Root Cause Analysis of Delayed Emergency Department Computed Tomography Scans.

Introduction: A solution for emergency department (ED) congestion remains elusive. As reliance on imaging grows, computed tomography (CT) turnaround time has been identified as a major bottleneck. In this study we sought to identify factors associated with significantly delayed CT in the ED. Methods: We performed a retrospective analysis of all CT imaging completed at an urban, tertiary care ED from May 1-July 31, 2021. During that period, 5,685 CTs were performed on 4,344 patients, with a median time from CT order to completion of 108 minutes (Quartile 1 [Q1]: 57 minutes, Quartile 3 [Q3]: 182 minutes, interquartile range [IQR]: 125 minutes). Outliers were defined as studies that took longer than 369 minutes to complete (Q3 + 1.5 × IQR). We systematically reviewed outlier charts to determine factors associated with delay and identified five factors: behaviorally non-compliant or medically unstable patients; intravenous (IV) line issues; contrast allergies; glomerular filtration rate (GFR) concerns; and delays related to imaging protocol (eg, need for IV contrast, request for oral and/or rectal contrast). We calculated confidence intervals (CI) using the modified Wald method. Inter-rater reliability was assessed with a kappa analysis. Results: We identified a total of 182 outliers (4.2% of total patients). Fifteen (8.2%) cases were excluded for CT time-stamp inconsistencies. Of the 167 outliers analyzed, 38 delays (22.8%, 95% confidence interval [CI] 17.0-29.7) were due to behaviorally non-compliant or medically unstable patients; 30 (18.0%, 95% CI 12.8-24.5) were due to IV issues; 24 (14.4%, 95% CI 9.8-20.6) were due to contrast allergies; 21 (12.6%, 95% CI 8.3-18.5) were due to GFR concerns; and 20 (12.0%, 95% CI 7.8-17.9) were related to imaging study protocols. The cause of the delay was unknown in 55 cases (32.9%, 95% CI 26.3-40.4). Conclusion: Our review identified both modifiable and non-modifiable factors associated with significantly delayed CT in the ED. Patient factors such as behavior, allergies, and medical acuity cannot be controlled. However, institutional policies regarding difficult IV access, contrast administration in low GFR settings, and study protocols may be modified, capturing up to 42.6% of outliers.

Validation of the peripheral trigger point theory of migraine headaches: single-surgeon experience using botulinum toxin and surgical decompression.

BACKGROUND: Migraine headache is a widespread neurovascular disorder that is often suboptimally or incompletely treated. This article confirms the efficacy of botulinum toxin treatment with surgical decompression as a deactivator of migraine headache trigger sites through the retrospective analysis of a single surgeon's experience. METHODS: A retrospective chart review was performed on 24 patients presenting with the diagnosis of migraine headache. Botulinum toxin type A injections were used to identify frontal, temporal, and/or occipital trigger points. The nasal trigger point was diagnosed with a decongestant trial, intranasal examination, and computed tomographic scan. Those patients with more than one trigger point underwent multiple surgical procedures, which were performed concomitantly during the same operation. All botulinum toxin injections, surgical procedures, and patient meetings were conducted by the principal investigator (J.E.J.), minimizing intrapatient treatment variability and multiprovider bias. RESULTS: Patient progress was tracked by consolidating migraine frequency, severity, and duration as a Migraine Headache Index. Nineteen patients (79.2 percent) benefited from surgery. Two patients (8.3 percent) reported migraine elimination and 17 patients (70.8 percent) reported significant improvement of their migraine symptoms. Among those patients who responded to surgery, average improvement from baseline levels was 96.9 percent. Among the entire patient population, average improvement was 78.2 percent from baseline. The mean postsurgical follow-up was 661 days. CONCLUSION: This study found botulinum toxin treatment with surgical decompression to be a potent deactivator of migraine headache trigger sites, corroborating the findings of the current literature in the field and underlining the reproducibility of the treatment. CLINICAL QUESTION/LEVEL OF EVIDENCE: : Therapeutic, IV.(Figure is included in full-text article.).