate (Pearson's R2=0.43; P<0.001). From the pooled sample, 59% of CTPAs done were in women, with 21% of all CTPAs performed on women under 45 years of age, and 1.4% (1.3%-1.5%) on children. The most frequent diagnoses were symptom-based descriptions of chest pain (34%) and shortness of breath (6.5%) and the condition-based diagnosis of pneumonia (4.1%). CONCLUSIONS Over-testing for PE in American EDs remains a major public health problem. Centers with higher D-dimer ordering had higher yield of PE on CTPA. These data suggest the potential for implementation of D-dimer based protocols to reduce low-yield CTPA ordering.
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Affiliation(s)
- Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (J.A.K., E.J.S., C.C.S.)
| | - John S Garrett
- Department of Emergency Medicine, Baylor University Medical Center, Dallas, TX (J.S.G.)
| | - Elisa J Sarmiento
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (J.A.K., E.J.S., C.C.S.)
| | - Christian C Strachan
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (J.A.K., E.J.S., C.C.S.)
| | - D Mark Courtney
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, TX (D.M.C.)
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Yun BJ, Rodriguez RM, Prabhakar AM, Peak DA, Baymon DE, Raja AS. Utilization of chest CT for injured patients during visits to U.S. emergency departments: 2012-2015. Am J Emerg Med 2018; 37:909-912. [PMID: 30100335 DOI: 10.1016/j.ajem.2018.08.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 08/06/2018] [Accepted: 08/07/2018] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Increased use of computed tomography (CT) during injury-related Emergency Department (ED) visits has been reported, despite increased awareness of CT radiation exposure risks. We investigated national trends in the use of chest CT during injury-related ED visits between 2012 and 2015. METHODS Analyzing injury-related ED visits from the 2012-2015 United States (U.S.) National Hospital Ambulatory Medical Care Survey (NHAMCS), we determined the percentage of visits that had a chest CT and the diagnostic yield of these chest CTs for clinically-significant findings. We used survey-weighted multivariable logistic regression to determine which patient and visit characteristics were associated with chest CT use. RESULTS Injury-related visits accounted for 30% of the 135 million yearly ED visits represented in NHAMCS. Of these visits, 817,480 (2%) received a chest CT over the study period. The diagnostic yield was 3.88%. Chest CT utilization did not change significantly from a rate of 1.73% in 2012 to a rate of 2.31% in 2015 (p = 0.14). Multivariate logistic regression demonstrated increased odds of chest CT for patients seen by residents versus by attendings (adjusted odds ratio [AOR] 2.08, 95% confidence interval [CI] 1.41-3.08). Patients aged 18-59 and 60+ had higher AORs (5.75, CI 3.44-9.61 and 9.81, CI 5.90-16.33, respectively) than those <18 years of receiving chest CT. CONCLUSIONS Overall chest CT utilization showed an increased trend from 2012 to 2015, but the results were not statistically significant.
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Affiliation(s)
- Brian J Yun
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Center for Research in Emergency Department Operations (CREDO), Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Robert M Rodriguez
- Department of Emergency Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Anand M Prabhakar
- Center for Research in Emergency Department Operations (CREDO), Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - David A Peak
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - DaMarcus E Baymon
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Harvard Affiliated Emergency Medicine Residency Program, Massachusetts General Hospital and Brigham and Women's Hospital, Boston, MA, USA
| | - Ali S Raja
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Center for Research in Emergency Department Operations (CREDO), Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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12
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Gupta M, Mower WR, Rodriguez RM, Hendey GW. Validation of the Pediatric NEXUS II Head Computed Tomography Decision Instrument for Selective Imaging of Pediatric Patients with Blunt Head Trauma. Acad Emerg Med 2018; 25:729-737. [PMID: 29665151 DOI: 10.1111/acem.13431] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 03/27/2018] [Accepted: 04/01/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Data suggest that clinicians, when evaluating pediatric patients with blunt head trauma, may be overordering head computed tomography (CT). Prior decision instruments (DIs) aimed at aiding clinicians in safely forgoing CTs may be paradoxically increasing CT utilization. This study evaluated a novel DI that aims for high sensitivity while also improving specificity over prior instruments. METHODS We conducted a planned secondary analysis of the NEXUS Head CT DI among patients less than 18 years old. The rule required patients satisfy seven criteria to achieve "low-risk" classification. Patients were assigned "high-risk" status if they fail to meet one or more criteria. Our primary outcome was the ability of the rule to identify all patients requiring neurosurgical intervention. RESULTS The study enrolled 1,018 blunt head injury pediatric patients. The DI assigned high-risk status to 27 of 27 patients requiring neurosurgical intervention (sensitivity = 100.0%, 95% confidence interval [CI] = 87.2%-100%]). The instrument assigned low-risk status to 330 of 991 patients who did not require neurosurgical intervention (specificity = 33.3%, 95% CI = 30.3%-36.3%). None of the 991 low-risk patients required neurosurgical intervention (negative predictive value [NPV] = 100%, 95% CI = 99.6%-100%). The DI correctly assigned high-risk status to 48 of the 49 patients with significant intracranial injuries, yielding a sensitivity of 98.0% (95% CI = 89.1%-99.9%). The instrument assigned low-risk status to 329 of 969 patients who did not have significant injuries to yield a specificity of 34.0% (95% CI = 31.0%-37.0%). Significant injuries were absent in 329 of the 330 patients assigned low-risk status to yield a NPV of 99.7% (95% CI = 98.3%-100%). CONCLUSIONS The Pediatric NEXUS Head CT DI reliably identifies blunt trauma patients who require head CT imaging and could significantly reduce the use of CT imaging.
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Affiliation(s)
- Malkeet Gupta
- UCLA Department of Emergency Medicine Ronald Reagan UCLA Medical Center Los Angeles CA
- Antelope Valley Hospital Emergency Department Lancaster CA
| | - William R. Mower
- UCLA Department of Emergency Medicine Ronald Reagan UCLA Medical Center Los Angeles CA
| | - Robert M. Rodriguez
- Zuckerberg San Francisco General Hospital Department of Emergency Medicine–UCSF School of Medicine San Francisco CA
| | - Gregory W. Hendey
- UCLA Department of Emergency Medicine Ronald Reagan UCLA Medical Center Los Angeles CA
- UCSF Fresno Community Regional Medical Center Fresno CA
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13
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Yun BJ, Borczuk P, Zachrison KS, Goldstein JN, Berlyand Y, Raja AS. Utilization of head CT during injury visits to United States emergency departments: 2012-2015. Am J Emerg Med 2018; 36:1463-1466. [PMID: 29779675 DOI: 10.1016/j.ajem.2018.05.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 05/09/2018] [Accepted: 05/12/2018] [Indexed: 10/16/2022] Open
Abstract
INTRODUCTION Studies have shown increasing utilization of head computed tomography (CT) imaging of emergency department (ED) patients presenting with an injury-related visit. Multiple initiatives, including the Choosing Wisely™ campaign and evidence-based clinical decision support based on validated decision rules, have targeted head CT use in patients with injuries. Therefore, we investigated national trends in the use of head CT during injury-related ED visits from 2012 to 2015. METHODS This was a secondary analysis of data from the annual United States (U.S.) National Hospital Ambulatory Medical Care Survey from 2012 to 2015. The study population was defined as injury-related ED visits, and we sought to determine the percentage in which a head CT was ordered and, secondarily, to determine both the diagnostic yield of clinically significant intracranial findings and hospital characteristics associated with increased head CT utilization. RESULTS Between 2012 and 2015, 12.25% (95% confidence interval [CI] 11.48-13.02%) of injury-related visits received at least one head CT. Overall head CT utilization showed an increased trend during the study period (2012: 11.7%, 2015: 13.23%, p = 0.09), but the results were not statistically significant. The diagnostic yield of head CT for a significant intracranial injury over the period of four years was 7.4% (9.68% in 2012 vs. 7.67% in 2015, p = 0.23). CONCLUSIONS Head CT use along with diagnostic yield has remained stable from 2012 to 2015 among patients presenting to the ED for an injury-related visit.
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Affiliation(s)
- Brian J Yun
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Center for Research in Emergency Department Operations (CREDO), Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Pierre Borczuk
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | | | - Ali S Raja
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Center for Research in Emergency Department Operations (CREDO), Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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14
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Neep MJ, Steffens T, Eastgate P, McPhail SM. Evaluating the effectiveness of intensive versus non-intensive image interpretation education for radiographers: a randomised control trial study protocol. J Med Radiat Sci 2018; 65:63-70. [PMID: 29388344 PMCID: PMC5846025 DOI: 10.1002/jmrs.264] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 09/18/2017] [Accepted: 11/03/2017] [Indexed: 12/01/2022] Open
Abstract
Radiographer commenting systems have not been successfully implemented in many Australian hospitals, despite evidence of their benefit and adoption elsewhere, such as the United Kingdom. An important contributor to the lack of widespread adoption of radiographer commenting in Australia (and likely elsewhere) is the limited availability of accessible education options for radiographers. The purpose of this randomised controlled trial is to compare the effectiveness of the same image interpretation education program delivered over an intensive 2-day period (intensive format) versus a series of shorter regular workshops (non-intensive format). The study design is a multicentre, stratified (by years of experience) two group parallel-arm single-blind (assessor blinded) randomised controlled trial. Participants will be allocated to one of the two groups: (1) intensive format of education or (2) non-intensive format of education in a 1:1 ratio. Participants will undergo assessments before education, at 1 week post-intervention completion and at 12 weeks post-intervention completion. Findings from this trial will be of relevance to radiographers seeking image interpretation training as well as organisations providing image interpretation education to prepare clinical staff for participation in a radiographer commenting system. A limitation of the trial is that the sample will be inclusive of radiographers, and findings may not be able to be directly extrapolated to other clinical disciplines (e.g. junior doctors, physiotherapists or nurse practitioners).
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Affiliation(s)
- Michael J. Neep
- Department of Medical ImagingLogan HospitalMeadowbrookQueenslandAustralia
- Centre for Functioning and Health ResearchMetro South HealthBrisbaneAustralia
- School of Public Health & Social WorkQueensland University of TechnologyKelvin Grove, BrisbaneAustralia
- Institute of Health and Biomedical InnovationQueensland University of TechnologyKelvin Grove, BrisbaneAustralia
| | - Tom Steffens
- Department of Medical ImagingPrincess Alexandra HospitalBrisbaneAustralia
| | - Patrick Eastgate
- School of Public Health & Social WorkQueensland University of TechnologyKelvin Grove, BrisbaneAustralia
- Institute of Health and Biomedical InnovationQueensland University of TechnologyKelvin Grove, BrisbaneAustralia
- Department of Medical ImagingSunshine Coast University HospitalBirtinyaAustralia
| | - Steven M. McPhail
- Centre for Functioning and Health ResearchMetro South HealthBrisbaneAustralia
- School of Public Health & Social WorkQueensland University of TechnologyKelvin Grove, BrisbaneAustralia
- Institute of Health and Biomedical InnovationQueensland University of TechnologyKelvin Grove, BrisbaneAustralia
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15
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Evans LR, Fitzgerald MC, Varma D, Mitra B. A novel approach to improving the interpretation of CT brain in trauma. Injury 2018; 49:56-61. [PMID: 28882376 DOI: 10.1016/j.injury.2017.08.056] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 08/16/2017] [Accepted: 08/23/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Computed tomography of the brain (CTB) has a fundamental role in the diagnosis and management of traumatic brain injury (TBI). There may be substantial discordance between initial CTB interpretation by emergency clinicians and the final radiology report. This study aimed to assess the utility of a structured reporting template in improving the accuracy of CTB interpretation by emergency clinicians. METHOD A prospective pre- and post-intervention cohort study was undertaken using a study population of emergency medicine trainees. The CTB reporting template was created with consultation from radiology, emergency medicine and trauma specialists. Participants reported on a set of randomly selected trauma CTBs first without, and then with, the reporting template. Each case was independently assessed for concordance with the radiology report by two blinded assessors (including a radiologist) and the proportion of concordant reports in each phase calculated. RESULTS There were 26 participants recruited to the study who reported on a total of 320 CTBs. In the pre-intervention phase, 121 (76%) cases were concordant with the radiology report compared to 147 (92%) post-intervention (p<0.01). The AUROC was 0.84 (95% CI: 0.78-0.89) pre-intervention and improved to 0.94 (95% CI: 0.88-0.99) with the intervention (p=0.01). A higher level of baseline accuracy was observed in advanced trainees (78%) compared to basic trainees (72%), but both improved to a similar level of 92% with the use of the CTB reporting template. There was a marked reduction in false negative errors, with increased identification of critical diagnoses such as cerebral herniation and diffuse axonal injury. CONCLUSION The use of the CTB reporting template significantly increased the accuracy of emergency medicine trainees and reduced the number of missed critical diagnoses. Reporting templates may represent an effective strategy to improve CTB interpretation and enhance the initial care of head injured patients.
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Affiliation(s)
- L R Evans
- National Trauma Research Institute, Melbourne, Australia; Monash University, Melbourne, Australia.
| | - M C Fitzgerald
- National Trauma Research Institute, Melbourne, Australia; Trauma Service, Alfred Health, Melbourne, Australia
| | - D Varma
- Department of Radiology, Alfred Health, Melbourne, Australia
| | - B Mitra
- National Trauma Research Institute, Melbourne, Australia; Emergency & Trauma Centre, Alfred Health, Melbourne, Australia; Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia
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16
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Bellolio MF, Heien HC, Sangaralingham LR, Jeffery MM, Campbell RL, Cabrera D, Shah ND, Hess EP. Increased Computed Tomography Utilization in the Emergency Department and Its Association with Hospital Admission. West J Emerg Med 2017; 18:835-845. [PMID: 28874935 PMCID: PMC5576619 DOI: 10.5811/westjem.2017.5.34152] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 05/05/2017] [Accepted: 05/26/2017] [Indexed: 12/17/2022] Open
Abstract
Introduction Our goal was to investigate trends in computed tomography (CT) utilization in emergency departments (EDs) and its association with hospitalization. Methods We conducted an analysis of an administrative claims database of U.S. privately insured and Medicare Advantage enrollees. We identified ED visits from 2005 through 2013 and assessed for CT use, associated factors, and hospitalization after CT, along with patient demographics. We used both descriptive methods and regression models adjusted for year, age, sex, race, geographic region, and Hwang comorbidity score to explore associations among CT use, year, demographic characteristics, and hospitalization. Results We identified 33,144,233 ED visits; 5,901,603 (17.8%) involved CT. Over time, CT use during ED visits increased 59.9%. CT use increased in all age groups but decreased in children since 2010. In propensity-matching analysis, odds of hospitalization increased with age, comorbidities, male sex, and CT use (odds ratio, 2.38). Odds of hospitalization over time decreased more quickly for patients with CT. Conclusion CT utilization in the ED has increased significantly from 2005 through 2013. For children, CT use after 2010 decreased, indicating caution about CT use. Male sex, older age, and higher number of comorbidities were predictors of CT in the ED. Over time, odds of hospitalization decreased more quickly for patients with CT.
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Affiliation(s)
- M Fernanda Bellolio
- Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota.,Mayo Clinic, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota.,Mayo Clinic, Division of Health Care Policy and Research, Rochester, Minnesota
| | - Herbert C Heien
- Mayo Clinic, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
| | - Lindsey R Sangaralingham
- Mayo Clinic, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
| | - Molly M Jeffery
- Mayo Clinic, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota.,Mayo Clinic, Division of Health Care Policy and Research, Rochester, Minnesota
| | - Ronna L Campbell
- Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota
| | - Daniel Cabrera
- Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota
| | - Nilay D Shah
- Mayo Clinic, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota.,Mayo Clinic, Division of Health Care Policy and Research, Rochester, Minnesota.,OptumLabs, Cambridge, Massachusetts
| | - Erik P Hess
- Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota.,Mayo Clinic, Division of Health Care Policy and Research, Rochester, Minnesota
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17
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Mower WR, Gupta M, Rodriguez R, Hendey GW. Validation of the sensitivity of the National Emergency X-Radiography Utilization Study (NEXUS) Head computed tomographic (CT) decision instrument for selective imaging of blunt head injury patients: An observational study. PLoS Med 2017; 14:e1002313. [PMID: 28700585 PMCID: PMC5507397 DOI: 10.1371/journal.pmed.1002313] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 04/28/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Clinicians, afraid of missing intracranial injuries, liberally obtain computed tomographic (CT) head imaging in blunt trauma patients. Prior work suggests that clinical criteria (National Emergency X-Radiography Utilization Study [NEXUS] Head CT decision instrument [DI]) can reliably identify patients with important injuries, while excluding injury, and the need for imaging in many patients. Validating this DI requires confirmation of the hypothesis that the lower 95% confidence limit for its sensitivity in detecting serious injury exceeds 99.0%. A secondary goal of the study was to complete an independent validation and comparison of the Canadian and NEXUS Head CT rules among the subgroup of patients meeting the inclusion and exclusion criteria. METHODS AND FINDINGS We conducted a prospective observational study of the NEXUS Head CT DI in 4 hospital emergency departments between April 2006 and December 2015. Implementation of the rule requires that patients satisfy 8 criteria to achieve "low-risk" classification. Patients are excluded from "low-risk" classification and assigned "high-risk" status if they fail to meet 1 or more criteria. We examined the instrument's performance in assigning "high-risk" status to patients requiring neurosurgical intervention among a cohort of 11,770 blunt head injury patients. The NEXUS Head CT DI assigned high-risk status to 420 of 420 patients requiring neurosurgical intervention (sensitivity, 100.0% [95% confidence interval [CI]: 99.1%-100.0%]). The instrument assigned low-risk status to 2,823 of 11,350 patients who did not require neurosurgical intervention (specificity, 24.9% [95% CI: 24.1%-25.7%]). None of the 2,823 low-risk patients required neurosurgical intervention (negative predictive value [NPV], 100.0% [95% CI: 99.9%-100.0%]). The DI assigned high-risk status to 759 of 767 patients with significant intracranial injuries (sensitivity, 99.0% [95% CI: 98.0%-99.6%]). The instrument assigned low-risk status to 2,815 of 11,003 patients who did not have significant injuries (specificity, 25.6% [95% CI: 24.8%-26.4%]). Significant injuries were absent in 2,815 of the 2,823 patients assigned low-risk status (NPV, 99.7% [95% CI: 99.4%-99.9%]). Of our patients, 7,759 (65.9%) met the inclusion and exclusion criteria of the Canadian Head CT rule, including 111 patients (1.43%) who required neurosurgical intervention and 306 (3.94%) who had significant intracranial injuries. In our study, the Canadian criteria for neurosurgical intervention identified 108 of 111 patients requiring neurosurgical intervention to yield a sensitivity of 97.3% (95% CI: 92.3%-99.4%) and exhibited a specificity of 58.8% (95% CI: 57.7%-59.9%). The NEXUS rule, when applied to this same cohort, identified all 111 patients requiring neurosurgical intervention, yielding a sensitivity of 100% (95% CI: 96.7%-100.0%) with a specificity of 32.6% (95% CI: 31.5%-33.6%). Our study found that the Canadian medium-risk factors identified 301 of 306 patients with significant injuries (sensitivity = 98.4%; 95% CI: 96.2%-99.5%), while the NEXUS rule identified 299 of these patients (sensitivity = 97.7%; 95% CI: 95.3%-99.1%). In our study, the Canadian medium-risk rule exhibited a specificity of 12.3% (95% CI: 11.6%-13.1%), while the NEXUS rule exhibited a specificity of 33.3% (95% CI: 32.3%-34.4%). Limitations of the study may arise from application of the rule by different clinicians in different environments. Clinicians may vary in their interpretation and application of the instrument's criteria and risk assignment and may also vary in deciding which patients require intervention. The instrument's specificity is also subject to spectrum bias and may change with variations in the proportion of "low-risk" patients seen in other centers. CONCLUSIONS The NEXUS Head CT DI reliably identifies blunt trauma patients who require head CT imaging and could significantly reduce the use of CT imaging.
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Affiliation(s)
- William R. Mower
- UCLA Department of Emergency Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, California, United States of America
- * E-mail:
| | - Malkeet Gupta
- UCLA Department of Emergency Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, California, United States of America
- Antelope Valley Hospital Emergency Department, Lancaster, California, United States of America
| | - Robert Rodriguez
- San Francisco General Hospital, Department of Emergency Medicine, UCSF School of Medicine, San Francisco, California, United States of America
| | - Gregory W. Hendey
- UCLA Department of Emergency Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, California, United States of America
- UCSF Fresno, Community Regional Medical Center, Fresno, California, United States of America
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18
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Mullins PM, Mazer-Amirshahi M, Pines JM. Alcohol-Related Visits to US Emergency Departments, 2001-2011. Alcohol Alcohol 2016; 52:119-125. [PMID: 27998923 DOI: 10.1093/alcalc/agw074] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 09/14/2016] [Accepted: 09/15/2016] [Indexed: 11/14/2022] Open
Abstract
AIMS Alcohol intoxication is a source of significant illness and injury commonly resulting in emergency department (ED) visits. We characterize recent trends in alcohol-related visits to US EDs using nationally representative data. METHODS We conducted a retrospective review of data on national ED visits among patients aged 18 years or older with alcohol intoxication between 2001 and 2011 using the National Hospital Ambulatory Medical Care Survey (NHAMCS). Demographic and resource utilization trends in alcohol-related visits were examined. We also assessed ED length of stay (LOS) across the study period, as well as the total hours spent on ED care for alcohol-related complaints. RESULTS Between 2001-2002 and 2010-2011, alcohol-related visits increased from 2,459,748 to 3,856,346 (P = 0.049). Utilization of resources such as laboratory tests, medications and radiography increased, with the use of advanced imaging (i.e. computed tomography and magnetic resonance imaging) increasing 232.2% (P < 0.001) from 2001-2002 to 2010-2011. Overall LOS increased 16.1% (P = 0.028), while LOS among patients admitted to the hospital increased 24.9% (P = 0.076). Total alcohol-related hours spent in EDs nationwide increased from 5.6 million in 2001 to 11.6 million in 2011, an increase of 108.5% (P < 0.001) compared with an increase in overall ED hours of 54.0% (P < 0.001). CONCLUSION Alcohol-related ED visits are increasing at a greater rate than overall ED visits and represent a growing burden on hospital resources.
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Affiliation(s)
- Peter M Mullins
- Center for Healthcare Innovation and Policy Research, School of Medicine and Health Sciences, The George Washington University, 2100 Pennsylvania Ave, Suite 300, Washington, DC 20037, USA
| | - Maryann Mazer-Amirshahi
- Department of Emergency Medicine, Medstar Washington Hospital Center, 110 Irving Street NW, Suite NA 1177, Washington, DC 20010, USA
| | - Jesse M Pines
- Center for Healthcare Innovation and Policy Research, School of Medicine and Health Sciences, The George Washington University, 2100 Pennsylvania Ave, Suite 300, Washington, DC 20037, USA.,Departments of Emergency Medicine and Health Policy and Management, The George Washington University, 2100 Pennsylvania Ave, Suite 300, Washington, DC 20037, USA
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19
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Knieling F, Waldner MJ. Light and sound - emerging imaging techniques for inflammatory bowel disease. World J Gastroenterol 2016; 22:5642-5654. [PMID: 27433080 PMCID: PMC4932202 DOI: 10.3748/wjg.v22.i25.5642] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 05/02/2016] [Accepted: 05/23/2016] [Indexed: 02/06/2023] Open
Abstract
Patients with inflammatory bowel disease are known to have a high demand of recurrent evaluation for therapy and disease activity. Further, the risk of developing cancer during the disease progression is increasing from year to year. New, mostly non-radiant, quick to perform and quantitative methods are challenging, conventional endoscopy with biopsy as gold standard. Especially, new physical imaging approaches utilizing light and sound waves have facilitated the development of advanced functional and molecular modalities. Besides these advantages they hold the promise to predict personalized therapeutic responses and to spare frequent invasive procedures. Within this article we highlight their potential for initial diagnosis, assessment of disease activity and surveillance of cancer development in established techniques and recent advances such as wide-view full-spectrum endoscopy, chromoendoscopy, autofluorescence endoscopy, endocytoscopy, confocal laser endoscopy, multiphoton endoscopy, molecular imaging endoscopy, B-mode and Doppler ultrasound, contrast-enhanced ultrasound, ultrasound molecular imaging, and elastography.
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20
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Carney D, Rodriguez RM. Achieving the Triple Aim Through Informed Consent for Computed Tomography. West J Emerg Med 2016; 16:1030-2. [PMID: 26759648 PMCID: PMC4703145 DOI: 10.5811/westjem.2015.12.29466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 12/08/2015] [Accepted: 12/09/2015] [Indexed: 11/25/2022] Open
Affiliation(s)
- Dylan Carney
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Robert M Rodriguez
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
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Berdahl C, Schuur JD, Fisher NL, Burstin H, Pines JM. Policy Measures and Reimbursement for Emergency Medical Imaging in the Era of Payment Reform: Proceedings From a Panel Discussion of the 2015 Academic Emergency Medicine Consensus Conference. Acad Emerg Med 2015; 22:1393-9. [PMID: 26568025 PMCID: PMC4715479 DOI: 10.1111/acem.12829] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 07/07/2015] [Indexed: 11/28/2022]
Abstract
The Affordable Care Act (ACA) of 2010 is expanding the use of quality measurement and promulgating new payment models that place downward pressure on health care utilization and costs. As emergency department (ED) computed tomography utilization has tripled in the past decade, stakeholders have identified advanced imaging as an area where quality and efficiency measures should expand. On May 12, 2015, Academic Emergency Medicine convened a consensus conference titled "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization." As part of the conference, a panel of health care policy leaders and emergency physicians discussed the effect of the ACA and other quality programs on ED diagnostic imaging, specifically the way that quality metrics may affect ED care and how ED diagnostic imaging fits in the broader strategy of the U.S. government. This article discusses the content of the panel's presentations.
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Affiliation(s)
- Carl Berdahl
- Department of Emergency Medicine, University of Southern California, Los Angeles, CA
| | - Jeremiah D Schuur
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
| | - Nancy L Fisher
- Centers for Medicare and Medicaid Services, Region 10, Seattle, WA
| | | | - Jesse M Pines
- Departments of Emergency Medicine and Health Policy and Management, The George Washington University, Washington, DC
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22
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Raja AS, Lanning J, Gower A, Langdorf MI, Nishijima DK, Baumann BM, Hendey GW, Medak AJ, Mower WR, Rodriguez RM. Prevalence of Chest Injury With the Presence of NEXUS Chest Criteria: Data to Inform Shared Decisionmaking About Imaging Use. Ann Emerg Med 2015; 68:222-6. [PMID: 26607334 DOI: 10.1016/j.annemergmed.2015.09.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 09/15/2015] [Accepted: 09/21/2015] [Indexed: 10/22/2022]
Abstract
STUDY OBJECTIVE The NEXUS chest decision instrument identifies a very-low-risk population of patients with blunt trauma for whom chest imaging can be avoided. However, it requires that all 7 National Emergency X-Ray Utilization Study (NEXUS) chest criteria be absent. To inform patient and physician shared decisionmaking about imaging, we describe the test characteristics of individual criteria of the NEXUS chest decision instrument and provide the prevalence of injuries when 1, 2, or 3 of the 7 criteria are present. METHODS We conducted this secondary analysis of 2 prospectively collected cohorts of patients with blunt trauma who were older than 14 years and enrolled in NEXUS chest studies between December 2009 and January 2012. Physicians at 9 US Level I trauma centers recorded the presence or absence of the 7 NEXUS chest criteria. We calculated test characteristics of each criterion and combinations of criteria for the outcome measures of major clinical injuries and thoracic injury observed on chest imaging. RESULTS We enrolled 21,382 patients, of whom 992 (4.6%) had major clinical injuries and 3,135 (14.7%) had thoracic injuries observed on chest imaging. Sensitivities of individual test characteristics ranged from 15% to 56% for major clinical injury and 14% to 53% for thoracic injury observed on chest imaging, with specificities varying from 71% to 84% for major clinical injury and 67% to 84% for thoracic injury observed on chest imaging. Individual criteria were associated with a prevalence of major clinical injury between 1.9% and 3.8% and of thoracic injury observed on chest imaging between 5.3% and 11.5%. CONCLUSION Patients with isolated NEXUS chest criteria have low rates of major clinical injury. The risk of major clinical injury for patients with 2 or 3 factors range from 1.7% to 16.6%, depending on the combination of criteria. Criteria-specific risks could be used to inform shared decisionmaking about the need for imaging by patients and their physicians.
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Affiliation(s)
- Ali S Raja
- Department of Emergency Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, MA.
| | - Jennifer Lanning
- Department of Emergency Medicine, University of California, San Francisco, CA
| | - Arian Gower
- Chicago Medical School at Rosalind Franklin University of Medicine and Science, North Chicago, IL
| | - Mark I Langdorf
- Department of Emergency Medicine, University of California, Irvine, CA
| | | | - Brigitte M Baumann
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ
| | - Gregory W Hendey
- Department of Emergency Medicine, University of California, San Francisco Fresno Medical Education Program, San Francisco, CA
| | - Anthony J Medak
- Department of Emergency Medicine, University of California, San Diego School of Medicine, San Diego, CA
| | - William R Mower
- Department of Emergency Medicine, University of California, Los Angeles, CA
| | - Robert M Rodriguez
- Department of Emergency Medicine, University of California, San Francisco, CA
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