Are Electronic Notifications in Imaging Order Communication Systems an Effective Means of Changing Clinicians' Behaviour?

Introduction Order Communication Systems (Ordercomms) are computer applications used to enter diagnostic and therapeutic patient care orders and view test results. These electronic systems allow the integration of Clinical Decision Support Systems (CDSS). CDSS are computer applications designed to aid clinicians in making diagnostic and therapeutic decisions in patient care (e.g. can notify clinicians of best practice guidelines when requesting investigations or prescribing medications). The aims of this study were to determine whether electronic notifications (via Ordercomms) are effective in improving clinician compliance with the Ottawa Rules in plain radiographs requesting for ankle trauma, and the efficacy of electronic notifications in reducing inappropriate imaging requests. Methods The Ottawa Rules are a globally validated clinical decision tool with a sensitivity of 99%-100% for ankle fractures. When used, they can reduce the number of unnecessary radiographs by 30%-40%. Importantly, the Royal College of Radiologists stipulates that a patient must fulfill the Ottawa Rules in order to proceed with a plain radiograph of the ankle in trauma. A retrospective analysis of 366 plain ankle radiographs was performed to exclude bony injury in the emergency department between February and March 2018. Information gathered included patient demographics, the request form completed by the emergency department clinician, and radiology report. A pop-up reminder was then implemented on the electronic requesting system to prompt clinicians to apply the Ottawa Ankle Rules and document their plain radiograph request accordingly. Following the intervention, a further 473 plain radiographs were analysed in the same way over a three-month period (April-June 2018). Results In the two months prior to the intervention, 366 plain radiographs were performed for ankle trauma. Of these, 45.1% fulfilled the Ottawa Rules. In the three months following our intervention, 473 plain radiographs were carried out. There was no significant increase in the percentage of requests fulfilling the Ottawa Rules (45.7%). Unnecessary radiographs (those which did not fulfill the Ottawa Rules and consequently showed no fracture) also showed no change. The data demonstrates that the electronic reminder asking individuals to apply and document the Ottawa Rules appropriately had no impact on the imaging requesting behaviour, and subsequently on the number of unnecessary plain radiographs. Conclusion Electronic notifications in Order Communication Systems did not change clinicians' behaviour in this specific circumstance. This study has implications for electronic notifications in prescribing systems and pathology requesting systems. Further research is needed to determine if the findings are replicated with other imaging types.

Improving Patient Flow in the Surgical Assessment Unit by Facilitating Access to Computer Tomography Scanning.

Introduction Patient flow is "the ability of healthcare systems to manage patients effectively and with minimal delays as they move through stages of care". National Health Service (NHS) England has highlighted the importance of improving patient flow, and the many benefits to both staff and patients, including: "improved clinical outcome and experience of patients"; "eliminating waits and delays"; "saving time and effort by avoiding duplication of work"; "saving money"; and "improving the reputation of the NHS". Limited access to computerised tomography (CT) imaging for surgical patients can disrupt patient flow through delayed diagnosis, management, and discharge. The aims of this quality improvement project were to assess the effect of a dedicated Surgical Assessment Unit (SAU) radiologist on access to CT scanning and its impact on patient flow. The measured outcomes were time from admission to CT scanning, and length of admission. Method In June 2020, a radiology registrar was allocated to the SAU to vet and report CT imaging. CT requests from the SAU were identified from Picture Archiving and Communication System (PACS) in the first two weeks of June 2019 and 2020 during normal working hours (Monday to Friday, between 0900 and 1700). We performed a retrospective audit and compared data from 2019 and 2020. The measured primary outcome was time from admission to imaging. The secondary outcome was the length of admission. Results In the two-week period in June 2019, 25 patients requiring a CT scan presented to SAU during normal working hours. In 2020, this number increased to 40 patients. In 2019, 5 patients had a CT scan performed within four hours of admission (20%). In 2020, following the allocation of a radiologist to the SAU, 33 patients (82.5%) had their CT performed within four hours of admission. In 2019, one patient (4%) was discharged within six hours of admission. A further 16% had a length of admission between six and 12 hours. The majority of patients (80%) remained in the hospital for more than 12 hours. In 2020, 45% of patients were discharged within four hours following a CT scan. More than half of the patients (57.5%) were discharged within 12 hours. Conclusion The allocation of a radiologist in the SAU led to both a reduction in time to perform CT scans and an increased number of patients being discharged within 12 hours. These results suggest that early access to imaging improves patient flow. Further research will help to establish whether the allocation of a radiologist in the SAU is a beneficial and cost-effective method of improving patient flow, and whether this may help reduce the current pressure on NHS services.

The smoking-dyslipidaemia dyad: A potent synergistic risk for atherosclerotic coronary artery disease.

BACKGROUND: Smoking and dyslipidaemia are known individual risk factors of coronary artery disease (CAD). The present study examined the combined risk of smoking and dyslipidaemia on coronary atherosclerosis. METHODS: Coronary artery calcium (CAC), measured by cardiac CT, was used to assess the extent of CAD, which was related to smoking and dyslipidaemia using logistic regression, adjusted for age, sex, hypertension, BMI and family history of ischaemic heart disease. RESULTS: Seventy-one patients (46 men, 25 women: median age of 53.7yrs; IQR = 47.0-59.5) were recruited. The mean log10 CAC score in never-smokers without dyslipidaemia (reference group) was 0.37 (SD = 0.73), while the value in those with a history of smoking was 0.44 ± 0.48 (mean difference: 0.07, 95%CI:-0.67 to 0.81, p = 0.844), dyslipidaemia was 1.07 ± 1.08 (mean difference: 0.71, 95%CI: 0.24 to 1.17, p = 0.003), and both risk factors was 1.82 ± 0.64 (mean difference: 1.45, 95%CI:0.88 to 2.02, p < 0.001). For individuals in the reference group, the proportions with none, one and multiple vessel disease were 80.6%, 16.1% and 3.2%; for those with a history of smoking or with dyslipidaemia were 50.0%, 25.0% and 25.0%; and for those with both risk factors were 8.3%, 25.0% and 66.7%. Patients with a history of both risk factors had greater adjusted risks of having one- vessel disease - OR = 14.3 (95%CI = 2.1-98.2) or multiple vessel disease: OR = 51.8 (95%CI = 4.2-609.6). CONCLUSIONS: Smoking and dyslipidaemia together are associated with high coronary artery calcification and CAD, independent of other major risk factors.

Sex differences in the agreement between left ventricular ejection fraction measured by myocardial perfusion scintigraphy and by echocardiography.

BACKGROUND: Left ventricular ejection fraction (LVEF) is generally measured by echocardiography but is increasingly available with myocardial perfusion scintigraphy. With myocardial perfusion scintigraphy, the threshold of LVEF below which there is a risk for myocardial infarct or sudden cardiac death is higher for women (51%) than for men (43%). We tested the hypothesis that such a sex difference may also occur with echocardiography and myocardial perfusion scintigraphy. METHODS: Four hundred and four men, mean age = 67.7 ± SD = 12.3 yr; 339 women, 67.7 ± 11.7 yr had separate myocardial perfusion scintigraphy and echocardiography examinations within six months. A subset of 327 of these patients (181 men, 68.8 ± 12.1 yr; 146 women, 66.4 ± 12.1 yr) had examinations within one month and were additionally analysed as this sub-group. Myocardial perfusion scintigraphy and echocardiography were used to measure LVEF at rest and their agreement (neither considered as a reference method) was assessed by Bland-Altman plots: LVEF difference (myocardial perfusion scintigraphy minus echocardiography ) against average LVEF ( MPS + Echo 2 ). RESULTS: Of patients who had myocardial perfusion scintigraphy and echocardiography performed within six months, mean LVEF difference = +1.1% (95% limits of agreement: -19.3 to +21.6) in men but +10.9% (-10.7 to +32.5) in women. LVEF difference diverged from zero marginally in men (mean difference = +1.1, 95%CI = +0.1 to +2.1, p = 0.028) but more in women (+10.9, +9.8 to +12.1, p < 0.001). The LVEF difference correlated with average LVEF itself in both men (r = 0.305, p < 0.001) and women (r = 0.361, p < 0.001), and with age in women (r = 0.117, p = 0.031). Similar results were observed for the subset. CONCLUSIONS: Caution should be taken when interpreting LVEF measured by different techniques due to their wide limits of agreement and systematic bias, more markedly in women.