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.

Yield of pelvic CT in emergency department patients undergoing CT torso for generalized or multiple complaints.

PURPOSE: To evaluate the utility of pelvic computed tomography (CT) in emergency department (ED) patients undergoing chest CT angiogram (CTA) for chest pain or suspected pulmonary embolism (PE) followed by abdominopelvic CT in the same session for additional multisystem or generalized complaints. METHODS: This retrospective study included consecutive adult ED patients from January 2017 to December 2019 who underwent CTA for suspected PE followed by portovenous abdominopelvic CT for multisystem or generalized complaints. Patient demographics, vitals, laboratory values, exam indication, malignancy history, and recent surgery/intervention were recorded. CT reports were reviewed for acute chest, abdomen, and/or pelvic pathology. RESULTS: There were 400 patients with 243 (61%) women and mean age of 59.8 years. Acute pelvic findings were seen in 11% (45/400). In 53% (24/45) of these, pelvic pathology could be diagnosed based on the abdominal portion of the CT. Five percent (21/400) of patients demonstrated isolated acute pelvic findings with 86% of these (18/21) clinically suspected prior to imaging. Acute pelvic pathology was associated with female gender (p = 0.015) and elevated white blood cell count (WBC) (p = 0.03). Specific pelvic CT indications and female gender were significantly associated with (p = 0.02 each) and independent predictors of isolated acute pelvic pathology. CONCLUSION: In ED patients undergoing chest CTA for chest pain or suspected PE combined with abdominopelvic CT, the presence of acute pelvic-related pathology not visualized on abdominal CT is low. For this ED patient cohort, pelvic CT may not be necessary in men with normal WBC and a low pre-imaging clinical suspicion for acute pelvic pathology.

Estimating maximum patient throughput at an ED scanner: Is three patients per hour the magic number?

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Diagnostic Utility of CT and Fluoroscopic Esophagography for Suspected Esophageal Perforation in the Emergency Department.

OBJECTIVE. We evaluated the diagnostic utility of CT in emergency department (ED) patients with suspected esophageal perforation and assessed whether subsequent fluoroscopic esophagography is necessary. MATERIALS AND METHODS. This retrospective study included consecutive adult patients presenting to an urban academic tertiary care ED from January 1, 2000, to August 31, 2017, who underwent CT and fluoroscopic esophagography within 1 calendar day (< 27 hours) of each other for suspected esophageal perforation. The use of oral or IV contrast material and the CT findings (i.e., pneumomediastinum, pleural effusion, pneumothorax, unexplained mediastinal fluid or stranding, esophageal wall air or frank esophageal wall disruption, or extraluminal oral contrast material) were documented. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Surgical or procedural intervention results or clinical follow-up results were the reference standard. RESULTS. One hundred three patients met the inclusion criteria. Sensitivity, specificity, PPV, and NPV for diagnosing esophageal perforation were 100.0%, 79.8%, 32.1%, and 100.0%, respectively, with CT and 77.8%, 98.9%, 87.5%, and 97.9% with fluoroscopic esophagography. Combining CT and fluoroscopic esophagography did not improve sensitivity, specificity, PPV, or NPV relative to using CT alone. The true-positive esophageal perforation rate was 8.7% for CT and 6.8% for fluoroscopic esophagography. When CT showed only pneumomediastinum (n = 51) or no pneumomediastinum (n = 14), the NPV of CT was 100.0%. CT with oral contrast material had a PPV of 38.5%, whereas CT without oral contrast material had a PPV of 26.7%. CONCLUSION. CT has a high NPV similar to that of fluoroscopic esophagography and has greater sensitivity than fluoroscopic esophagography for diagnosing suspected esophageal perforation. Fluoroscopic esophagrams do not provide additional information that changes clinical management beyond the information that CT provides. In ED patients with suspected esophageal perforation, CT with oral contrast material should be considered the initial imaging examination and can obviate fluoroscopic esophagography.

Chest computed tomography imaging utility for radiographically occult rib fractures in elderly fall-injured patients.

BACKGROUND: Previous studies demonstrate an association between rib fractures and morbidity and mortality in trauma. This relationship in low-mechanism injuries, such as ground-level fall, is less clearly defined. Furthermore, computed tomography (CT) has increased sensitivity for rib fractures compared with chest x-ray (CXR); its utility in elderly fall patients is unknown. We sought to determine whether CT-diagnosed rib fractures in elderly fall patients with a normal CXR were associated with increased in-hospital resource utilization or mortality. METHODS: Retrospective analysis of emergency department patients presenting over a 3-year period. INCLUSION CRITERIA: age, 65 years or older; chief complaint, including mechanical fall; and both CXR and CT obtained. We quantified rib fractures on CXR and CT and reported operating characteristics for both. Outcomes of interest included hospital admission/length of stay (LOS), intensive care unit (ICU) admission/LOS, endotracheal intubation, tube thoracostomy, locoregional anesthesia, pneumonia, in-hospital mortality. RESULTS: We identified 330 patients, mean age was 84 years (±SD, 9.4 years); 269 (82%) of 330 were admitted. There were 96 (29%) patients with CT-diagnosed rib fracture, 56 (17%) by CT only. Compared with CT, CXR had a sensitivity of 40% (95% confidence interval, 30-50%) and specificity of 99% (95% confidence interval, 97-100%) for rib fracture. A median of two additional radiographically occult rib fractures were identified on CT. Despite an increased hospital admission rate (91% vs. 78%) p = 0.02, there was no difference between patients with and without radiographically occult (CT+ CXR-) rib fracture(s) for: median LOS (4; interquartile range (IQR) 2-7 vs 4, IQR 2-8); p = 0.92), ICU admission (28% vs. 27%) p = 0.62, median ICU LOS (2, IQR 1-8 vs 3, IQR 1-5) p = 0.54, or in-hospital mortality (10.3% vs. 7.3%) p = 0.45. CONCLUSION: Among elderly fall patients, CT-identified rib fractures were associated with increased hospital admissions. However, there was no difference in procedural interventions, ICU admission, hospital/ICU LOS or mortality for patients with and without radiographically occult fractures. LEVEL OF EVIDENCE: Diagnostic, level III.

The Potential Role of Ultrasound in the Work-up of Appendicitis in the Emergency Department.

BACKGROUND: Acute appendicitis is common in the adult emergency department (ED). Computed tomography (CT) scan is frequently used to diagnose this condition, but ultrasound (US)-commonly used in pediatric diagnosis-may also have a role. OBJECTIVES: Review the clinical utility and define the frequency and diagnostic accuracy of US to diagnose appendicitis in an adult population in the ED setting. METHODS: Retrospective cohort study of patients who underwent appendiceal US in an academic, tertiary ED from July 2013-October 2015. RESULTS: There were 174 patients included, of which 39 (22%) had pathology-confirmed appendicitis. There were 25 patients who had an US scan that was positive for appendicitis, 146 (84%) were indeterminate, and 3 (1.7%) were negative. Among patients with a positive US, 25/25 (100%, 95% confidence interval [CI] 84-100%) had appendicitis, 32/146 (22%, 95% CI 16-29%) with an indeterminate US had appendicitis, and 0/3 (0%, 95% CI 0-6.2%) with a negative US had appendicitis. In the 28 definitive cases, US had a sensitivity of 64%, specificity of 2%, positive predictive value of 100%, and negative predictive value of 100%. The likelihood ratio positive and negative were 173 and 0, respectively. CONCLUSION: Our initial data suggest that an US that shows appendicitis seems to be reliable; however, a high prevalence of indeterminate studies limits the diagnostic utility as a universal approach in adult patients in the ED setting. Larger studies are needed to identify which patient populations would benefit from US as the initial imaging modality, what factors contribute to the large numbers of indeterminate results, and if any interventions may reduce the number of indeterminate results.

Multidetector CT Imaging of Bowel and Mesenteric Injury: Review of Key Signs.

In contemporary practice, multidetector computed tomography plays a critical role in the diagnostic evaluation of patients with suspected acute mesenteric and bowel trauma. Although less common than solid organ injuries, it may be seen in up to 5% of blunt trauma patients. Evaluation with CT remains challenging even with improvements in technology. The major imaging signs of mesenteric and bowel trauma and what is known about their applicability in clinical practice are reviewed here. Examples illustrate both the subtlety and variable significance of many of the key signs as well as how these are typically integrated into clinical practice.

Acute Abdominal Pain Following Optical Colonoscopy: CT Findings and Clinical Considerations.

OBJECTIVE: Optical colonoscopy is a common procedure; more than 14 million are performed annually in the United States. Serious colonoscopy complications are uncommon, but they can be life-threatening if not quickly recognized. CONCLUSION: Optical colonoscopy complications that can be detected at CT include bowel perforation, postprocedural hemorrhage, postpolypectomy syndrome, splenic injury, appendicitis, and diverticulitis. Radiologist awareness of optical colonoscopy complications seen at CT is imperative for appropriate diagnosis and prompt patient management.

Limited added utility of performing follow-up contrast-enhanced CT in patients undergoing initial non-enhanced CT for evaluation of flank pain in the emergency department.

In our emergency department (ED), patients with flank pain often undergo non-enhanced computed tomography (NECT) to assess for nephroureteral (NU) stone. After immediate image review, decision is made regarding need for subsequent contrast-enhanced CT (CECT) to help assess for other causes of pain. This study aimed to review the experience of a single institution with this protocol and to assess the utility of CECT. Over a 6 month period, we performed a retrospective analysis on ED patients presenting with flank pain undergoing CT for a clinical diagnosis of nephroureterolithiasis. Patients initially underwent abdominopelvic NECT. The interpreting radiologist immediately decided whether to obtain a CECT to evaluate for another etiology of pain. Medical records, CT reports and images, and 7-day ED return were reviewed. CT diagnoses on NECT and CECT were compared. Additional information from CECT and changes in management as documented in the patient's medical record were noted. Three hundred twenty-two patients underwent NECT for obstructing NU stones during the study period. Renal or ureteral calculi were detected in 143/322 (44.4 %). One hundred fifty-four patients (47.8 %) underwent CECT. CECT added information in 17/322 cases (5.3 %) but only changed management in 6/322 patients (1.9 %). In four of these patients with final diagnosis of renal infarct, splenic infarct, pyelonephritis and early acute appendicitis in a thin patient, there was no abnormality on the NECT (4/322 patients, 1.2 %). In the remaining 2 patients, an abnormality was visible on the NECT. In patients presenting with flank pain with a clinical suspicion of nephroureterolithiasis, CECT may not be indicated. While CECT provided better delineation of an abnormality in 5.3 % of cases, changes in management after CECT occurred only in 2 %. This included 1 % of patients in whom a diagnosis of organ infarct, pyelonephritis or acute appendicitis in a thin patient could only be made on CECT.

Findings of chronic sinusitis on brain computed tomography are not associated with acute headaches.

BACKGROUND: Headache is a common complaint in emergency department (ED) patients. Nearly 15% of ED headache patients will have brain computed tomography (CT) done. One frequent finding on these scans is "chronic sinusitis." Assuming that "chronic sinusitis" is the cause of the patient's headache is a potential source of mis-diagnosis. STUDY OBJECTIVE: We hypothesized that CT findings of chronic sinusitis occur with equal frequency in patients with atraumatic headache as in control patients with minor head injury. METHODS: This is a retrospective, single-center medical record review of consecutive discharged patients who received noncontrast head CT scans in an urban ED for either minor closed head injury or atraumatic headache. Each patient's head CT radiologic report was reviewed for findings of sinusitis and classified as chronic sinusitis, indeterminate for sinusitis, air-fluid levels, or no findings of sinusitis. RESULTS: We enrolled 500 patients (234 in the atraumatic headache group, 266 in the minor head injury group). The two groups were similar except that more women were enrolled in the atraumatic headache group. CT findings of chronic sinusitis in the atraumatic headache group (22.2%) and the minor head injury group (17.7%; difference 4.5%; 95% confidence interval of -2.5-11.6%). CONCLUSION: Prevalence of CT findings of sinusitis in ED patients with atraumatic headaches and mild head injury are similar. This strongly suggests that CT findings of chronic sinusitis in patients with atraumatic headache may be incidental, and are rarely the cause of a patient's acute headache.

Differentiation between pelvic abscesses and pelvic tumors with diffusion-weighted MR imaging: a preliminary study.

PURPOSE: Use diffusion-weighted magnetic resonance imaging (MRI) in differentiating pelvic abscess from pelvic cystic tumor. MATERIALS AND METHODS: Patients with pelvic abscess (n=23) or pelvic cystic tumor (n=15) who underwent diffusion-weighted MRI were reviewed. RESULTS: Pelvic abscesses showed hyperintensity on diffusion-weighted MRI and hypointensity on apparent diffusion coefficient (ADC) map. The mean ADC values of fluid in pelvic abscess and pelvic tumors were 0.73 ± 0.15 × 10(-3) and 2.27 ± 0.45 × 10(-3) mm(2)/s, respectively. Pelvic abscesses had significantly lower ADC values than pelvic cystic tumors (P<.001). CONCLUSION: Diffusion-weighted MRI provides a noncontrast method for interpreting pelvic cystic lesions.

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.

Image-guided drainage of tuboovarian abscesses of gastrointestinal or genitourinary origin: a retrospective analysis.

PURPOSE: To analyze the authors' success with image-guided drainage of tuboovarian abscesses (TOAs). MATERIALS AND METHODS: Retrospective analysis of patients with image-guided TOA drainage from 1999 to 2008 was performed. Patient recovery without salpingo-oophorectomy was considered clinical success. A total of 57 TOAs were drained in 49 female patients (mean age, 43; range, 12 to > 89). RESULTS: Thirty-three (58%) TOAs were drained percutaneously using computed tomography guidance and 24 were ultrasound guided (21 transvaginally, three transabdominally). Fifty-three TOAs were drained with catheter placement, and four were drained with aspiration alone. Abscess etiologies include pelvic inflammatory disease (n = 21, 37%), gastrointestinal conditions related (n = 21, 37%), gynecologic surgery (n = 8, 14%), and other (12%). Image-guided drainage resolved TOAs without salpingo-oophorectomy in 74% of cases overall (42 of 57) and 88% (29 of 33) of gynecologic-related cases, including 95% (20 of 21) of pelvic inflammatory disease cases. Salpingo-oophorectomy was performed more often in gastrointestinal-related cases (10 of 21, 48%) than for all other causes (five of 36, 14%; P < .001), with concurrent bowel surgery performed in the majority of the gastrointestinal-related cases. Mean follow-up after image-guided drainage was 48 months (range, 1-113) in patients who did not have related surgery. In patients who underwent salpingo-oophorectomy, it was performed on average 2.2 months (range, 0.5-5) after initial drainage. Two minor complications occurred; both involved catheter transgression of the urinary bladder in patients with transvaginal ultrasound-guided drainages. The patients were successfully treated conservatively with Foley catheter bladder decompression, without prolonged hospitalization. CONCLUSIONS: TOAs, especially of gynecologic origin, can often be managed successfully with image-guided drainage. After image-guided drainage, patients with gynecologic-related TOA were less likely to undergo salpingo-oophorectomy than patients with gastrointestinal-related TOAs.

Imaging of female urethral diverticulum: an update.

Female urethral diverticulum is an uncommon pathologic entity and can manifest with a variety of symptoms involving the lower urinary tract. Selection of the appropriate imaging modality is critical in establishing the diagnosis. Urethrography has traditionally been used in the evaluation of urethral diverticulum but provides only intraluminal information. Ultrasonography is advantageous in that it does not involve ionizing radiation and has the capacity to help detect a diverticulum without contrast agent filling. Multidetector computed tomographic (CT) voiding urethrography yields urethral images during micturition. In addition, the diverticulum and diverticular orifice can be visualized on two- and three-dimensional reformatted CT images. Interactive virtual urethroscopy provides simulated visualization of the intraluminal anatomy and the diverticular orifice. New magnetic resonance imaging techniques that make use of a surface or endoluminal coil have higher diagnostic accuracy and can delineate the diverticular cavity and help detect related complications. Clinicians should consider the possibility of a urethral diverticulum in women with chronic or recurrent lower urinary tract symptoms. Moreover, because female urethral diverticulum is becoming more prevalent in clinical practice, radiologists should be familiar with its imaging features and with the imaging techniques that are optimal for its evaluation.

Fournier gangrene: role of imaging.

Fournier gangrene is a rapidly progressing necrotizing fasciitis involving the perineal, perianal, or genital regions and constitutes a true surgical emergency with a potentially high mortality rate. Although the diagnosis of Fournier gangrene is often made clinically, emergency computed tomography (CT) can lead to early diagnosis with accurate assessment of disease extent. CT not only helps evaluate the perineal structures that can become involved by Fournier gangrene, but also helps assess the retroperitoneum, to which the disease can spread. Findings at CT include asymmetric fascial thickening, subcutaneous emphysema, fluid collections, and abscess formation. Subcutaneous emphysema is the hallmark of Fournier gangrene but is not seen in all cases. Compared with radiography and ultrasonography, CT provides a higher specificity for the diagnosis of Fournier gangrene and superior evaluation of disease extent; however, diagnosis and evaluation can also be performed with these other modalities. The administration of broad-spectrum antibiotics and aggressive surgical débridement of the nonviable tissue are both essential for successful treatment. An awareness of the CT features of Fournier gangrene is imperative for prompt diagnosis and effective treatment planning.

Dropped gallstones and surgical clips after cholecystectomy: CT assessment.

AIM: To describe the spectrum of computed tomographic (CT) findings in patients with dropped gallstones or dropped surgical clips after cholecystectomy. MATERIALS AND METHODS: Seventeen patients diagnosed with dropped gallstones and 26 patients with dropped surgical clips on computed tomography after cholecystectomies were included in this study. The CT scans were evaluated for the number, location, size, and density of dropped gallstones or surgical clips and for the presence of an abscess. The cases were evaluated for the outcome on clinical and/or CT follow-up. RESULTS: The location for dropped gallstones and dropped surgical clips after cholecystectomy was the Morrison's pouch in 17 and 12 patients, respectively. There were 9 abscesses in the study, all located in the Morrison's pouch. Duration from surgery to observation of abscess on computed tomography ranged from 5 days to more than 4.7 years. None of the patients with a dropped surgical clip from cholecystectomy developed an associated abscess. CONCLUSIONS: Subhepatic location was the most common location for dropped gallstones with associated abscess and for dropped surgical clips. Dropped cholecystectomy clips are not associated with increased risk of abscess formation and therefore do not need screening follow-up or operative removal. Abscess formation around dropped gallstone is a more common complication and requires surgical treatment in most when associated with an abscess.

Ureteral fibroepithelial polyp diagnosed preoperatively on virtual CT ureteroscopy.

We report a 28-year-old man who presented with hematuria and intermittent flank pain. Conventional CT urography showed mild left hydronephrosis and an undetermined lesion in the left ureter. By virtual CT ureteroscopy, a fibroepithelial polyp (FEP) was preoperatively diagnosed. The patient had segmental resection of the ureter and pathological proof of FEP was obtained.