Critical findings: timing of notification in neuroradiology

Utilization of Teleradiology by Intensive Care Units: A Cohort Study

Aim and background

Imaging is indispensable to the diagnostic and treatment process. By facilitating access to rapid timely image interpretation, teleradiology plays a prominent role in improving access, quality of critical care, and management of the patients in intensive care units (ICU). The aim of the study is to investigate the role of teleradiology in ICU patient care and management.

Materials and methods

In our study, a total of 22,081 studies of a cohort of 14,900 patients which had been transmitted from intensive care units of 80 hospitals located across the United States of America through a teleradiology reporting workflow, were interpreted by the American Board Certified Radiologists empanelled by a teleradiology service provider, located in India.

Results

Among all modalities, the highest percentage of studies performed were computed tomography scan (47%) followed by radiographs (37.22%). Out of 22,081 cases under the study, 16,582 cases were reported during nighttime with a mean turnaround time (TAT) of 46.66 minutes 95% CI (46.27-47.04) while 5,499 cases were reported during daytime with a mean TAT of 44.66 minutes 95% CI (45.40-43.92).

Conclusion

Setting up teleradiology service connectivity with a teleradiology service provider located in India, providing high-quality diagnostic interpretations and lower turnaround time with the ICUs in the US hospitals reduces the interval to intervention time and leads to efficient patient care management. Moreover, it also provides time advantage for US hospitals when on-site radiologists at night are unable to provide immediate coverage.

Clinical significance

The ICU teleradiology service model designed in the study would greatly help overcome the shortfall of radiologists in the hospitals, provide better patient management and care by quality reporting in short turnaround time, not only during daytime but also in the night hours or on holidays when on-site radiologists are unable to provide immediate coverage.

How to cite this article

Rao P, Mathur N, Kalyanpur A. Utilization of Teleradiology by Intensive Care Units: A Cohort Study. Indian J Crit Care Med 2024;28(1):20-25.

Machine Learning and Improved Quality Metrics in Acute Intracranial Hemorrhage by Noncontrast Computed Tomography

OBJECTIVE

The timely reporting of critical results in radiology is paramount to improved patient outcomes. Artificial intelligence has the ability to improve quality by optimizing clinical radiology workflows. We sought to determine the impact of a United States Food and Drug Administration-approved machine learning (ML) algorithm, meant to mark computed tomography (CT) head examinations pending interpretation as higher probability for intracranial hemorrhage (ICH), on metrics across our healthcare system. We hypothesized that ML is associated with a reduction in report turnaround time (RTAT) and length of stay (LOS) in emergency department (ED) and inpatient populations.

MATERIALS AND METHODS

An ML algorithm was incorporated across CT scanners at imaging sites in January 2018. RTAT and LOS were derived for reports and patients between July 2017 and December 2017 prior to implementation of ML and compared to those between January 2018 and June 2018 after implementation of ML. A total of 25,658 and 24,996 ED and inpatient cases were evaluated across the entire healthcare system before and after ML, respectively.

RESULTS

RTAT decreased from 75 to 69 minutes (P <0.001) at all facilities in the healthcare system. At the level 1 trauma center specifically, RTAT decreased from 67 to 59 minutes (P <0.001). ED LOS decreased from 471 to 425 minutes (P <0.001) for patients without ICH, and from 527 to 491 minutes for those with ICH (P = 0.456). Inpatient LOS decreased from 18.4 to 15.8 days for those without ICH (P = 0.001) and 18.1 to 15.8 days for those with ICH (P = 0.02).

CONCLUSION

We demonstrated that utilization of ML was associated with a statistically significant decrease in RTAT. There was also a significant decrease in LOS for ED patients without ICH, but not for ED patients with ICH. Further evaluation of the impact of such tools on patient care and outcomes is needed.

Artificial Intelligence Applications for Workflow, Process Optimization and Predictive Analytics

There is great potential for artificial intelligence (AI) applications, especially machine learning and natural language processing, in medical imaging. Much attention has been garnered by the image analysis tasks for diagnostic decision support and precision medicine, but there are many other potential applications of AI in radiology and have potential to enhance all levels of the radiology workflow and practice, including workflow optimization and support for interpretation tasks, quality and safety, and operational efficiency. This article reviews the important potential applications of informatics and AI related to process improvement and operations in the radiology department.

Contextual Structured Reporting in Radiology: Implementation and Long-Term Evaluation in Improving the Communication of Critical Findings

Structured reporting contributes to the completeness of radiology reports and improves quality. Both the content and the structure are essential for successful implementation of structured reporting. Contextual structured reporting is tailored to a specific scenario and can contain information retrieved from the context. Critical findings detected by imaging need urgent communication to the referring physician. According to guidelines, the occurrence of this communication should be documented in the radiology reports and should contain when, to whom and how was communicated. In free-text reporting, one or more of these required items might be omitted. We developed a contextual structured reporting template to ensure complete documentation of the communication of critical findings. The WHEN and HOW items were included automatically, and the insertion of the WHO-item was facilitated by the template. A pre- and post-implementation study demonstrated a substantial improvement in guideline adherence. The template usage improved in the long-term post-implementation study compared with the short-term results. The two most often occurring categories of critical findings are “infection / inflammation” and “oncology”, corresponding to the a large part of urgency level 2 (to be reported within 6 h) and level 3 (to be reported within 6 days), respectively. We conclude that contextual structured reporting is feasible for required elements in radiology reporting and for automated insertion of context-dependent data. Contextual structured reporting improves guideline adherence for communication of critical findings.

Impact of an educational initiative targeting non-radiologist staff on overall notification times of critical findings in radiology

INTRODUCTION

The timely reporting of critical findings is considered by the Joint Commission as one of the main patient safety goals. Delays in critical radiological findings communication are directly related to delayed treatment initiation and death, constituting a major cause of medical malpractice suits. The aim of this study was to evaluate the impact of an educational initiative performed to reduce the notification times of critical radiological findings.

MATERIALS AND METHODS

All records of critical findings reported in the Radiology Department were evaluated. The notification times before and after performing the educational intervention taking into account the patient type, study, and critical diagnosis were calculated, evaluated, and compared. T test and chi-square test were used for statistical analysis, considering a p value less than 0.05 to indicate statistically significant differences.

RESULTS

We included 1949 reports, 805 before (41.3%) and 1144 (58.7%) after the intervention. Before the intervention, the mean time of critical finding report was 2.85 h for emergency patients and 3.07 h for hospitalized patients. After the intervention, a statistically significant decrease in the notification time was observed with a mean of 1.37 h for emergency patients and 2.43 h in the hospitalization patients. A statistically significant increase was observed in the proportion of reported findings in less than 15 min (7.08%, p < 0.01), 45 min (45.55%, p < 0.01), 60 min (55.86%, p < 0.01), and 120 min (80.68%, p < 0.01).

CONCLUSION

The healthcare process in the Department of Radiology involves multiple actors who must be sensitized in the identification and reporting of critical radiological findings in order to reduce the notification times. Ensuring effective communication of critical findings is indispensable to ensure timely medical treatment.

Whole-body MRI for preventive health screening: A systematic review of the literature

Background

The yield of whole‐body MRI for preventive health screening is currently not completely clear.

Purpose

To systematically review the prevalence of whole‐body MRI findings in asymptomatic subjects.

Study Type

Systematic review and meta‐analysis.

Subjects

MEDLINE and Embase were searched for original studies reporting whole‐body MRI findings in asymptomatic adults without known disease, syndrome, or genetic mutation. Twelve studies, comprising 5373 asymptomatic subjects, were included.

Field Strength/Sequence

1.5T or 3.0T, whole‐body MRI.

Assessment

The whole‐body MRI literature findings were extracted and reviewed by two radiologists in consensus for designation as either critical or indeterminate incidental finding.

Statistical Tests

Data were pooled using a random effects model on the assumption that most subjects had ≤1 critical or indeterminate incidental finding. Heterogeneity was assessed by the I² statistic.

Results

Pooled prevalences of critical and indeterminate incidental findings together and separately were 32.1% (95% confidence interval [CI]: 18.3%, 50.1%), 13.4% (95% CI: 9.0%, 19.5%), and 13.9% (95% CI: 5.4%, 31.3%), respectively. There was substantial between‐study heterogeneity (I² = 95.6–99.1). Pooled prevalence of critical and indeterminate incidental findings together was significantly higher in studies that included (cardio)vascular and/or colon MRI compared with studies that did not (49.7% [95% CI, 26.7%, 72.9%] vs. 23.0% [95% CI, 5.5%, 60.3%], P < 0.001). Pooled proportion of reported verified critical and indeterminate incidental findings was 12.6% (95% CI: 3.2%, 38.8%). Six studies reported false‐positive findings, yielding a pooled proportion of 16.0% (95% CI: 1.9%, 65.8%). None of the included studies reported long‐term (>5‐year) verification of negative findings. Only one study reported false‐negative findings, with a proportion of 2.0%.

Data Conclusion

Prevalence of critical and indeterminate incidental whole‐body MRI findings in asymptomatic subjects is overall substantial and with variability dependent to some degree on the protocol. Verification data are lacking. The proportion of false‐positive findings appears to be substantial.

Level of Evidence: 4

Technical Efficacy: Stage 3

J. Magn. Reson. Imaging 2019;50:1489–1503.

Reshaping Radiology Precall Preparation: Integrating a Cloud-Based PACS Viewer Into a Flipped Classroom Model

Preparing residents for the on-call experience in Radiology is one of the most important aspects of education within a training program. Traditionally, this preparation has occurred via a combination of case conferences and didactic lectures by program faculty, daily teaching at the workstation, and precall assessments. Recently, a blended curricular model referred to as the flipped classroom has generated a lot of attention within the realm of graduate medical education. We applied this technique to resident precall education in the subspecialty of Neuroradiology, and surveyed the participants about their perceptions of the course. The structure, implementation, and web-based platform used to create the flipped classroom experience is described herein.

Critical Findings: Attempts at Reducing Notification Errors

PURPOSE

Ineffective communication of critical findings (CFs) is a patient safety issue. The aim of this study was to assess whether a feedback program for faculty members failing to correctly report CFs would lead to improved compliance.

METHODS

Fifty randomly selected reports were reviewed by the chief of neuroradiology each month for 42 months. Errors included (1) not calling for a CF, (2) not identifying a CF as such, (3) mischaracterizing non-CFs as CFs, and (4) calling for non-CFs. The number of appropriately handled and mishandled reports in each month was recorded. The trend of error reduction after the division chief provided feedback in the subsequent months was evaluated, and the equality of time interval between errors was tested.

RESULTS

Among 2,100 reports, 49 (2.3%) were handled inappropriately. Among non-CF reports, 98.97% (1,817 of 1,836) were appropriately not called and not flagged, and 88.64% (234 of 264) of CF reports were called and flagged appropriately. The error rate during the 11th through 32nd months of review (1.28%) was significantly lower than the error rate in the first 10 months of review (3.98%) (P = .001). This benefit lasted for 21 months.

CONCLUSIONS

Review and giving feedback to radiologists increased their compliance with the CF protocol and decreased deviations from standard operating procedures for about 2 years (from month 10 to month 32). Developing new ideas for improving CF policy compliance may be required at 2- to 3-year intervals to provide continuous quality improvement.