Peer learning in emergency radiology: effects on learning, error identification, and radiologist experience.

PURPOSE: We established and evaluated a peer learning program in an emergency radiology (ER) division. Peer learning is an alternative to peer review focusing on non-punitive error reporting to mitigate consequences of inevitable human error. The central component is the peer learning conference, where cases are presented, key teaching points are discussed, and process improvement ideas are solicited. METHODS: We established a prior imaging-based case identification system and a bimonthly remote videoconference where ER faculty discuss 5-15 cases selected for learning or process improvement opportunities. Case identification and conference characteristics were captured. A survey focused on learning and performance outcomes was administered to faculty initially and showed improved scores after 6 months. RESULTS: Cases selected for conference favored perception errors (46%), with great calls (17%) and process improvement (15%) the next most common categories. A variety of anatomical regions were represented, with abdominal (35%) and musculoskeletal (29%) most common. Error detection was improved over peer review. All participants find the system easy to use and prefer peer learning to peer review for learning and process improvement. CONCLUSION: A peer learning program can be successfully implemented within a busy academic emergency radiology division, as evidenced by increasing buy-in and engagement scores over time. When tied to a departmental peer learning infrastructure, interdisciplinary expertise and robust case identification can be leveraged to increase learning opportunities.

COVID-19 and its Mimics: What the Radiologist Needs to Know.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the current outbreak of Coronavirus disease 2019 (COVID-19). Although imaging should not be used for first-line screening or diagnosis, radiologists need to be aware of its imaging features, and those of common conditions that may mimic COVID-19 pneumonia. In this Pictorial Essay, we review frequently encountered conditions with imaging features that overlap with those that are typical of COVID-19 (including other viral pneumonias, chronic eosinophilic pneumonia, and organizing pneumonia), and those with features that are indeterminate for COVID-19 (including hypersensitivity pneumonitis, pneumocystis pneumonia, diffuse alveolar hemorrhage, pulmonary edema, and pulmonary alveolar proteinosis).

Development and Implementation of an e-Trigger Tool for Adverse Drug Events in a Swiss University Hospital.

PURPOSE: The purpose of the study was to develop and implement an institution-specific trigger tool based on the Institute for Healthcare Improvement medication module trigger tool (IHI MMTT) in order to detect and monitor ADEs. METHODS: We performed an investigator-driven, single-center study using retrospective and prospective patient data to develop ("development phase") and implement ("implementation phase") an efficient, institution-specific trigger tool based on the IHI MMTT. Complete medical data from 1008 patients hospitalized in 2018 were used in the development phase. ADEs were identified by chart review. The performance of two versions of the tool was assessed by comparing their sensitivities and specificities. Tool A employed only digitally extracted triggers ("e-trigger-tool") while Tool B employed an additional manually extracted trigger. The superior tool - taking efficiency into account - was applied prospectively to 19-22 randomly chosen charts per month for 26 months during the implementation phase. RESULTS: In the development phase, 189 (19%) patients had ≥1 ADE (total 277 ADEs). The time needed to identify these ADEs was 15 minutes/chart. A total of 203 patients had ≥1 trigger (total 273 triggers - Tool B). The sensitivities and specificities of Tools A and B were 0.41 and 0.86, and 0.43 and 0.86, respectively. Tool A was more time-efficient than Tool B (4 vs 9 minutes/chart) and was therefore used in the implementation phase. During the 26-month implementation phase, 22 patients experienced trigger-identified ADEs and 529 did not. The median number of ADEs per 1000 patient days was 6 (range 0-13). Patients with at least one ADE had a mean hospital stay of 22.3 ± 19.7 days, compared to 8.0 ± 7.6 days for those without an ADE (p = 2.7×10-14). CONCLUSION: We developed and implemented an e-trigger tool that was specific and moderately sensitive, gave consistent results and required minimal resources.

Eliminating routine oral contrast use for CT in the emergency department: impact on patient throughput and diagnosis.

This study aimed to assess the effect of eliminating routine oral contrast use for abdominopelvic (AP) computed tomography (CT) on emergency department (ED) patient throughput and diagnosis. Retrospective analysis was performed on patients undergoing AP CT during 2-month periods prior to and following oral contrast protocol change in an urban, tertiary care ED. Patients with inflammatory bowel disease, prior gastrointestinal tract-altering surgery, or lean body habitus continued to receive oral contrast. Oral contrast was otherwise eliminated from the AP CT protocol. Patients were excluded if they would not have typically received oral contrast, regardless of the intervention. Data recorded include patient demographics, ED length of stay (LOS), time from order to CT, 72-h ED return, and repeat imaging. Two thousand and one ED patients (1,014 before and 987 after protocol change) underwent AP CT during the study period. Six hundred seven pre-intervention and 611 post-intervention were eligible for oral contrast and included. Of these, 95 % received oral contrast prior to the intervention and 42 % thereafter. After the intervention, mean ED LOS among oral contrast eligible patients decreased by 97 min, P < 0.001. Mean time from order to CT decreased by 66 min, P < 0.001. No patient with CT negative for acute findings had additional subsequent AP imaging within 72 h at our institution that led to a change in diagnosis. Eliminating routine oral contrast use for AP CT in the ED may be successful in decreasing LOS and time from order to CT without demonstrated compromise in acute patient diagnosis.

Formal reporting of second-opinion CT interpretation: experience and reimbursement in the emergency department setting.

The purpose of this study is to describe a system for formally reporting second-opinion interpretations of CT imaging exams accompanying patients transferred emergently to a tertiary care center. Second-opinion interpretations of cross-sectional imaging exams rendered in the emergency department setting over 6 months spanning 22 September 2009 to 22 March 2010 were reviewed and tallied by two radiologists and a research assistant, with a focus on professional fee reimbursement rates. A more in depth review was performed of those exams for which a clinical referral request form was available, detailing such information as the clinical history, content and source of available initial interpretation, and congruity of the initial interpretation with clinical data. Discrepancies between outside and second-opinion interpretations were also assessed. This quality assurance exercise was reviewed by our institutional review board, which waived formal informed consent. Formal second-opinion interpretation was rendered for 370 exams on 198 patients (mean age, 53.5 years; 45.1% female), received from 50 referring facilities. Head CT was the most common imaging exam referred for second opinion. Forty-one of 370 exams (11%) were submitted for self-pay, and 43 (12%) were written off as free care. The remaining 286 exams (77%) were submitted for reimbursement of the professional fee only. Ultimately, of the 286 exams submitted, 260 (91%) were reimbursed for professional fees, 199 (70%) on the initial submission. Of 29 health plans contracted with our facility, 22 ultimately approved all claims made. Three plans denied all claims submitted. The largest payer was Medicare, which reimbursed 88 of 90 submitted claims. Clinical intake forms were available for 184 exams on 107 patients (mean age, 52.7 years, 43.0% female). Trauma was the most common indication, or history, provided (55% of 184 exams, 40% of 107 patients). An outside report of some form was available for 112 of the 184 exams (61%), although only 18 were formal, signed radiology reports from the referring facility. Discrepancies between available outside reports and second-opinion interpretations were noted for 17 out of 112 exams. Need for reimaging was substantially curtailed, with only ten exams repeated within 24 h. A formal process for issuing second-opinion interpretations of cross-sectional exams performed at outside institutions is feasible in the emergency department setting. In the majority of cases, reimbursement for full professional fees can be obtained.

Anterior versus lateral needle decompression of tension pneumothorax: comparison by computed tomography chest wall measurement.

OBJECTIVES: Recent research describes failed needle decompression in the anterior position. It has been hypothesized that a lateral approach may be more successful. The aim of this study was to identify the optimal site for needle decompression. METHODS: A retrospective study was conducted of emergency department (ED) patients who underwent computed tomography (CT) of the chest as part of their evaluation for blunt trauma. A convenience sample of 159 patients was formed by reviewing consecutive scans of eligible patients. Six measurements from the skin surface to the pleural surface were made for each patient: anterior second intercostal space, lateral fourth intercostal space, and lateral fifth intercostal space on the left and right sides. RESULTS: The distance from skin to pleura at the anterior second intercostal space averaged 46.3 mm on the right and 45.2 mm on the left. The distance at the midaxillary line in the fourth intercostal space was 63.7 mm on the right and 62.1 mm on the left. In the fifth intercostal space the distance was 53.8 mm on the right and 52.9 mm on the left. The distance of the anterior approach was statistically less when compared to both intercostal spaces (p < 0.01). CONCLUSIONS: With commonly available angiocatheters, the lateral approach is less likely to be successful than the anterior approach. The anterior approach may fail in many patients as well. Longer angiocatheters may increase the chances of decompression, but would also carry a higher risk of damage to surrounding vital structures.

Prospective gating with 320-MDCT angiography: effect of volume scan length on radiation dose.

OBJECTIVE: The purpose of this study was to evaluate the relation between radiation dose reduction and volume scan length for prospectively ECG-gated 320-MDCT angiography in the diagnosis of coronary artery disease. MATERIALS AND METHODS: MDCT with prospective ECG gating was performed at one of the three volume scan lengths depending on heart length. Of 175 patients, 95 (55%; body mass index, 29 ± 5.9; mean heart rate, 59 ± 7 beats/min) underwent scanning at 160 mm; 46 (26%; body mass index, 30 ± 4.1; mean heart rate, 56 ± 5.74 beats/min) at 140 mm; and 34 (19%; body mass index, 30 ± 3.71; mean heart rate, 58 ± 3.96 beats/min) at 120 mm. RESULTS: The median radiation doses were 6.5 mSv (95% CI, 6.03-7.2 mSv) for the 95 patients who underwent scanning at a volume scan length of 160 mm, 4.33 mSv (95% CI, 4.06-6.62 mSv) for the 46 patients who underwent scanning at 140 mm, and 3.47 mSv (95% CI, 3.15-3.62 mSv) for the 34 patients who underwent scanning at 120 mm. The reduction in scan length from 160 to 140 mm represented a reduction in scan length of 12.5% and the reduction to 120 mm a reduction of 25%. The median radiation dose was reduced 33% when volume scan length was changed to 140 mm and 47% when the length was changed to 120 mm. CONCLUSION: Dose optimization remains an important concern in cardiac CT, and for 320-MDCT angiography, substantial dose reduction can be achieved by reducing volume scan length so that it is in concert with the patient's heart length.

Annular pancreas: Radiologic features of a case with recurrent acute pancreatitis.

A 67-year-old female presented to the emergency department with epigastric and left-upper-quadrant abdominal pain. The patient reported history of multiple episodes of abdominal pain similar in nature over the last 2 years. Computed tomography (CT) and magnetic resonance imaging (MRI) of the abdomen demonstrated acute pancreatitis along with the presence of pancreatic tissue around the descending portion of the duodenum (a characteristic feature of annular pancreas). The findings on different imaging modalities are described.