Preliminary interpretations of after-hours CT and sonography by radiology residents versus final interpretations by body imaging radiologists at a level 1 trauma center

Discrepancy rate and clinical impact of preliminary reports from radiology residents

Background

Residents usually cover night and weekend shifts issuing the preliminary reading of radiological studies in university hospitals. This is essential to strengthening decision-making skills when facing complex cases independently. However, there should be a balance between patient safety and academic experience since some concern has been expressed about the accuracy of the interpretations generated by trainees. This work aims to evaluate and characterize the discrepancies in preliminary reports issued by radiology residents.

Material and methods

Radiologists filled out a questionnaire to evaluate preliminary reports of trainees considering diagnosis, findings description, clinical approach changes, and critical findings. Analysis was performed considering modality, imaging type, body part, and resident academic year. A Chi-square test with a significance level α of 0.05 was used to make group comparisons.

Results

A total of 9072 studies were reviewed. Major and minor overall discrepancy rates were 1.7% and 8.3%, respectively. Minor discrepancy rate, findings description, and critical findings identification improved with increasing academic year, both overall and by modality. Discrepancy rates were lower for CT than MR and neuroimaging than for body-imaging studies. The highest major and minor discrepancy rates as abdomen/pelvis CT and lumbar-spine MR, respectively. Two percent of reports presented discrepancies that could generate a medical approach change.

Conclusion

Discrepancy rates are low and comparable with those reported in the literature. These rates tend to improve as the resident's academic year increases. Our results suggest that radiology residents' coverage of night shifts and weekends is a practice that benefits the educational process without negatively impacting patient safety.

Radiology Residents' Independent Diagnosis of Appendicitis Using 2-mSv Computed Tomography: A Secondary Analysis of a Large Pragmatic Randomized Trial

OBJECTIVE

To compare the diagnostic performance and clinical outcomes of 2-mSv computed tomography (CT) and conventional-dose CT (CDCT), following radiology residents' interpretation of CT examinations for suspected appendicitis.

MATERIALS AND METHODS

Altogether, 3074 patients with suspected appendicitis aged 15-44 years (28 ± 9 years, 1672 females) from 20 hospitals were randomly assigned to the 2-mSv CT (n = 1535) or CDCT (n = 1539) groups in a pragmatic trial from December 2013 and August 2016. Overall, 107 radiology residents participated in the trial as readers in the form of daily practice after online training for 2-mSv CT. They made preliminary CT reports, which were later finalized by attending radiologists via addendum reports, for 640 and 657 patients in the 2-mSv CT and CDCT groups, respectively. We compared the diagnostic performance of the residents, discrepancies between preliminary and addendum reports, and clinical outcomes between the two groups.

RESULTS

Patient characteristics were similar between the 640 and 657 patients. Residents' diagnostic performance was not significantly different between the 2-mSv CT and CDCT groups, with a sensitivity of 96.0% and 97.1%, respectively (difference [95% confidence interval {CI}], -1.1% [-4.9%, 2.6%]; P = 0.69) and specificity of 93.2% and 93.1%, respectively (0.1% [-3.6%, 3.7%]; P > 0.99). The 2-mSv CT and CDCT groups did not significantly differ in discrepancies between the preliminary and addendum reports regarding the presence of appendicitis (3.3% vs. 5.2%; -1.9% [-4.2%, 0.4%]; P = 0.12) and alternative diagnosis (5.5% vs. 6.4%; -0.9% [-3.6%, 1.8%]; P = 0.56). The rates of perforated appendicitis (12.0% vs. 12.6%; -0.6% [-4.3%, 3.1%]; P = 0.81) and negative appendectomies (1.9% vs. 1.1%; 0.8% [-0.7%, 2.3%]; P = 0.33) were not significantly different between the two groups.

CONCLUSION

Diagnostic performance and clinical outcomes were not significantly different between the 2-mSv CT and CDCT groups following radiology residents' CT readings for suspected appendicitis.

Interpretation of computed tomography of the cervical spine by non-radiologists: a systematic review and meta-analysis

BACKGROUND

After trauma, clearance of the cervical spine refers to the exclusion of underlying serious injuries. Accurate assessment of computed tomography (CT) is commonly required prior to clearance of the cervical spine. Delays to clearance can lead to prolonged immobilization with associated patient discomfort and adverse effects. This systematic review aimed to determine performance of non-radiologists to evaluate cervical spine CT.

METHODS

MEDLINE, EMBASE, Cochrane library with sources of grey literature and reference lists of selected articles were appraised from inception to April 2021. We included manuscripts that reported discordance in CT cervical spine interpretation between non-radiologists and radiologists. The Newcastle-Ottawa scale (NOS) was used to assess quality of included studies and statistical heterogeneity was assessed using the I² statistic.

RESULTS

There were 43 studies identified for eligibility and 4 manuscripts included in the final analysis. There were two studies that reported on the performance of radiology residents, one study on the performance of surgical residents and one on emergency physicians. The pooled discordance was 0.25 (95%CI 0.21-0.28) but was lower for radiology residents (range 0.007-0.05). There was significant statistical heterogeneity (I²  = 99.6%, P < 0.001) among studies.

CONCLUSION

There is a paucity of evidence documenting the ability of non-radiologists in accurately interpreting CT of the cervical spine. A number of discordant findings suggest that studies with larger sample sizes are indicated to accurately ascertain the ability of non-radiologists in this area.

Concordance Between Resident and Attending Radiologist in Reporting Pneumothorax on Intensive Care Unit and Emergency Room Chest Radiographs

Introduction

Pneumothorax is a common medical emergency and has potentially life-threatening consequences, so it is important for radiology residents and consultants to know its radiographic appearance so that timely diagnosis and appropriate management can be done. Patients with pneumothorax have nonspecific complaints, and clinical examinations are not confirmatory. The chest X-ray is easily available and has high accuracy in the detection of pneumothorax. The aim of this study is to determine the agreement between the on-call radiology resident and the attending radiologist in the diagnosis of pneumothorax on chest radiographs.

Materials and methods

This cross-sectional study was performed in the Department of Radiology at Aga Khan University Hospital, Karachi. After approval from the ethical review committee (ERC), the study was carried out. A total of 174 patients were included in the study. The resident interpreting the radiograph commented on the pneumothorax and recorded it on the “Comments” section of the picture archiving and communication system (PACS). Further entries were made in the department’s “Panic Logbook.” Subsequently, the final report by the attending radiologist was tallied, and the decision of both the resident and the attending radiologist regarding the presence or absence of pneumothorax was compared for interobserver agreement.

Results

Of the 174 patients, 139 (79.9%) were male and 35 (20.1%) were female. The mean age of the patients was 45.6 ± 12.4 years. Pneumothorax was reported by the resident in 164 (94.25%) cases, while the attending radiologist reported it in 167 (96%) cases. The remaining 4% of cases were ultimately diagnosed on a CT scan of the chest performed at the request of the primary team; they were too small to be detected on a chest radiograph.

The most common side involved was the right side, with 112 (64.4%) cases, followed by the left side with 55 (31.6%) and both sides with five (2.9%), while in two cases, pneumothorax was not reported by the resident and the attending radiologist. The position of the pneumothorax was as follows: apex in 80 (46%), base in 56 (32.2%), and along the lateral border of the lung in 93 (53.4%). Concordance between the resident and the radiologist was found to be 92.5% (kappa = 0.20; p = 0.008). Stratification for age, gender, the position of pneumothorax, and the level of residency was also carried out.

Conclusion

In our setting, there was a high level of agreement (92.5%) between the resident and the attending radiologist in reporting pneumothorax on chest radiographs (kappa = 0.20; p = 0.008).

Interpretation discrepancies of abdominal imaging by on-call radiology residents: Evaluation of risk factors

The aim of this study was to determine the rate, important findings, and risk factors related to discrepancies between on-call residents’ and attending radiologists’ interpretations of abdominal examinations. We identified 1132 eligible patients with abdominal radiology findings that were preliminary interpreted by on-call residents between February 2016 and September 2019. The preliminary interpretations were compared with the final interpretations by abdominal attending radiologists, including clinical data. The preliminary interpretations were analyzed by three radiologists in consensus, who categorized the reports according to organs, important findings (i.e., active bleeding, bowel obstruction, organ ischemia or infarction, and organ rupture), clinical outcomes, and discrepancies with respect to final interpretations. Multiple logistic regression analysis was used to evaluate the risk factors for important discrepant findings. Of 1132 patients, the bowel (n = 567, 50.1%) was the most common organ interpreted by on-call residents, followed by gallbladder/bile duct/pancreas (n = 139, 12.3%) and liver (n = 116, 10.2%). Of 1132, 359 patients (31.7%) had disease with 379 important findings: active bleeding (n = 222), organ rupture (n = 77), bowel obstruction (n = 52), bowel ischemia (n = 24), and organ infarction (n = 4). Sixty-four patients (5.6%) showed discrepancies, and 30 (2.6%) showed 32 important discrepant findings comprising 14 active bleeding, 10 bowel obstructions, 6 organ ruptures, and 2 cases of bowel ischemia. Of the 64 discrepant patients, 33 underwent delayed surgery (n = 18, 28.1%) or interventional treatment (n = 15, 23.4%). In multivariable analysis, bowel obstruction (adjusted odds ratio, 2.52; p = 0.049) was an independent risk factor for determining discrepancy between preliminary and final interpretations. The rate of overall and important discrepancies between on-call residents’ and final interpretations was low. However, given that the bowel was the most frequently interpreted organ, bowel obstruction was identified as a risk factor for discrepant interpretations. The identified risk factor and findings may be useful for residents to minimize discrepancies.

Night Radiology Coverage for Trauma: Residents, Teleradiology, or Both?

BACKGROUND

Overnight radiology coverage for trauma patients is often addressed with a combination of on-call radiology residents (RR) and a teleradiology service; however, the accuracy of these 2 readers has not been studied for trauma. We aimed to compare the accuracy of RR versus teleradiologist interpretations of CT scans for trauma patients.

STUDY DESIGN

A retrospective analysis (March 2019 through May 2020) of trauma patients presenting to a single American College of Surgeons Level I trauma center was performed. Patients whose CT scans were performed between 10 pm to 8 am were included, because their scans were interpreted by both a RR and teleradiologist. Interpretations were compared with the final attending faculty radiologist's interpretation and graded for accuracy based on the RADPEER scoring system. Discrepancies were characterized as traumatic injury or incidental findings and missed findings or overcalls. Turnaround time was also compared.

RESULTS

A total of 1,053 patients and 8,226 interpretations were included. Compared with teleradiologists, RR had a lower discrepancy (7.7% vs 9.0%, p = 0.026) and major discrepancy rate (3.8% vs 5.2%, p = 0.003). Among major discrepancies, RR had a lower rate of traumatic injury discrepancies (3.2% vs 4.4%, p = 0.004) and missed findings (3.4% vs 5.1%, p < 0.001), but a higher rate of overcalls (0.5% vs 0.1%, p < 0.001) compared with teleradiologists. The mean turnaround time was shorter for RR (51.3 vs 78.8 minutes, p < 0.001). The combination of both RR and teleradiologist interpretations had a lower overall discrepancy rate than RR (5.0% vs 7.7%, p < 0.001).

CONCLUSIONS

This study identified lower discrepancy rates and a faster turnaround time by RR compared with teleradiologists for trauma CT studies. The combination of both interpreters had an even lower discrepancy rate, suggesting this combination is optimal when an in-house attending radiologist is not available.

Value of Clinical Information on Radiology Reports in Oncological Imaging

Radiological reporting errors have a direct negative impact on patient treatment. The purpose of this study was to investigate the contribution of clinical information (CI) in radiological reporting of oncological imaging and the dependence on the radiologists’ experience level (EL). Sixty-four patients with several types of carcinomas and twenty patients without tumors were enrolled. Computed tomography datasets acquired in primary or follow-up staging were independently analyzed by three radiologists (R) with different EL (R1: 15 years; R2: 10 years, R3: 1 year). Reading was initially performed without and 3 months later with CI. Overall, diagnostic accuracy and sensitivity for primary tumor detection increased significantly when receiving CI from 77% to 87%; p = 0.01 and 73% to 83%; p = 0.01, respectively. All radiologists benefitted from CI; R1: 85% vs. 92%, p = 0.15; R2: 77% vs. 83%, p = 0.33; R3: 70% vs. 86%, p = 0.02. Overall, diagnostic accuracy and sensitivity for detecting lymphogenous metastases increased from 80% to 85% (p = 0.13) and 42% to 56% (p = 0.13), for detection of hematogenous metastases from 85% to 86% (p = 0.61) and 46% to 60% (p = 0.15). Specificity remained stable (>90%). Thus, CI in oncological imaging seems to be essential for correct radiological reporting, especially for residents, and should be available for the radiologist whenever possible.

Patient recalls associated with resident-to-attending radiology report discrepancies: predictive factors for risky discrepancies

BACKGROUND

This study aimed to identify predictive factors for risky discrepancies in the emergency department (ED) by analyzing patient recalls associated with resident-to-attending radiology report discrepancies (RRDs).

RESULTS

This retrospective study analyzed 759 RRDs in computed tomography (CT) and magnetic resonance imaging and their outcomes from 2013 to 2021. After excluding 73 patients lost to follow-up, we included 686 records in the final analysis. Risky discrepancies were defined as RRDs resulting in (1) inpatient management (hospitalization) and (2) adverse outcomes (delayed operations, 30-day in-hospital mortality, or intensive care unit admission). Predictors of risky discrepancies were assessed using multivariable logistic regression analysis. The overall RRD rate was 0.4% (759 of 171,419). Of 686 eligible patients, 21.4% (147 of 686) received inpatient management, and 6.0% (41 of 686) experienced adverse outcomes. RRDs with neurological diseases were associated with the highest ED revisit rate (79.4%, 81 of 102) but not with risky RRDs. Predictive factors of inpatient management were critical finding (odds ratio [OR], 5.60; p < 0.001), CT examination (OR, 3.93; p = 0.01), digestive diseases (OR, 2.54; p < 0.001), and late finalized report (OR, 1.65; p = 0.02). Digestive diseases (OR, 6.14; p = 0.006) were identified as the only significant predictor of adverse outcomes.

CONCLUSIONS

Risky RRDs were associated with several factors, including CT examination, digestive diseases, and late finalized reports, as well as critical image findings. This knowledge could aid in determining the priority of discrepancies for the appropriate management of RRDs.

Evaluation of neuroradiology emergency MRI interpretations: low discrepancy rates between on-call radiology residents' preliminary interpretations and neuroradiologists' final reports

OBJECTIVES

To evaluate the performance of on-call radiology residents in interpreting alone brain and spine MRI studies performed after hours, to describe their mistakes, and to identify influencing factors that increased the occurrence of errors.

METHODS

A total of 328 MRI examinations performed during a 13-month period (from December 1, 2019, to January 1, 2021) were prospectively included. Discrepancies between the preliminary interpretation of on-call radiology residents and the final reports of attending neuroradiologists were noted and classified according to a three-level score: level 1 (perfect interpretation or minor correction), level 2 (important correction without immediate change in patient management), or level 3 (major correction with immediate change in patient management). Categorical data were compared using Fisher's exact test.

RESULTS

The overall discrepancy rate (level-2 and level-3 errors) was 16%; the rate of major discrepancies (only level-3 errors) was 5.5%. The major-discrepancy rate of second-year residents, when compared with that of senior residents, was significantly higher (p = 0.02). Almost all of the level-3 errors concerned cerebrovascular pathology. The most common level-2 errors involved undescribed aneurysms. We found no significant difference in the major-discrepancy rate regarding time since the beginning of the shift.

CONCLUSIONS

The great majority of examinations were correctly interpreted. The rate of major discrepancies in our study was comparable to the data in the literature, and there was no adverse clinical outcome. The level of residency has an effect on the rate of serious errors in residents' reports.

KEY POINTS

• The rate of major discrepancies between preliminary MRI interpretations by on-call radiology residents and final reports by attending neuroradiologists is low, and comparable to discrepancy rates reported for head CT interpretations. • The youngest residents made significantly more serious errors when compared to senior residents. • There was no adverse clinical outcome in patient morbidity as a result of an initial misdiagnosis.

Evaluating discrepancy rates of radiology resident provisional reports for cross-sectional body imaging studies at a tertiary hospital

Introduction

Urgent radiological studies obtained during on-call hours are often preliminarily read by on-call residents before consultant radiologists finalise the reports at a later time. Such provisional radiology reports provide important information to guide initial patient management. This study aims to determine discrepancy rates between provisional reports and final interpretations, and to assess the clinical significance of such discrepancies.

Methods

This retrospective quality assurance project reviewed a total of 1218 cross-sectional imaging studies of the body (thorax, abdomen and pelvis) done between July 2015 and May 2016 during on-call hours. The studies included 1201 Computed tomography (CT) scans and 17 Magnetic Resonance Imaging (MRI) scans. Studies with incomplete or unavailable reports were excluded. Conclusions of both the provisional and final reports of each study were reviewed for concordance, with reference to the full report if needed. Discrepancies were graded according to the ACR 2016 RADPEER scoring system.

Results

There were 1210 studies with complete reports. Discrepant reports were noted in 183 (15.1%) studies. Of these, 89 (7.3%) were assessed to be clinically significant and the majority of these (55) were due to interpretations which should be made most of the time. CT of the abdomen and pelvis were the most prone to discrepant reports, accounting for 148 cases (80.9%).

Conclusion

The majority of preliminary reports for on-call body scans were concordant with final interpretations. The discrepancy rates for provisional body scan reports provided by residents while on call were comparable to those previously reported in literature.

Accuracy of after-hours trauma cervical spine CT reporting by radiology trainees: Experiences from two Australian teaching hospitals

INTRODUCTION

Like many teaching hospitals in Australia, after-hours computed tomography (CT) reporting at our institution is undertaken by the on-call radiology registrar. The accuracy of these reports is important as management is often initiated based on the interim findings, prior to review by the consultant radiologist. A common exception to this approach is cervical CT (CCT), as many hospital protocols recommend patients to remain in spinal precautions until the report is finalised by a consultant, although there are very few studies to support this practice.

METHODS

The interim registrar reports for all CCTs performed after-hours over a 12-month period were retrospectively reviewed. The final consultant report was used as the gold standard to establish accuracy of the registrar report. The primary outcome was discrepancy between the provisional and final reports. Any discrepancy was classified as either an 'overcall' or 'miss'. Discrepancies were graded by the RADPEER scoring system.

RESULTS

A total of 1084 after-hours CCT studies were reviewed. The number of cases positive for injury was 37 (3.4%). The total number of discrepancies was 14 (discrepancy rate 1.3%), including 4 overcalls (0.3%) and 10 misses (0.9%). The discrepancy rates for junior and senior registrars were 1.7% and 0.7% respectively. Only 5 misses (0.5%) were considered clinically significant.

CONCLUSION

Registrars reporting after-hours CCT have low rates of discrepancy with very few clinically significant misses. However, the reduced registrar sensitivity for detection of cervical injury highlights the ongoing importance of consultant review in the process of cervical spine clearance pathways.

How Well Are Radiology Residents Prepared for Practice After Training? A Survey of French-Speaking Quebec Recent Graduates and Department Chiefs

OBJECTIVE

Radiology residents must fulfill a standardized curriculum to complete residency and pass a certification exam before they are granted a licence to practice. We sought to evaluate how well residency prepares trainees for practice as perceived by recent graduates and their department chiefs. Subjects and Methods: Radiologists who graduated from the 4 Quebec radiology residency programs between 2005 and 2016 (n = 237) and Quebec radiology department chiefs (n = 98) were anonymously surveyed. Two electronic surveys were created, for recent graduates (74 questions) and for department chiefs (11 questions), with multiple-choice questions and open questions covering all fields of radiology. Surveys were administered between April and June 2016 using the Association des radiologistes du Québec database.

RESULTS

Response rate was 75 (31.6%) of 237 from recent graduates and 96% rated their training as excellent or good. Satisfaction with training in computed tomography and magnetic resonance imaging was high, with musculoskeletal (MSK) imaging, particularly MSK ultrasound (US), as well as pediatric, cardiac, and vascular imaging needing more training. Thirty-nine (39.8%) of 98 department chiefs answered the survey and highlighted weaknesses in the interpretation of conventional radiography, obstetrical US, and invasive procedures, as well as limited leadership and administrative skills. Recent graduates and department chiefs both reported difficulties in the ability to interpret daily volume of examinations as scheduled and invasive procedure competency.

CONCLUSION

This survey highlights areas of the radiology curriculum which may benefit from more emphasis during training. Adjustments in the residency program would ensure graduates are successful both in their certification exams and clinical practice.

Availability of a final abdominopelvic CT report before emergency department disposition: risk-adjusted outcomes in patients with abdominal pain

OBJECTIVE

To determine whether availability of a final radiologist report versus an experienced senior resident preliminary report prior to disposition affects major care outcomes in emergency department (ED) patient presenting with abdominal pain undergoing abdominopelvic CT.

MATERIALS AND METHODS

This single-institution, IRB-approved, HIPAA-compliant retrospective cohort study included 5019 ED patients with abdominal pain undergoing abdominopelvic CT from October 2015 to April 2019. Patients were categorized as being dispositioned after either an experienced senior resident preliminary report (i.e., overnight model) or the final attending radiologist interpretation (i.e., daytime model) of the CT was available. Multivariable regression models were built accounting for demographic data, clinical factors (vital signs, ED triage score, laboratory data), and disposition timing to analyze the impact on four important patient outcomes: inpatient admission (primary outcome), readmission (within 30 days), second operation within 30 days, and death.

RESULTS

In the setting of an available experienced senior resident preliminary report, timing of the final radiologist report (before vs. after disposition) was not a significant multivariable predictor of inpatient admission (p = 0.63), readmission within 30 days (p = 0.66), second operation within 30 days (p = 0.09), or death (p = 0.63). Unadjusted event rates for overnight vs daytime reports, respectively, were 37.2% vs. 38.0% (inpatient admission), 15.9% vs. 16.5% (30-day readmission), 0.65% vs. 0.3% (second operation within 30 days), and 0.85% vs. 1.3% (death).

CONCLUSION

Given the presence of an experienced senior resident preliminary report, availability of a final radiology report prior to ED disposition did not affect four major clinical care outcomes of patients with abdominal pain undergoing abdominopelvic CT.

Emergency Computed Tomography: How Misinterpretations Vary According to the Periods of the Nightshift?

OBJECTIVE

To evaluate the accuracy of initial computed tomography (CT) interpretations made by radiology residents during nightshifts in the emergency department.

METHODS

Preliminary CT reports performed by radiology residents during 120 consecutive nightshifts (08:30 pm to 08:30 am) were reviewed, attendings' final interpretation being the reference standard. Nightshifts were divided into four consecutive periods of 3 hours. Major misinterpretations were related to potentially life-threatening conditions if not treated immediately after CT. The rate of misinterpretations was calculated for all CT examinations, separately for nightshift's periods and for residents' training years.

RESULTS

Misinterpretations were recorded in 155 (7.4%) of 2102 CT examinations, 0.6% (13/2102) were major. There were 2.2% (4/186) major misinterpretations that occurred during the last period of the nightshift versus 0.4% (9/1916) during the first periods of the night (P < 0.05). Of all misinterpretations, 8.5% (130/1526) were made by third- and fourth-year residents and 4.3% (25/576) by fifth-year residents (P < 0.005).

CONCLUSIONS

Major misinterpretations occur at the end of the nightshift, which may be explained by the fatigue effect. The rate of misinterpretations is lower among fifth-year residents, which may be related to their prior experience in reading emergency cases.

Radiographic Reread Protocols to Identify Clinically Relevant Errors in Initial Trauma Evaluations

INTRODUCTION

Diagnostic radiology interpretive errors in trauma patients can lead to missed diagnoses, compromising patient care. Due to this, our level II trauma center implemented a reread protocol of all radiographic imaging within 24 hours on our highest trauma activation level (Code T). We sought to determine the efficacy of this reread protocol in identifying missed diagnoses in Code T patients. We hypothesized that a few, but clinically relevant errors, would be identified upon reread.

METHODS

All radiographic study findings (initial read and reread) performed for Code T admissions from July 2015 to May 2016 were queried. The reviewed radiological imaging was given one of four designations: agree with interpretation, minor (non-life threatening) nonclinically relevant error(s)-addendum/correction required or clinically relevant error(s) (major [life threatening] and minor)-addendum/correction required, and trauma surgeon notified. The results were compiled, and the number of each type of error was calculated.

RESULTS

Of the 752 radiological imaging studies reviewed on the 121 Code T patients during this period, 3 (0.40%) contained minor clinically relevant errors, 11 (1.46%) contained errors that were not clinically relevant, and 738 (98.1%) agreed with the original interpretation. The three clinically relevant errors included a right mandibular fracture found on X-ray and a temporal bone fracture that crossed the clivus and bilateral rib fractures found on computerized tomography.

DISCUSSION

Clinically relevant errors, although minimal, were discovered during rereads for Code T patients. Although the clinical errors were significant, none affected patient outcomes. We propose that the implementation of reread protocols should be based upon institution-specific practices.

Interpretation of emergency CT scans in polytrauma: trauma surgeon vs radiologist

Introduction

Time is critical in the trauma setting. Emergency computed tomography (CT) scans are usually interpreted by the attending doctor and plans to manage the patient are implemented before the formal radiological report is available. This study aims to investigate the discrepancy in interpretation of emergency whole body CT scans in trauma patients by the trauma surgeon and radiologist and to determine if the difference in trauma surgeon and radiologist interpretation of emergency trauma CT scans has an impact on patient management.

Method

This prospective observational comparative study was conducted over a 6 month period (01 April–30 September 2016) at the Inkosi Albert Luthuli Central Hospital which has a level 1 trauma department. The study population comprised 62 polytrauma patients who underwent a multiphase whole body CT scans as per the trauma imaging protocol. The trauma surgeons' initial interpretation of the CT scan and radiological report were compared. All CT scans reported by the radiology registrar were reviewed by a consultant radiologist. The time from completion of the CT scan and completion of the radiological report was analysed.

Results

Since the trauma surgeon accompanied the patient to radiology and reviewed the images as soon as the scan was complete, the initial interpretation of the CT was performed within 15–30 min. The median time between the CT scan completion and reporting turnaround time was 75 (16–218) min. Critical findings were missed by the trauma surgeon in 4.8% of patients (bronchial transection, abdominal aortic intimal tear and cervical spine fracture) and non-critical/incidental findings in 41.94%. The trauma surgeon correctly detected and graded visceral injury in all cases.

Conclusion

There was no significant discrepancy in the critical findings on interpretation of whole body CT scans in polytrauma patients by the trauma surgeon and radiologist and therefore no negative impact on patient management from missed injury or misdiagnosis.

The turnaround time for the radiology report does not allow for timeous management of the trauma patient.

Impact of 24/7/365 Attending Radiologist Coverage on the Turnaround Time in an Emergency and Trauma Radiology Department

OBJECTIVE

To study the impact of 24/7/365 attending radiologist coverage on the turnaround time (TAT) of trauma and nontrauma cases in an emergency and trauma radiology department.

PATIENTS AND METHODS

This was a retrospective chart review in which TAT of patients coming to the emergency department between 2 periods: (1) December 1, 2012, to September 30, 2013, and (2) January 1, 2017, to January 30, 2018, and whose reports were read by an attending emergency and trauma radiologist was noted.

RESULTS

The 24/7/365 radiology coverage was associated with a significant reduction in TAT of computed tomography reports, and the time reduction was comparable between trauma and nontrauma cases. In adjusted models, the extension of radiology coverage was associated with an average of 7.83 hours reduction in overall TAT (95% confidence interval [CI]: 7.44-8.22) for reports related to trauma, in which 2.73 hours were due to reduction in completion to transcription time (TC; 95% CI: 2.53-2.93), and 5.10 hours were due to reduction in transcription to finalization time (TF; 95% CI: 4.75-5.44). For reports related to nontrauma cases, 24/7/365 coverage was associated with an average of 6.07 hours reduction in overall TAT (95% CI: 3.54-8.59), 2.91 hours reduction in TC (95% CI: 1.55-4.26), and 3.16 hours reduction in TF (95% CI: 0.90-5.42).

CONCLUSION

Our pilot study demonstrates that the implementation of on-site 24/7/365 attending emergency radiology coverage at a tertiary care center was associated with a reduced TAT for trauma and nontrauma patients imaging studies. Although the magnitude and precision of estimates were slightly higher for trauma cases as compared to nontrauma cases. Trauma examinations stand to benefit the most from 24/7/365 attending level radiology coverage.

Exploratory data analysis for pre and post 24/7/365 attending radiologist coverage support in an emergency department: fundamentals of data science

OBJECTIVE

To present a detailed exploratory data analysis for critically investigating the patterns in medical doctor (MD) to disposition time, pre and post 24/7/365 attending radiologist coverage, for patients presenting to an emergency department (ED).

MATERIALS AND METHODS

The process involved presenting several modeling techniques. To share an understanding of concepts and techniques, we used proportions, medians, and means, Mann-Whitney U test, Kaplan-Meier's (KM) survival analysis, linear and log-linear regression, log-ranked test, Cox proportional hazards model, Weibull parametric survival models and tertile analysis. Retrospective chart review was conducted to obtain a data set which was used to determine the trends in MD to disposition time. Data comprised of patients who had visited the emergency department (ED) during two distinct time periods and whose imaging studies were read by an attending emergency and trauma radiologist.

RESULTS

Median provided more insight into the data as compared with the mean. The Mann-Whitney U test was appropriate to evaluate MD to disposition time, but provided limited information. The Kaplan-Meier (KM) was able to offer more insight into the data since it did not assume an underlying model and that is the reason why it was appropriate. However, KM had limited ability to handle measured confounders and was unable to describe the magnitude of difference between curves. The Cox proportional hazards semi-parametric model or some other parametric model such as the Weibull could handle multiple measured confounders and described the magnitude of difference between two (survival) groups in the data set. However, both methods assumed underlying models that may not apply to the data set such as the one used in this study. Linear regression was unlikely to be appropriate due to the shape of survival time distributions, but log transforming the outcome could address the distribution issue. Nearly all the results of the KM subgroup analyses were consistent with the results of the log-transformed linear regression subgroup analyses and the interpretation of the results was the same for both.

CONCLUSION

Different statistical procedures may be applied to conduct exploratory subgroup analysis for a data set from a pre and post 24/7/365 attending coverage model. This could guide potential areas of further research to compare trends in MD to disposition time in ED. Pattern analysis provides evidence for various stakeholders to rethink the discourse about trends in MD to disposition time, pre and post 24/7/365 attending coverage. Graphical Illustration: The role of Emergency and Trauma Radiology in an Emergency Department.

Discrepancies in interpretation of night-time emergency computed tomography scans by radiology residents

Background

In many emergency radiology units, most of the night-time work is performed by radiology residents. Residents’ preliminary reports are typically reviewed by an attending radiologist. Accordingly, it is known that discrepancies in these preliminary reports exist.

Purpose

To evaluate the quality of night-time computed tomography (CT) interpretations made by radiology residents in the emergency department.

Material and Methods

Retrospectively, 1463 initial night-time CT interpretations given by a radiology resident were compared to the subspecialist’s re-interpretation given the following weekday. All discrepancies were recorded and classified into different groups regarding their possible adverse effect for the emergency treatment. The rate of discrepancies was compared between more and less experienced residents and between different anatomical regions.

Results

The overall rate of misinterpretations was low. In 2.3% (33/1463) of all night-time CT interpretations, an important and clinically relevant diagnosis was missed. No fatalities occurred due to CT misinterpretations during the study. The total rate of discrepancies including clinically irrelevant findings such as anatomical variations was 12.2% (179/1463). Less experienced residents were more likely to miss the correct diagnosis than more experienced residents (18.3% vs. 10.9%, odds ratio [OR] = 1.82, P = 0.001). Discrepancies were more common in body CT interpretations than in neurological CTs (18.1% vs. 9.1%, OR = 2.30, P < 0.0001).

Conclusion

The rate of clinically important misinterpretations in CT examinations by radiology residents was found to be low. Experience helps in lowering the rate of misinterpretations.

Overnight Resident versus 24-hour Attending Radiologist Coverage in Academic Medical Centers

Academic medical centers have long relied on radiology residents to provide after-hours coverage, which means that they essentially function with autonomy. In this approach, attending radiologist review of resident interpretations occurs the following morning, often by subspecialist faculty. In recent years, however, this traditional coverage model in academic radiology departments has been challenged by an alternative model, the 24-hour attending radiologist coverage. Proponents of this new model seek to improve patient care after hours by increasing report accuracy and the speed with which the report is finalized. In this article, we review the traditional and the 24-hour attending radiologist coverage models. We summarize previous studies that indicate that resident overnight error rates are sufficiently low so that changing to an overnight attending model may not necessarily provide a meaningful increase in report accuracy. Whereas some centers completely replaced overnight residents, we note that most centers use a hybrid model, and overnight residents work alongside supervising attending radiologists, much as they do during the day. Even in this hybrid model, universal double reading and subspecialist final review, typical features of the traditional autonomous resident coverage model, are generally sacrificed. Because of this, changing from resident coverage to coverage by an attending radiologist that is 24 hours/day, 7 days/week may actually have detrimental effects to patient safety and quality of care provided. Changing to an overnight attending radiologist model may also have negative effects on the quality of radiology resident training, and it significantly increases cost.

Diagnostic performance of emergency physician-performed point-of-care ultrasonography for acute appendicitis: A meta-analysis

OBJECTIVE

To assess the sensitivity and specificity of emergency physician-performed point-of-care ultrasonography (EP-POCUS) for diagnosing acute appendicitis (AA).

MATERIAL AND METHODS

The PubMed and EMBASE databases were searched, and the diagnostic performance of EP-POCUS was evaluated using bivariate modeling and hierarchical summary receiver operating characteristic curves. Subgroup analysis was performed for pediatric patients to compare EP-POCUS and radiologist-performed ultrasonography (RADUS). Meta-regression analyses were performed according to patient and study characteristics.

RESULTS

In 17 studies (2385 patients), EP-POCUS for diagnosing AA exhibited a pooled sensitivity of 84% (95% confidence interval [CI]: 72%-92%) and a pooled specificity of 91% (95% CI: 85%-95%), with even better diagnostic performance for pediatric AA (sensitivity: 95%, 95% CI: 75%-99%; specificity: 95%, 95% CI: 85%-98%). A direct comparison revealed no significant differences (p = 0.18-0.85) between the diagnostic performances of EP-POCUS (sensitivity: 81%, 95% CI: 61%-90%; specificity: 89%, 95% CI: 77%-95%) and RADUS (sensitivity: 74%, 95% CI: 65%-81%; specificity: 97%, 95% CI: 93%-98%). The meta-regression analyses revealed that study location, AA proportion, and mean age were sources of heterogeneity. Higher sensitivity and specificity tended to be associated with an appendix diameter cut-off value of 7 mm and the EP as the initial operator.

CONCLUSION

The diagnostic performances of EP-POCUS and RADUS were excellent for AA, with EP-POCUS having even better performance for pediatric AA. Accurate diagnoses may be achieved when the attending EP is the initial POCUS operator and uses a 7-mm cut-off value.

The Clinical Impact of Resident-attending Discrepancies in On-call Radiology Reporting: A Retrospective Assessment

RATIONALE AND OBJECTIVES

The purpose of this study is to quantify the clinical impact of resident-attending discrepancies at a tertiary referral academic radiology residency program by assessing rates of intervention, discrepancy confirmation, recall rate, and management change rate; furthermore, a discrepancy categorization system will be assessed.

MATERIALS AND METHODS

Retrospective review of the records was performed for n = 1482 discrepancies that occurred in the 17-month study period to assess the clinical impact of discrepancies. Discrepancies were grouped according to a previously published classification system. Management changes were recorded and grouped by severity. The recall rate was estimated for discharged patients. Any confirmatory testing was reviewed to evaluate the accuracy of the discrepant report. Categorical variables were compared to the chi-square test.

RESULTS

The 1482 discrepancies led to management change in 661 cases (44.6%). The most common management change was follow-up imaging. Procedural interventions including surgery occurred in 50 cases (3.3%). The recall rate was 2.6%. Management changes were more severe with computed tomography examinations, inpatients, and when the discrepancy was in the chest and abdomen subspecialty. Also, management changes correlated with the discrepancy category assigned by the attending at the time of review.

CONCLUSIONS

Resident-attending discrepancies do cause management changes in 44.6% of discrepancies (0.62% overall); the most frequent change is follow-up imaging. The discrepancy categorization assigned by the attending correlated with the severity of management change.

Preliminary Interpretations of Transthoracic Echocardiograms by Cardiology Fellows

BACKGROUND

Echocardiograms are often obtained after business hours on an urgent or emergent basis to assist in the care of patients with complex presentations. Considerable variation exists among academic medical centers with regard to who performs and interprets these studies, with different levels of cardiology fellow involvement in scanning and/or interpreting. On-call echocardiographic interpretation can be educationally valuable for cardiologists in training but may come at the expense of patient care. The aim of this study was to examine the agreement of preliminary fellows' interpretations of weekend on-call transthoracic echocardiograms with official attending cardiologists' interpretations.

METHODS

Cardiology fellows perform preliminary interpretations of sonographer-obtained echocardiograms obtained on weekends, with final reports performed by attending cardiologists the following business day. In this study, 358 consecutive echocardiograms obtained on weekends over a 12-month period were reviewed. Discrepancies between the preliminary and final interpretations were categorized as either major (diagnoses with implications for urgent change in management) or minor (diagnoses without such implications). All discrepancies were also categorized as a missed diagnosis, an overcall (of severity), or an undercall.

RESULTS

No preliminary interpretation was identified in 18.4% of the studies (66 of 358). Of the remaining on-call echocardiograms (n = 292), the overall discrepancy rate in interpretations between fellows and attending cardiologists was 16.8%. Out of these, the minor discrepancy rate was 14.4% (42 of 292), and the major discrepancy rate was 2.4% (seven of 292). Misses, overcalls, and undercalls accounted for 29%, 31%, and 40% of all discrepancies, respectively.

CONCLUSIONS

The results indicate that although minor discrepancies between fellows' and attending cardiologists' interpretations were common (14.4%), major discrepancies were uncommon (2.4%) and similar to major discrepancy rates from the radiology literature. In general, discrepant interpretations were more likely to result from changes in severity, but misses accounted for almost all of the major discrepancies. Further research is needed to compare the clinical impact of different models of on-call echocardiographic services.

The accuracy of interpretation of emergency abdominal CT in adult patients who present with non-traumatic abdominal pain: results of a UK national audit

AIM

To evaluate major/minor discrepancy rates for provisional (initial) and addendum (supplementary senior review) emergency computed tomography (CT) reports in patients presenting with non-traumatic abdominal pain.

MATERIALS AND METHODS

Ethical approval for this type of study is not required in the UK. All radiology departments with an approved lead for audit registered with the Royal College of Radiologists were invited to participate in this retrospective audit. The first 50 consecutive patients (25 surgical, 25 non-surgical) who underwent emergency abdominal CT for non-traumatic abdominal pain in 2013 were included. Statistical analyses were performed to identify organisational and report/patient-related variables that might be associated with major discrepancy.

RESULTS

One hundred and nine (58%) of 188 departments supplied data to the study with a total of 4,931 patients (2,568 surgical, 2,363 non-surgical). The audit standard for provisional report major discrepancy was achieved for registrars (target <10%, achieved 4.6%), for on-site consultants (target <5%, achieved 3.1%) and consultant addendum (target <5%, achieved 2.9%). Off-site reporters failed to meet the standard target (<5%, achieved 8.7% overall and 12.7% in surgical patients). The standard for patients coming to harm was not met in the surgical group (target <1%, achieved 1.5%) and was narrowly missed overall (target <1%, achieved 1%).

CONCLUSION

This study should be used to provide impetus to improve aspects of out-of-hours CT reporting. Clear benefits of CT interpretation/review by on-site and more senior (consultant) radiologists have been demonstrated.

Discrepancy rates in reporting of acute stroke CT

INTRODUCTION

With increasing after-hours workloads there has been reliance on registrars to report after-hours acute stroke CT scans at our institution. This practice was reviewed for the perceived possibility of error and poor patient outcomes by the reliance on after-hours registrar reports. Through an audit of 3 years of these studies, we proposed to investigate if our current practice is safe and whether it results in poor patient outcomes.

METHODS

Following ethics approval, all after-hours acute stroke CT scan reports from September 2012 to August 2015 were identified using the PACS. All reports were reviewed with data recorded on a written worksheet then transferred to an Excel spreadsheet for analysis. The consultant report was used as the gold standard. In cases where discrepancies occurred, medical records were reviewed.

RESULTS

Eight hundred and ninety-four acute stroke CT scans were identified in the audit period with a subset of 316 studies identified where a registrar report was issued at time of scan and checked the following day by a radiology consultant. There were 114 discrepancies (10 were major, 51 were minor, and 53 other). In three discrepancy cases, the patient's clinical course was altered. There were no adverse outcomes as a result of a discrepancy. Using a radiology consultant as the gold standard the major discrepancy rate was ≈3% in the after-hours setting.

CONCLUSION

Our 3 year retrospective audit demonstrates that our practice of registrar report issued at the time of CT scan checked the following day by a radiologist has a low major discrepancy rate and that patient safety was not compromised. These results support the continuation of our current practice.

Interpretations of diffusion-weighted MR imaging by radiology residents in the emergency department: is diagnostic performance influenced by the level of residency training?

BACKGROUND

To evaluate the diagnostic performance of radiology residents' interpretations for diffusion-weighted MR imaging (DWI) in the emergency department at different levels of residency training.

METHOD AND MATERIALS

A total of 160 patients who underwent DWI with acute neurologic symptoms were included in this retrospective study with an institutional review board approval. Four radiology residents with different training years and one attending neuroradiologist independently assessed the DWI results. Discordances between the results of residents and attending neuroradiologist were classified as follows: false positive (FP) and false negative (FN). We also evaluated the diagnostic performance of four residents according to the reference standard.

RESULTS

Overall, the concordance rate was 84.8 %, with a 15.2 % overall discordance rate. There were 83 FN results. The most common misses were small vessel disease (n = 55), acute focal infarction (n = 10), diffuse axonal injury (n = 6), solitary mass (n = 5), extraaxial hemorrhages (n = 3), posterior reversible encephalopathy syndrome (n = 2), and postictal change (n = 2). Fourteen FP results were interpreted as hemorrhage and acute infarction. The 4th year resident exhibited the highest diagnostic performance, and the level of training had a significant influence on the rates of concordance (P < 0.05). Interobserver reliability was good between the interpretations of the residents and the final interpretations of the attending neuroradiologists.

CONCLUSION

The level of resident training had a significant effect on their diagnostic performance, and good interobserver reliability was noted between the results of the residents and attending neuroradiologist.

On-Call Radiology Resident Discrepancies: Categorization by Patient Location and Severity

PURPOSE

To report discrepancy rates for examinations interpreted by on-call residents overall and by resident training level, and to describe a novel discrepancy classification system based on patient location and severity that facilitates recording of discrepancy data, helps ensure proper communication of report changes, and allows our radiology department to assume responsibility for contacting discharged patients with non-time-dependent results.

METHODS

A HIPAA-compliant, institutional review board-exempt review of two years (January 2013 to December 2014) of discrepancy data was retrospectively performed for total number of examination interpreted, discrepancy rates, resident training level, and discrepancy categories. Most common diagnoses and means of results communication for discharged patients were also recorded.

RESULTS

Radiology residents interpreted 153,420 examinations after hours and had 2169 discrepancies, for an overall discrepancy rate of 1.4%. Discrepancy rates for postgraduate year (PGY)-3, PGY-4, and PGY-5 residents were 1.31%, 1.65%, and 1.88%, respectively. The rate of critical discrepancies was extremely low (10/153,420 or 0.007%). A total of 502 patients (23.2% of all discrepancies) were discharged at the time their discrepancy was identified, 60% of whom had non-time-dependent discrepancies that were communicated by radiologists; 32.4% of these had addended results telephoned to a PCP, 43.4% had addended results telephoned to the patient, and the remaining 24.2% required a registered letter. Eight percent of patients with non-time-dependent findings were lost to follow-up.

CONCLUSIONS

Our resident discrepancy rates were comparable to those published previously, with extremely low rates of critical discrepancies. Radiologists assumed responsibility for contacting the majority of discharged patients with discrepant results, a minority of whom were lost to follow-up.

Second-Opinion Subspecialty Consultations in Musculoskeletal Radiology

OBJECTIVE

The purpose of this article is to evaluate the significance of subspecialty second-opinion consultations for CT and MRI examinations in musculoskeletal (MSK) radiology.

MATERIALS AND METHODS

All 3165 MSK CT and MRI examinations referred to one academic institution for second-opinion consultation during a 24-month period were reviewed by three MSK-trained radiologists. Outside and inside reports were compared by two independent MSK radiology fellows using a previously published 5-point scale. Clinically important differences (categories 4 and 5) were defined as those likely to change patient management. Statistical comparisons of rates were performed using a chi-square test with Bonferroni corrections. Interobserver reliability was reported using linear weighted kappa statistics and the percentage of agreement.

RESULTS

Of all second-opinion examinations, 73.5% (2326/3165) had an outside report available for comparison and inclusion in this study. There were 610 of 2326 (26.2%) examinations with clinically important differences. The rate of clinically important discrepant readings was even higher in oncologic cases (36.3%; 331/911). When the final diagnosis was determined from pathology reports performed after internal interpretation, the second-opinion consultation was noted to be correct in 82.0% (334/407) of examinations with category 4 or 5 discrepancies. There was very good agreement (κ = 0.93) in scoring the discrepancies between second-opinion consultants.

CONCLUSION

The subspecialty second-opinion consultation was more accurate than outside reports in 82.0% of examinations when pathologic confirmation was made. A moderate rate (26.2%) of discrepant interpretations was noted between outside and inside MSK imaging examinations, especially in tumor cases (36.3%). Most discrepancies were in interpreting rather than detecting abnormalities.

Variability in Observer Performance Between Faculty Members and Residents Using Breast Imaging Reporting and Data System (BI-RADS)-Ultrasound, Fifth Edition (2013)

Background

Ultrasonography (US) is a useful tool for breast imaging, yet is highly operator-dependent.

Objectives

We evaluated inter-observer variability and performance discrepancies between faculty members and radiology residents when describing breast lesions, by the fifth edition of breast imaging reporting and data system (BI-RADS)-US lexicon, and then attempted to identify whether inter-observer variability could be improved after one education session.

Patients and Methods

In total, 50 malignant lesions and 70 benign lesions were considered in our retrospective study. Two faculty members, two senior residents, and two junior residents separately assessed the US images. After the first assessment, the readers received one education session, and then reassessed the images in a random order. Inter-observer variability was measured using the kappa coefficient (κ). Performance discrepancy was evaluated by receiver operating characteristic (ROC) curves.

Results

For the faculty members, fair-to-good agreement was obtained in all descriptors and final assessment, while for residents, poor-to-moderate agreement was obtained. The areas under the ROC curves were 0.78 for the faculty members, 0.59 for the senior residents, and 0.52 for the junior residents, respectively. Diagnostic performance was significantly higher in the faculty members than the senior and junior residents (P = 0.0001 and < 0.0001, respectively). After one education session, the agreement in the final assessment was one level higher in the faculty members and senior residents, yet in the senior residents, the degree of agreement was still only fair. Moreover, in the junior residents, there was no improvement.

Conclusion

Investigative assessment of breast US by residents is inadvisable. We recommend continued professional resident training to improve the degree of agreement and performance.

The clinical impact of subspecialized radiologist reinterpretation of abdominal imaging studies, with analysis of the types and relative frequency of interpretation discrepancies

PURPOSE

The primary objective of this study was to determine the clinical impact and value of abdominal imaging reinterpretations by subspecialized abdominal imagers.

METHODS

Secondary interpretations for computed tomography (CT), magnetic resonance (MR), and ultrasound (US) abdominal studies performed outside our institution over a 7-month period were retrospectively compared to the primary (outside) interpretation, with interpretive differences recorded. Clinical notes, pathology and subsequent imaging determined ground truth diagnosis and the clinical impact of any interpretive discrepancies were graded as having high, medium, or little/no clinical impact. Interpretive comparisons were scored into categories: (1) no difference; (2) incidental findings of no clinical impact; (3) finding not reported; (4) significance of finding undercalled; (5) significance of finding overcalled; (6) finding misinterpreted; and (7) multiple discrepancy types in one report.

RESULTS

398 report comparisons were reviewed on 380 patients. There were 300 CT, 60 MR, and 38 US examinations. The primary report had 5.0% (20/398) high clinical impact interpretive discrepancies and 7.5% (30/398) medium clinical impact discrepancies. The subspecialized secondary report had no high clinical impact discrepancies and 8/398 (2.0%) medium clinical impact discrepancies. In order of frequency, high and medium impact discrepancies in the primary report consisted of 50% overcalls, 26% unreported findings, 18% undercalls, 4% misinterpretations, and 2% multiple discrepancies.

CONCLUSIONS

Subspecialty review of abdominal imaging exams can provide clinical benefit. Half of the discrepancies in this series of abdominal reinterpretations were due to overcalls.

The discrepancy rate between preliminary and official reports of emergency radiology studies: a performance indicator and quality improvement method

BACKGROUND

At teaching hospitals, radiology residents give preliminary reports for imaging studies requested from the Emergency Department (ED). Discrepancy rates between preliminary and final reports represent an important performance indicator.

PURPOSE

To present a system for feedback and follow-up of discrepancies, identify the variables associated with the rate and severity of such discrepancies, target the weaknesses, and suggest the need of a standard reference value for comparison among institutions.

MATERIAL AND METHODS

A monitoring and communication system between the Department of Diagnostic Radiology and Emergency Department was initiated to mark and follow all studies from the ED for which the official reading was different than the preliminary interpretation. Data analysis was performed on all studies from 1 June 2011 to 31 May 2012, based on the severity of the discrepancy, imaging modality, resident training level, and organ system. The distribution of the number of discrepancies among the different resident levels and imaging modalities was determined, as well as the distribution of three severity scores in correlation with other variables.

RESULTS

The overall discrepancy rate was 1.62%. The discrepancy rate was higher for first and second year residents (1.62% and 1.96%) than for third and fourth year residents (1.35% and 1.24%). It was higher for computed tomography (2.13%) than for radiographs (1.29%) and ultrasound (0.8%) (P value < 0.01), and higher for musculoskeletal (1.61%) than non-musculoskeletal (0.99%) radiographs (P value = 0.0003). Discrepancies with severity score one constituted 35.5% of the total discrepancies, those with severity scores two and three constituted 22.9% and 41.6%, respectively.

CONCLUSION

We have demonstrated a system for follow-up of discrepancy in interpreting emergency radiology studies, and recorded the discrepancy rate, with further analysis based on different variables. In terms of quality assurance, a periodical analysis might help to reduce the number of discrepant reports by targeted intervention.

Double reading rates and quality assurance practices in Norwegian hospital radiology departments: two parallel national surveys

BACKGROUND

Double reading as a quality assurance (QA) tool is employed extensively in Norwegian hospital radiology departments. The practice is resource consuming and regularly debated.

PURPOSE

To investigate the rates of double reading in Norwegian hospital radiology departments, to identify department characteristics associated with double reading rates, and to investigate associations between double reading and other quality improvement.

MATERIAL AND METHODS

We issued two parallel national surveys to management and to consultant radiologists, respectively. Management was defined as the chief medical officer and/or the head of the radiology department. The management survey covered staffing, perceived resource situation, double reading, guidelines, and quality improvement. The radiologist survey served to validate management responses concerning double reading. Management survey items concerning practices of quality improvement were organized into three indices reflecting different quality approaches, namely: appropriateness of investigations; personal performance feedback; and system performance feedback.

RESULTS

The response rates of the surveys were 100% (45/45) for management and 55% (266/483) for radiologists. Of all exams read by consultants, 33% were double read. The double reading rate was highest in university hospital departments (59%), intermediate in other teaching departments (30%), and lowest in non-teaching departments (11%) (P = 0.01). Among the quality indices, mean scores were highest on appropriateness index (68%), intermediate on the person index (56%), and lowest on system index (37%). There were no correlations between double reading rates and scores on any of the quality indices.

CONCLUSION

The rate of double reading in Norwegian hospital radiology is significantly correlated to department teaching status, but not to other practices of quality work.

Reliability of on-call radiology residents' interpretation of 64-slice CT pulmonary angiography for the detection of pulmonary embolism

BACKGROUND

Computed tomography (CT) angiography for pulmonary embolism (PE) is the present standard for diagnosing PE. In many teaching hospitals, radiology residents are the first to review the case and to make an initial interpretation of the images. Accurate diagnosis of PE is crucial, especially in the emergency care setting.

PURPOSE

To evaluate the discrepancies between resident and staff interpretations of 64-slice CT angiogram for PE.

MATERIAL AND METHODS

Discrepancies between the preliminary reports by the on-call radiology resident were compared to the final report by the staff radiologist in 215 consecutive cases of 64-slice CT angiogram performed for PE, from May 2005 to March 2008.

RESULTS

Discrepancies were noted in 25 of the 215 studies (11.6%). These residents' discrepancies consisted of three false-positive, four false-negative, and 18 equivocal cases. There was a decrease in the discrepancy rate from the second year to the fifth year of training by approximately 60%.

CONCLUSION

The rate of discrepancy fell steeply between the second and fifth year of the residents training from 18.5% to 6.9%. Our study suggests that it is reasonable to have on-call radiology residents perform the preliminary interpretations of 64-slice CT for PE studies.

Residents' performance in the interpretation of on-call "triple-rule-out" CT studies in patients with acute chest pain

RATIONALE AND OBJECTIVES

To evaluate the performance of radiology residents in the interpretation of on-call, emergency "triple-rule-out" (TRO) computed tomographic (CT) studies in patients with acute chest pain.

MATERIALS AND METHODS

The study was institutional review board-approved and Health Insurance Portability and Accountability Act compliant. Data from 617 on-call TRO studies were analyzed. Dedicated software enables subspecialty attendings to grade discrepancies in interpretation between preliminary trainee reports and their final interpretation as "unlikely to be significant" (minor discrepancies) or "likely to be significant" for patient management (major discrepancies). The frequency of minor, major and all discrepancies in resident's TRO interpretations was compared to 609 emergent non-electrocardiography (ECG)-synchronized chest CT studies using Pearson χ(2) test.

RESULTS

Minor discrepancies occurred more often in the TRO group (9.1% vs. 3.9%, P < .001), but there was no difference in the frequency of major discrepancies (2.1% vs. 2.8%, P = .55). Minor discrepancies in the TRO group most commonly resulted from missed extrathoracic findings with missed liver lesions being the most frequent. Major discrepancies mostly encompassed cardiac and extracardiac vascular findings but did not result in unnecessary interventions, significant immediate changes in management, or adverse patient outcomes.

CONCLUSIONS

On-call resident interpretation of TRO CT studies in patients with acute chest pain is congruent with final subspecialty attending interpretation in the overwhelming majority of cases. The rate of discrepancies likely to affect patient management in this domain is not different from emergent non-ECG-synchronized chest CT.

24/7/365 in-house radiologist coverage: effect on resident education

RATIONALE AND OBJECTIVES

To compare programs with and without 24-hour/7 days a week/365 days a year (24/7/365) in-house radiologist coverage regarding resident perceptions of their on-call experience, volume of resident dictations on call, and report turnaround time.

MATERIALS AND METHODS

Residents from six academic radiology departments were invited to participate in an 11-item online survey. Survey items were related to workload, level of autonomy, faculty feedback, comfort level, faculty supervision, and overall educational experience while on call from 8 pm to 8 am. Each site provided data on imaging volume, radiologist coverage, volume of examinations dictated by residents, number of residents on call, and report turnaround time from 8 pm to 8 am. F-ratios and eta-squares were calculated to determine the relationships between dependent and independent variables. A P value < .05 was considered statistically significant.

RESULTS

A total of 146 (67%) of 217 residents responded. Residents in programs with 24/7/365 in-house radiologist coverage dictated a lower percentage of examinations (46%) compared with other residents (81%) and rated faculty feedback more positively (mean 3.8 vs. 3.3) but rated their level of autonomy (mean 3.6 vs. 4.5) and educational experience (mean 3.6 vs. 4.2) more negatively (all P < .05). Report turnaround time was lower in programs with 24/7/365 coverage than those without (mean 1.7 hours vs. 9.1 hours). The majority of resident comments were negative and related to loss of autonomy with 24/7/365 coverage.

CONCLUSION

More rapid report turnaround time related to 24/7/365 coverage may come at the expense of resident education.

Clinical impact of extending after-hours radiology coverage for emergency department computed tomography imaging

Background

Academic emergency departments (EDs) are often reliant on preliminary interpretation by radiology residents for after-hours computed tomography (CT) images. Identifying residents’ errors in diagnostic interpretation and ensuring appropriate contact with affected patients are areas of continuing concern.

Objective

The Mount Sinai Hospital ED and Medical Imaging Department in Toronto, Canada sought to examine the clinical impact of extending reporting hours of senior attending radiologists for ED patients undergoing CT imaging.

Methods

All evening CT studies were read by the on-call sub-specialist staff radiologist before 10 pm; while studies done after 10 pm were read by 8 am, permitting review of final reports by the ordering ED physician. A retrospective review of radiology and ED metrics was performed on ED patients undergoing CT imaging 12 weeks before and 12 weeks after implementation of the extended reading hours.

Results

In the 12 weeks prior to implementation of extended senior attending radiologist coverage, 871 CT scans were performed as compared to 944 CT scans after implementation. Time from performance of CT scan to obtaining a dictated report decreased from 10.4 hours to 2.8 hours (P<0.001), and time from performance of CT scan to report verification by the radiologist decreased from 29.7 hours to 9.4 hours (P<0.001). There were no statistically significant changes in ED length of stay, rates of admission, or rates of consultation. However, there was a significant reduction in (median) time taken for ED physicians to resolve discrepant reports in the radiology information system queue (20.7 hours versus 13.3 hours, P<0.001).

Conclusion

The extension of reporting hours reduced the time for ED physicians to review discrepant reports, while balancing educational needs of residents. This project has been considered a success by stakeholders and has now been implemented on a permanent basis.

Review of outside studies by radiology residents: national survey of chief residents

The purpose of this study was to establish practice patterns of radiology residents in regards to interpretation and reporting of outside studies for transferred patients. We performed a national survey of radiology residency chief residents, administered by email through the Association of Program Directors in Radiology (APDR). There were 81 chief resident respondents, representing 42.8 % of 187 total Accreditation Council for Graduate Medical Education (ACGME)-approved radiology residency training programs in the USA. In 97.5 % of programs, residents perform interpretations of outside studies. Up to 76.7 % of respondents state that when outside studies are reviewed by residents, an original report is available in less than one quarter of cases. While 55.1 % of respondents state that there is a mechanism for recording their findings and impressions for outside studies, only 32.1 % are aware of a policy requiring documentation. Of the respondents, 42.3 % report they have no means for documenting their findings and impressions on outside studies. Further, 65.4 % state that there is no policy requiring an attending to review and document agreement with their interpretation of outside studies. There is wide institutional variation in both policy and practice regarding reinterpretation of outside studies for patients transferred to academic hospitals. While the majority of radiology residents are providing the service of reinterpreting outside studies, only a minority of residency programs have a policy requiring (1) documentation of their impressions or (2) attending oversight and documentation of discrepant opinions.