The effect of PACS on the time required for technologists to produce radiographic images in the emergency department radiology suite.

The purpose of this study was to evaluate the effect of a switch to a filmless image management system on the time required for technologists to produce radiographic images in the emergency department (ED) after controlling for exam difficulty and a variable workload. Time and motion data were collected on patients who had radiographic images taken while being treated in the emergency department over the 3 1/2-year period from April 1997 to November 2000. Event times and demographic data were obtained from the radiology information system, from the hospital information system, from emergency department records, or by observation by research coordinators. Multiple least squares regression analysis identified several independent predictors of the time required for technologists to produce radiographic images. These variables included the level of technologist experience, the number of trauma-alert patient arrivals, and whether a filmless image management system was used (all P <.05). Our regression model explained 22% of the variability in technologist time (R2 Adjusted, 0.22; F = 24.01; P <.0001). The regression model predicted a time saving of 2 to 3 minutes per patient in the elapsed time from notification of a needed examination until image availability because of the implementation of PACS, a delay of 4 to 6 minutes per patient who were imaged by technologists who spent less than 10% of their work assignments within the ED, and a delay of 18 to 27 minutes in radiology workflow because of the arrival of a trauma alert patient. A filmless system decreased the amount of time required to produce radiographs. The arrival of a trauma alert patient delayed radiology workflow in the ED. Inexperienced technologists require 4 to 6 minutes of additional time per patient to complete the same amount of work accomplished by an experienced technologist.

From being a radiologist to watching a radiologist: impact of filmless operation on the training of radiology residents.

RATIONALE AND OBJECTIVES: The authors performed this study to investigate the impact of changing from a film-based image interpretation system to one using digital image workstations on the training of radiology residents in the interpretation of radiographs. MATERIALS AND METHODS: Data were collected during a period when a conventional system of image interpretation with hard-copy images and multiviewers was used and during a period when digital image workstations were used. During each period, it was noted whether the first interpretation of the radiographs was performed by a radiology resident, by an attending radiologist, or as a group effort including both an attending radiologist and a radiology resident(s). In addition, it was noted whether a radiology resident or an attending radiologist dictated the report. RESULTS: The proportion of images first interpreted by the radiology resident alone decreased from 38% (53 of 139) when using the conventional system to 17% (34 of 199) after the switch to interpreting images on the workstations (P = .001). During the film-based period, radiology residents dictated 45% of reports (141 of 312), but during the workstation period, radiology residents dictated only 4% of reports (24 of 667; P = .001). CONCLUSION: The authors observed a decrease in autonomous participation by radiology residents in image interpretation and dictation of reports and an increase in "group reading" after the switch from a film-based system to a workstation system.

Effect of ethnicity on denial of authorization for emergency department care by managed care gatekeepers.

OBJECTIVE: After a pilot study suggested that African American patients enrolled in managed care organizations (MCOs) were more likely than whites to be denied authorization for emergency department (ED) care through gatekeeping, the authors sought to determine the association between ethnicity and denial of authorization in a second, larger study at another hospital. METHODS: A retrospective cohort design was used, with adjustment for triage score, age, gender, day and time of arrival at the ED, and type of MCO. RESULTS: African Americans were more likely to be denied authorization for ED visits by the gatekeepers representing their MCOs even after adjusting for confounders, with an odds ratio of 1.52 (95% CI = 1.18 to 1.94). CONCLUSIONS: African Americans were more likely than whites to be denied authorization for ED visits. The observational study design raises the possibility that incomplete control of confounding contributed to or accounted for the association between ethnicity and gatekeeping decisions. Nevertheless, the questions that these findings raise about equity of gatekeeping indicate a need for additional research in this area.

Ensuring the success of women faculty at AMCs: lessons learned from the National Centers of Excellence in Women's Health.

Since the early 1970s, the numbers of women entering medical school and, subsequently, academic medicine have increased substantially. However, women faculty have not advanced at the expected rate to senior academic ranks or positions of leadership. In 1996, to counter this trend, the U.S. Department of Health and Human Services (DHHS) Office on Women's Health included women's leadership as a required component of the nationally funded Centers of Excellence in Women's Health to identify effective strategies and initiate model programs to advance women faculty in academic medicine. The authors describe the experience of Centers at seven U.S. medical schools in initiating and sustaining leadership programs for women. The processes used for program formation, the current programmatic content, and program evaluation approaches are explained. Areas of success (e.g., obtaining support from the institution's leaders) and difficulties faced in maintaining an established program (such as institutional fiscal constraints and the diminishing time available to women to participate in mentoring and leadership activities) are reviewed. Strategies to overcome these and other difficulties (e.g., prioritize and tightly focus the program with the help of an advisory group) are proposed. The authors conclude by reviewing issues that programs for women in academic medicine will increasingly need to focus on (e.g., development of new kinds of skills; issues of recruitment and retention of faculty; and increasing faculty diversity).

An automated results notification system for PACS.

The purpose of this study was to determine if the interval between an examination being ordered by an Emergency Department physician and his or her review of the report and images could be shortened by notifying the physician that the results were available. This hypothesis was based on work done previously in the Medical Intensive Care Unit that showed that physicians would wait to review results for a time considerably longer than the time required for the radiologist to review the images and provide a preliminary report. The software developments operate properly and show that even simple integration of multiple information systems (PACS, RIS, speech recognition) can provide useful features. Early results indicate that the Emergency Department (ED) physicians prefer the notification system over the previous (travel to check on images and reports) methods. The hypothesized time reductions did occur, although it is not clear that the notification system accounted for all of them. A system for automated notification of radiology results availability has been shown to be possible and practical. To do this automated interaction of 3 systems with a low-level or no electronic integration was required. Although not fully successful for this study, early physician response has been positive, and requests to expand this service hospitalwide now are common.

Do quantitative changes in pain intensity correlate with pain relief and satisfaction?

OBJECTIVE: To correlate measured pain intensity (PI) changes with pain relief and satisfaction with pain management. METHODS: A prospective single-group repeated-measures design study. A heterogeneous group of patients were asked to record their levels of PI at initial presentation and at ED release using a numerical descriptor scale (NDS) and a visual analog scale (VAS). At release, a 5-point pain relief scale and a pain management satisfaction survey were also completed. RESULTS: A convenience sample of 81 patients were enrolled over the study period. The average reduction in PI for all patients was 33%. A 5%, 30%, and 57% reduction in PI correlated with "no," "some/partial," and "significant/complete" relief, respectively (p < 0.001). However, when patients were divided into 2 groups based on their initial PI scores, patients with moderate/severe pain (NDS > 5) required a reduction of 35% and 84% in PI to achieve "some/partial" and "significant/complete" relief, respectively. Patients in less pain (NDS < or = 5) needed 25% and 29% reductions in PI for the same categories (p=0.8). Patients were generally satisfied with their pain management. There was a positive association between pain relief and satisfaction with pain management. CONCLUSION: There is a significant association between changes in PI and pain relief. Greater reductions in PI are required for patients presenting with more severe initial pain to achieve relief compared with those who have lesser initial PI. While there is a linear relationship between increasing pain relief and satisfaction, relief of pain appears to only partially contribute to overall satisfaction with pain management.

Pelvic inflammatory disease in patients with bilateral tubal ligation.

Classic teaching has stated that women who have undergone bilateral tubal ligation (BTL) are not susceptible to pelvic inflammatory disease (PID). The purpose of this study was to confirm the existence of PID in patients with BTL and to compare clinical parameters of these patients with PID patients who have not had BTL. A retrospective chart review of emergency department (ED) patients diagnosed with PID over a 1-year period at a large urban university hospital found 209 patients who fulfilled the criteria for a definition of PID. Of the 209 patients with PID, 24 (11.7%) had undergone BTL. Patients with and without BTL were compared with respect to age, white blood cell count (WBC), temperature, admission rate, length of hospitalization, prior history of PID, culture results, presence of bilateral abdominal pain, presence of rebound tenderness, and complications of tubo-ovarian abscess (TOA) and hydrosalpinx. Patients with BTL had lower WBCs (11,100/microL v14,700/microL) and were 2.5 times less likely to be hospitalized compared to those patients without BTL. These results show that PID in the setting of a prior BTL not only exists but occurs with surprising frequency and deserves further study. Patients with BTL and PID may have a clinically milder form of PID than those patients without BTL.

Sulfonamide-induced iritis.

Anterior uveitis is a relatively rare adverse drug reaction when the prescription rate of sulfonamides is considered. Current medications should be included in the differential diagnosis of patients who present with uveitis, because discontinuation of the offending agent is mandatory to resolution of the problem. Lack of recognition and failure to discontinue the medication will increase the patient's risk of ocular injury.

Hydroxyapatite pseudopodagra in a young man: acute calcific periarthritis of the first metatarsophalangeal joint.

Pain and swelling at the first metatarsophalangeal joint can be caused by acute calcific periarthritis (ACP), an inflammatory condition resulting from deposition of hydroxyapatite crystals. A case is reported of a 23-year-old man in whom ACP was initially mistaken for gout, septic arthritis, and cellulitis. The diagnosis of ACP is based on the finding of inflammation around a joint along with radiographic evidence of periarticular soft tissue calcifications. Calcifications may disappear over time, as they did in this case. Failure to recognize this condition can lead to unnecessary testing and inappropriate treatment.

Massive pulmonary embolism.

Massive pulmonary embolism remains a clinical challenge where rapid diagnosis and appropriate therapy have a critical impact on patient outcome. This article reviews the pathophysiology, diagnosis, and therapeutic options involved in the management of pulmonary embolism. Clinical case discussions illustrate the principles that are described by the authors.

Needle thoracostomy fails to detect a fatal tension pneumothorax.

Needle thoracostomy is an emergency procedure used to both diagnose and initially treat a tension pneumothorax. We report a case of fatal tension pneumothorax in an intubated patient with chronic obstructive pulmonary disease that was missed by this technique. A tension pneumothorax involving only the right middle and lower lobes was found at autopsy. The autopsy also suggested that needle thoracostomy was misleading because it sampled air from a noncommunicating bulla in the right upper lobe rather than from the pleural space. Tension physiology can exist with only localized collapse of a lung, and diagnostic needle thoracostomy can be falsely negative. When tension pneumothorax is strongly suspected, if empiric thoracentesis does not vent air under pressure, subsequent tube thoracostomy is indicated.

Massive bilateral diaphragmatic rupture after an apparently minor automobile accident.

A case of massive bilateral diaphragmatic rupture following a low impact motor vehicle accident is described. The patient experienced herniation of intraabdominal contents into the thoracic cavity, but suffered no additional injuries. Few cases of bilateral diaphragmatic rupture have been reported and no cases of acute bilateral rupture have been described as an isolated injury. Diaphragmatic rupture in general may be a difficult injury to recognize. Based on our review of recent cases of diaphragmatic rupture (1979-1990), most patients presenting acutely have additional trauma (89.9%) but only vague symptoms related to their diaphragmatic insult. A chest roentgenogram may be a useful diagnostic tool, although many patients with diaphragmatic rupture have only nonspecific findings. A nasogastric tube placed prior to chest roentgenogram may enable the physician to recognize the injury more readily. A high index of suspicion is required to recognize diaphragmatic rupture and should be maintained for all victims of motor vehicle accidents with abnormal but nondiagnostic chest roentgenograms.

Serum concentrations of meperidine in patients with sickle cell crisis.

We compared mean serum concentrations of meperidine in sickle cell patients in crisis and control patients receiving meperidine prior to incision and drainage of abscesses. Eight sickle cell and five control patients without confounding illnesses consented to participate and received 100 mg meperidine in the deltoid or gluteal muscle for pain. Blood samples were drawn at baseline, 0.25, 0.50, 0.75, 1.0, 1.5, and 2.0 hours postinjection. In the sickle cell group, mean peak concentration of meperidine was 0.32 +/- 0.08 micrograms/mL at an average of 0.5 +/- 0.07 hours postinjection. Among controls mean peak concentration was 0.72 +/- 0.37 micrograms/mL at an average of 0.6 +/- 0.11 hours. The difference in peak concentrations was significant at all time intervals (P less than .01); the difference in times to peak was not significant. We conclude that, given a standard dose, serum concentrations of meperidine differ between sickle cell and control patients, which may suggest reasons for the relatively poor pain control often noted in sickle cell patients.

The stimulation of insight and self-awareness through body-movement exercise.

The results suggest that even a brief body-movement experience can enhance understanding and self-awareness among normal students in a classroom setting. It may be that exercises could be used in other areas of learning or exploration. These completely noverbal activities may have the same beneficial effects as role-playing, with respect to increasing insight and self-awareness.