Playing Well With Others: The Challenge of Academic and Community Radiology Practice Integration.

OBJECTIVE. In this article, we review models for clinical integration across the full spectrum of radiologic services in merged health systems that include both academic and community practice components. We also discuss the issues involved in the integration of disparate practice models and reward systems for both the community radiology group and the academic faculty practice group. CONCLUSION. Although we see advantages to the current trends in mergers and acquisitions within academic radiology, it remains to be seen whether academic and community practice radiology groups can truly work and play well together.

Curbing Inappropriate Usage of STAT Imaging at a Large Academic Medical Center.

PURPOSE: To evaluate a new system for processing and performing inpatient STAT diagnostic imaging with respect to utilization and time-based performance metrics. MATERIALS AND METHODS: This HIPAA-compliant study had institutional review board approval; informed consent was not required. The radiology information system of a large academic medical center was queried for all inpatient diagnostic imaging exams performed and interpreted from August 1, 2010, to October 31, 2012. Using customized software, data were evaluated based on order priority (non-STAT or STAT) and exam modality with respect to exam volume and time-based performance metrics (time-to-performance and preliminary interpretation time). Data were compared over 3 periods: August 1, 2010, to October 31, 2010 (preimplementation period); November 1, 2010, to October 31, 2011 (year 1 postimplementation); and November 1, 2011, to October 31, 2012 (year 2 postimplementation). RESULTS: In the first year after implementation of the new STAT policy, the percentage of inpatient exams ordered STAT significantly decreased from 22.1% to 5.4% (P < 0.001). This represented a proportional decrease of 26% (CT), 16% (MRI), 20% (US), and 24% (radiographs) relative to pre-STAT policy levels. The median time-to-performance and median preliminary interpretation time significantly decreased for all modalities after implementation of the policy (P < 0.05 for all modalities), decreasing by an average of 104 and 162 minutes, respectively. These changes persisted throughout year 2 postimplementation. CONCLUSION: A new institutional system for handling inpatient STAT diagnostic imaging results in a decreased number of STAT exams ordered and improved time-based performance metrics, thereby increasing workflow efficiency.

Checklist for a Radiology Information System Go-Live.

This article highlights the experience of a single center institution undergoing a change in radiology information system (RIS) software platforms, transitioning to an electronic medical record-RIS driven workflow. Ten planning and execution topics with recommendations are presented in checklist form from the radiology department perspective. The build process of creating a site specific RIS takes many months, beginning with the organization of a steering committee. On Go-Live, several checklist items are offered to help streamline the troubleshooting process and improve communication throughout the radiology department. The groundwork of the group effort in creating the infrastructure of the build process can continue to be useful beyond Go-Live, as RIS features are continually optimized.

Communicating Uncertainty in the Radiology Report.

OBJECTIVE: The purposes of this article are to explore the issue of diagnostic uncertainty in radiology and how the radiology report has often fallen short in this regard and to suggest approaches that can be helpful in addressing this challenge. CONCLUSION: The practice of medicine involves a great deal of uncertainty, which is an uncomfortable reality for most physicians. Radiologists are more often than not faced with considerable diagnostic uncertainty and in their written reports are challenged to effectively communicate that uncertainty to referring physicians and others.

Online Portals: Gateway to Patient-Centered Radiology.

OBJECTIVE: Online portals typically allow access to radiology reports, causing a shift in the communication. This article evaluates the studies available in the literature about patient portals and the use of patient portals in radiology. Patient and physician preferences and the impact on radiology reporting are presented. CONCLUSION: Patient portals provide an opportunity for radiologists to engage with their patients via a new method of communication. Radiologist collaboration with referring physicians is important in providing care in accordance with patient preferences.

A Patient-Centered Radiology Quality Process Map: Opportunities and Solutions.

OBJECTIVE: The purpose of this article is to review the tools and opportunities available for patient-centered care in radiology and to create a quality patient-centered care process map to organize them for radiology practices. CONCLUSION: This article provides a review of the many opportunities to increase and improve patient-centered care in radiology. A process map that organizes and highlights key elements of patient-centered care throughout the radiology care process is provided that can be implemented to enhance the patient experience of our services and improve the quality of care provided.

Spleen volume on CT and the effect of abdominal trauma.

The aim of this study is to determine the magnitude of change in spleen volume on CT in subjects sustaining blunt abdominal trauma without hemorrhage relative to patients without disease and how the spleen volumes are distributed. Sixty-seven subjects with blunt abdominal trauma and 101 control subjects were included in this retrospective single-center, IRB-approved, and HIPAA-compliant study. Patients with an injured spleen were excluded. Using a semiautomatic segmentation program, two readers computed spleen volumes from CT. Spleen volume distribution in male and female trauma and control cohorts were compared nonparametrically. Spleen volume plotted against height, weight, and age were analyzed by linear regression. The number of females and males are, respectively, 35 and 32 in trauma subjects and 69 and 32 among controls. Female trauma patients (49.6 years) were older than males (39.8 years) (p = 0.02). Distributions of spleen volume were not normal, skewed above their means, requiring a nonparametric comparison. Spleen volumes in trauma patients were smaller than those in controls with medians of 230 vs 294 mL in males(p < 0.006) and 163 vs 191 mL in females(p < 0.04). Spleen volume correlated positively with weight in females and with height in male controls, and negatively with age in male controls (p < 0.01). Variation in reproducibility and repeatability was acceptable at 1.5 and 4.9 %, respectively. Reader variation was 1.7 and 4.6 % for readers 1 and 2, respectively. The mean spleen volume in controls was 245 mL, the largest ever reported. Spleen volume decreases in response to blunt abdominal trauma. Spleen volumes are not normally distributed. Our population has the largest spleen volume reported in the literature, perhaps a consequence of the obesity epidemic.

Magnetic Resonance of Pelvic and Gastrointestinal Emergencies.

Magnetic resonance (MR) imaging is gaining increased acceptance in the emergency setting despite the continued dominance of computed tomography. MR has the advantages of more precise tissue characterization, superior soft tissue contrast, and a lack of ionizing radiation. Traditional barriers to emergent MR are being overcome by streamlined imaging protocols and newer rapid-acquisition sequences. As the utilization of MR imaging in the emergency department increases, a strong working knowledge of the MR appearance of the most commonly encountered abdominopelvic pathologies is essential. In this article, MR imaging protocols and findings of acute pelvic, scrotal, and gastrointestinal pathologies are discussed.

Rating and Classification of Incident Reporting in Radiology in a Large Academic Medical Center.

The purpose of this article is to provide a rate of safety incident report of adverse events in a large academic radiology department and to share the various types that may occur. This is a Health Insurance Portability and Accountability Act compliant, institutional review board-approved study. Consent requirement was waived. All incident reports from April 2006-September 2012 were retrieved. Events were further classified as follows: diagnostic test orders, identity document or documentation or consent, safety or security or conduct, service coordination, surgery or procedure, line or tube, fall, medication or intravenous safety, employee general incident, environment or equipment, adverse drug reaction (ADR), skin or tissue, and diagnosis or treatment. Overall rates and subclassification rates were calculated. There were 10,224 incident reports and 4,324,208 radiology examinations (rate = 0.23%). The highest rates of the incident reports were due to diagnostic test orders (34.3%; 3509/10,224), followed by service coordination (12.2%; 1248/10,224) and ADR (10.3%; 1052/4,324,208). The rate of incident reporting was highest in inpatient (0.30%; 2949/970,622), followed by emergency radiology (0.22%; 1500/672,958) and outpatient (0.18%; 4957/2,680,628). Approximately 48.5% (4947/10,202) of incidents had no patient harm and did not affect the patient, followed by no patient harm, but did affect the patient (35.2%, 3589/10,202), temporary or minor patient harm (15.5%, 1584/10,202), permanent or major patient harm (0.6%, 62/10,202), and patient death (0.2%, 20/10,202). Within an academic radiology department, the rate of incident reports was only 0.23%, usually did not harm the patient, and occurred at higher rates in inpatients. The most common incident type was in the category of diagnostic test orders, followed by service coordination, and ADRs.

Blast Injuries: From Improvised Explosive Device Blasts to the Boston Marathon Bombing.

Although most trauma centers have experience with the imaging and management of gunshot wounds, in most regions blast wounds such as the ones encountered in terrorist attacks with the use of improvised explosive devices (IEDs) are infrequently encountered outside the battlefield. As global terrorism becomes a greater concern, it is important that radiologists, particularly those working in urban trauma centers, be aware of the mechanisms of injury and the spectrum of primary, secondary, tertiary, and quaternary blast injury patterns. Primary blast injuries are caused by barotrauma from the initial increased pressure of the explosive detonation and the rarefaction of the atmosphere immediately afterward. Secondary blast injuries are caused by debris carried by the blast wind and most often result in penetrating trauma from small shrapnel. Tertiary blast injuries are caused by the physical displacement of the victim and the wide variety of blunt or penetrating trauma sustained as a result of the patient impacting immovable objects such as surrounding cars, walls, or fences. Quaternary blast injuries include all other injuries, such as burns, crush injuries, and inhalational injuries. Radiography is considered the initial imaging modality for assessment of shrapnel and fractures. Computed tomography is the optimal test to assess penetrating chest, abdominal, and head trauma. The mechanism of blast injuries and the imaging experience of the victims of the Boston Marathon bombing are detailed, as well as musculoskeletal, neurologic, gastrointestinal, and pulmonary injury patterns from blast injuries.

Contrast Media Extravasation of Computed Tomography and Magnetic Resonance Imaging: Management Guidelines for the Radiologist.

Intravenous contrast administration has been of great importance in diagnostic radiology, but it is not without risks either due to the local, systemic allergic reactions or due to subcutaneous extravasation of contrast media. Subcutaneous contrast medium extravasationis an infrequent, yet a well-recognized complication. However, most incidents are minor and can be managed conservatively, but there are a few cases that require immediate surgical intervention. This article discusses the risks factors, clinical manifestations, and conservative and surgical approaches of subcutaneous contrast media extravasation for both computed tomography and magnetic resonance imaging.

How often are Patients Harmed When They Visit the Computed Tomography Suite? A Multi-year Experience, in Incident Reporting, in a Large Academic Medical Center.

OBJECTIVES: Our goal is to present our multi-year experience in incident reporting in CT in a large medical centre. METHODS: This is an IRB-approved, HIPAA-compliant study. Informed consent was waived for this study. The electronic safety incident reporting system of our hospital was searched for the variables from April 2006 to September 2012. Incident classifications were diagnostic test orders, ID/documentation, safety/security/conduct, service coordination, surgery/procedure, line/tube, fall, medication/IV safety, employee general incident, environment/equipment, adverse drug reaction, skin/tissue and diagnosis/treatment. RESULTS: A total of 1918 incident reports occurred in the study period and 843,902 CT examinations were performed. The rate of safety incident was 0.22 % (1918/843,902). The highest incident rates were due to adverse drug reactions (652/843,902 = 0.077 %) followed by medication/IV safety (573/843,902 = 0.068 %) and diagnostic test orders (206/843,902 = 0.024 %). Overall 45 % of incidents (869/1918) caused no harm and did not affect the patient, 33 % (637/1918) caused no harm but affected the patient, 22 % (420/1918) caused temporary or minor harm/damage and less than 1 % (10/1918) caused permanent or major harm/damage or death. CONCLUSION: Our study shows a total safety incident report rate of 0.22 % in CT. The most common incidents are adverse drug reaction, medication/IV safety and diagnostic test orders. KEY POINTS: • Total safety incident report rate in CT is 0.22 %. • Adverse drug reaction is the most common safety incident in CT. • Medication/IV safety is the second most common safety incident in CT.

Rates of safety incident reporting in MRI in a large academic medical center.

PURPOSE: To describe our multiyear experience in incident reporting related to magnetic resonance imaging (MRI) in a large academic medical center. MATERIALS AND METHODS: This was an Institutional Review Board (IRB)-approved, Health Insurance Portability and Accountability Act (HIPAA)-compliant study. Incident report data were collected during the study period from April 2006 to September 2012. The incident reports filed during the study period were searched for all reports related to MRI. Incident reports were classified with regard to the patient type (inpatient vs. outpatient), primary reason for the incident report, and the severity of patient harm resulting from the incident. RESULTS: A total of 362,090 MRI exams were performed during the study period, resulting in 1290 MRI-related incident reports. The rate of incident reporting was 0.35% (1290/362,090). MRI-related incident reporting was significantly higher in inpatients compared to outpatients (0.74% [369/49,801] vs. 0.29% [921/312,288], P < 0.001). The most common reason for incident reporting was diagnostic test orders (31.5%, 406/1290), followed by adverse drug reactions (19.1%, 247/1290) and medication/IV safety (14.3%, 185/1290). Approximately 39.6% (509/1290) of reports were associated with no patient harm and did not affect the patient, followed by no patient harm but did affect the patient (35.8%, 460/1290), temporary or minor patient harm (23.9%, 307/1290), permanent or major patient harm (0.6%, 8/1290) and patient death (0.2%, 2/1290). CONCLUSION: MRI-related incident reports are relatively infrequent, occur at significantly higher rates in inpatients, and usually do not result in patient harm. Diagnostic test orders, adverse drug reactions, and medication/IV safety were the most frequent safety incidents.

CT in the Emergency Department: A Real-Time Study of Changes in Physician Decision Making.

PURPOSE: To determine how physicians' diagnoses, diagnostic uncertainty, and management decisions are affected by the results of computed tomography (CT) in emergency department settings. MATERIALS AND METHODS: This study was approved by the institutional review board and compliant with HIPAA. Data were collected between July 12, 2012, and January 13, 2014. The requirement to obtain patient consent was waived. In this prospective, four-center study, patients presenting to the emergency department who were referred for CT with abdominal pain, chest pain and/or dyspnea, or headache were identified. Physicians were surveyed before and after CT to determine the leading diagnosis, diagnostic confidence (on a scale of 0% to 100%), alternative "rule out" diagnosis, and management decisions. Primary measures were the proportion of patients for whom the leading diagnosis or admission decision changed and median changes in diagnostic confidence. Secondary measures addressed alternative diagnoses and return-to-care visits (eg, to emergency department) at 1-month follow-up. Regression analysis was used to identify associations between primary measures and site and participant characteristics. RESULTS: Both surveys were completed for 1280 patients by 245 physicians. The leading diagnosis changed in 235 of 460 patients with abdominal pain (51%), 163 of 387 with chest pain and/or dyspnea (42%), and 103 of 433 with headache (24%). Pre-CT diagnostic confidence was inversely associated with the likelihood of a diagnostic change (P < .0001). Median changes in confidence were substantial (increases of 25%, 20%, and 13%, respectively, for patients with abdominal pain, chest pain and/or dyspnea, and headache; P < .0001); median post-CT confidence was high (95% for all three groups). CT helped confirm or exclude at least 95% of alternative diagnoses. Admission decisions changed in 116 of 457 patients with abdominal pain (25%), 72 of 387 with chest pain and/or dyspnea (19%), and 81 of 426 with headache (19%). During follow-up, 70 of 450 patients with abdominal pain (15%), 53 of 387 with chest pain and/or dyspnea (14%), and 49 of 433 with headache (11%) returned for the same indication. In general, changes in leading diagnosis, diagnostic confidence, and admission decisions were not well explained with site or participant characteristics. CONCLUSION: Physicians' diagnoses and admission decisions changed frequently after CT, and diagnostic uncertainty was alleviated.

Detecting Aortic Graft Complications: A Spectrum of Computed Tomography Findings.

Endovascular aneurysm repair (EVAR) is a successful technique as well as an excellent alternative to the surgical management of abdominal aortic aneurysms. EVAR has improved the mortality and morbidity of many patients who would have otherwise suffered greatly from the consequences of abdominal aortic aneurysms. However, EVAR is not without complications. Some complications require lifelong surveillance, whereas others may necessitate immediate surgical intervention. We discuss the various modalities available for the surveillance as well as the common complications that can be seen on computed tomography.

Key Performance Indicators in Radiology: You Can't Manage What You Can't Measure.

Quality assurance (QA) is a fundamental component of every successful radiology operation. A radiology QA program must be able to efficiently and effectively monitor and respond to quality problems. However, as radiology QA has expanded into the depths of radiology operations, the task of defining and measuring quality has become more difficult. Key performance indicators (KPIs) are highly valuable data points and measurement tools that can be used to monitor and evaluate the quality of services provided by a radiology operation. As such, KPIs empower a radiology QA program to bridge normative understandings of health care quality with on-the-ground quality management. This review introduces the importance of KPIs in health care QA, a framework for structuring KPIs, a method to identify and tailor KPIs, and strategies to analyze and communicate KPI data that would drive process improvement. Adopting a KPI-driven QA program is both good for patient care and allows a radiology operation to demonstrate measurable value to other health care stakeholders.

JOURNAL CLUB: Radiology Report Addenda: A Self-Report Approach to Error Identification, Quantification, and Classification.

OBJECTIVE: The purpose of this study was to analyze report addenda to assess the self-reported error rate in radiologic study interpretation, the types of errors that occur, and the distribution of error by image modality. MATERIALS AND METHODS: Addenda to all diagnostic radiology reports were compiled over a 1-year period (n = 5568). The overall error rate was based on addenda frequency relative to the total number of studies performed. Addenda written over the most recent 2-month interval (n = 851) were classified into five major categories of predominant error type: underreading, overreading, poor communication, insufficient history, and poor technique. Each category was further divided into multiple subtypes. RESULTS: Diagnostic studies at our hospital had an error rate of 0.8%. Errors of poor communication occurred most frequently (44%), followed by underreading (7%), insufficient history (21%), overreading (8%), and poor technique (1%). Analyzed by imaging modality, most errors occurred in PET (19.45 per 1000 studies), followed by MRI (13.86 per 1000 studies) and CT (12.45 per 1000 studies). CONCLUSION: Through the use of report addenda to calculate error, discrepancy between individual radiologists is removed in a reproducible and widely applicable way. This approach to error typology eliminates sample bias and in a departure from previous analyses of difficult cases shows that errors of communication are most frequent, representing a clear area for targeted improvement.

Understanding and Confronting Our Mistakes: The Epidemiology of Error in Radiology and Strategies for Error Reduction.

Arriving at a medical diagnosis is a highly complex process that is extremely error prone. Missed or delayed diagnoses often lead to patient harm and missed opportunities for treatment. Since medical imaging is a major contributor to the overall diagnostic process, it is also a major potential source of diagnostic error. Although some diagnoses may be missed because of the technical or physical limitations of the imaging modality, including image resolution, intrinsic or extrinsic contrast, and signal-to-noise ratio, most missed radiologic diagnoses are attributable to image interpretation errors by radiologists. Radiologic interpretation cannot be mechanized or automated; it is a human enterprise based on complex psychophysiologic and cognitive processes and is itself subject to a wide variety of error types, including perceptual errors (those in which an important abnormality is simply not seen on the images) and cognitive errors (those in which the abnormality is visually detected but the meaning or importance of the finding is not correctly understood or appreciated). The overall prevalence of radiologists' errors in practice does not appear to have changed since it was first estimated in the 1960s. The authors review the epidemiology of errors in diagnostic radiology, including a recently proposed taxonomy of radiologists' errors, as well as research findings, in an attempt to elucidate possible underlying causes of these errors. The authors also propose strategies for error reduction in radiology. On the basis of current understanding, specific suggestions are offered as to how radiologists can improve their performance in practice.

Incidental findings and recommendations are common on ED CT angiography to evaluate for aortic dissection.

PURPOSE: The aim of this study was to assess the outcomes, incidental findings, recommendations, and adherence to recommendations on computed tomography angiography (CTA) studies obtained in the emergency department (ED) to evaluate for aortic dissection. METHODS: The institutional database of ED patients was retrospectively reviewed to identify CTA examinations for dissection during 2014. The radiology report and electronic medical records were reviewed to assess outcomes, radiology report incidental findings, and recommendations, as well as adherence to these recommendations. RESULTS: There were 370 dissection CTAs performed during the 12-month study period. The average age of the patients was 63 years (range, 15-97 years). Eighty-seven patients (23.5%) had clinically significant aortic pathology including 46 patients (12.4%) with dissection and 19 (5.1%) which were new. Three hundred twenty-nine (88.9%) of patients had at least 1 incidental finding. One hundred six (28.6%) of patients had recommendations on the radiology report, and 44.3% of these were for pulmonary nodules. Thirty recommendations (28.3%) were acted upon, most commonly related to pulmonary nodule. CONCLUSION: Computed tomography angiography is useful in detecting aortic pathology. However, emergency physicians should be aware of the potential for clinically significant incidental findings and recommendations. Adherence to recommendations was limited, and future research could investigate mechanisms to improve compliance.