The disproportionate impact of peer learning on emergency radiology.

PURPOSE: The use of peer learning methods in radiology continues to grow as a means to constructively learn from past mistakes. This study examined whether emergency radiologists receive a disproportionate amount of peer learning feedback entered as potential learning opportunities (PLO), which could play a significant role in stress and career satisfaction. Our institution offers 24/7 attending coverage, with emergency radiologists interpreting a wide range of X-ray, ultrasound and CT exams on both adults and pediatric patients. MATERIALS AND METHODS: Peer learning submissions entered as PLO at a single large academic medical center over a span of 3 years were assessed by subspecialty distribution and correlated with the number of attending radiologists in each section. Total number of studies performed on emergency department patients and throughout the hospital system were obtained for comparison purposes. Data was assessed using analysis of variance and post hoc analysis. RESULTS: Emergency radiologists received significantly more (2.5 times) PLO submissions than the next closest subspeciality division and received more yearly PLO submissions per attending compared to other subspeciality divisions. This was found to still be true when normalizing for increased case volumes; Emergency radiologists received more PLO submissions per 1000 studies compared to other divisions in our department (1.59 vs. 0.85, p = 0.04). CONCLUSION: Emergency radiologists were found to receive significantly more PLO submissions than their non-emergency colleagues. Presumed causes for this discrepancy may include a higher error rate secondary to wider range of studies interpreted, demand for shorter turn-around times, higher volumes of exams read per shift, and hindsight bias in the setting of follow-up review.

Management of Severe Allergic-Like Contrast Media Reactions: Pitfalls and Strategies, From the AJR Special Series on Contrast Media.

Adverse reactions to contrast media are often high-acuity events that are uncommon potentially life-threatening. Nonetheless, these events are treatable, and radiologists may be called upon to manage a contrast media reaction. However, because these events are infrequent, they are prone to management errors. This article highlights common pitfalls and practical tips for the management of acute contrast media reactions in children and adults. Recognition of frequent management errors and implementation of the mitigation strategies presented can ameliorate risk and improve patient outcomes. These measures include proper training on reaction management and medication administration, the prompt use of IM epinephrine autoinjectors whenever a severe allergic-like reaction is suspected, the use of visual aids for quick reference in the setting of a reaction, and the recognition of adverse events that are not allergic-like reactions, which commonly require only supportive care.

A Survey of Practicing Radiologists on the Use of Premedication Before Intravenous Iodinated Contrast Medium Administration.

OBJECTIVE: To determine whether updated guidance by the ACR in 2017 advocating use of intravenous (IV) premedication in emergency department (ED) patients and inpatients with reported iodinated contrast allergy was associated with a change in clinical practice. METHODS: An anonymous survey was distributed via e-mail in October 2020 to practicing radiologist members of the ACR interrogating use of corticosteroid premedication for two clinical vignettes: an indicated routine (perform within 24 hours) inpatient contrast-enhanced CT (CE-CT) and an indicated urgent (perform within 6 hours) ED CE-CT. In both scenarios, the patient had a prior moderate hypersensitivity reaction to iodinated contrast media. Clinical management was evaluated. Data were compared to historical controls from 2009. RESULTS: The response rate was 11% (724 of 6,616). For the inpatient scenario, 72% (518 of 724) would use corticosteroid premedication with CE-CT, and 28% (200 of 724) would perform noncontrast CT. For the ED scenario, 67% (487 of 724) would use corticosteroid premedication with CE-CT, and 30% (217 of 724) would perform noncontrast CT. Oral premedication (85%, 439 of 518) was preferred for routine inpatients, and rapid IV premedication (89%, 433 of 487) was preferred for urgent ED patients. Of those who provided rapid IV dosing data in the ED, two doses of corticosteroids were used by 53% (216 of 410) and one dose was used by 45% (185 of 410), with academic radiologists more likely than private or hybrid practice radiologists to administer two doses (74% [74 of 100] versus 48% [151 of 312], P < .001, odds ratio, 3.03; 95% confidence interval, 1.84-5.00). Rapid IV premedication was more commonly used in 2020 than in 2009 (60% [433 of 724] versus 29% [20 of 69], P < .001, odds ratio, 3.65; 95% confidence interval, 2.12-6.26). Antihistamine use was common in both inpatient (93%, 480 of 518) and ED settings (92%, 447 of 487). Only 32% (229 of 721) of radiologists practiced in accordance with ACR guidelines, suggesting no need for routine premedication before CE-CT in patients with prior severe hypersensitivity reaction to gadolinium-based contrast media. Nonetheless, most (93%, 670 of 724) said the ACR Manual on Contrast Media was a major determinant of their practice. CONCLUSIONS: Use of rapid IV premedication in urgent settings has increased since 2009, following updated ACR guidelines, but there is disagreement over whether one or two corticosteroid doses is required. Despite reported high reliance on ACR guidelines, deviations from those guidelines remain common. In general, when ACR guidelines were not followed, it was in a risk-averse direction.

Current State of Peer Learning in Radiology: A Survey of ACR Members.

PURPOSE: Peer learning (PL) programs seek to improve upon the limitations of score-based peer review and incorporate modern approaches to improve patient care. The aim of this study was to further understand the landscape of PL among members of the ACR in the first quarter of 2022. METHODS: Members of the ACR were surveyed to evaluate the incidence, current practices, perceptions, and outcomes of PL in radiology practice. The survey was administered via e-mail to 20,850 ACR members. The demographic and practice characteristics of the 1,153 respondents (6%) were similar to those of the ACR radiologist membership and correspond to a normal distribution of the population of radiologists and can therefore be described as representative of that population. Therefore, the error range for the results from this survey is ±2.9% at a 95% confidence level. RESULTS: Among the total sample, 610 respondents (53%) currently use PL, and 334 (29%) do not. Users of PL are younger (mode age ranges, 45-54 years for users and 55-64 years for nonusers; P < .01), more likely to be female (29% vs 23%, P < .05), and more likely to practice in urban settings (52% vs 40%, P = .0002). Users of PL feel that it supports an improved culture of safety and wellness (543 of 610 [89%]) and fosters continuous improvement initiatives (523 of 610 [86%]). Users of PL are more likely than nonusers to identify learning opportunities from routine clinical practice (83% vs 50%, P < .00001), engage in programming inclusive of more team members, and implement more practice improvement projects (P < .00001). PL users' net promoter score of 65% strongly suggests that users of PL are highly likely to recommend the program to colleagues. CONCLUSIONS: Radiologists across a breadth of radiology practices are engaged in PL activities, which are perceived to align with emerging principles of improving health care and enhance culture, quality, and engagement.

Practice Management Strategies for Imaging Facilities Facing an Acute Iodinated Contrast Media Shortage.

An unanticipated but severe shortage in iodinated contrast media (ICM) is currently affecting imaging practices across the globe and is expected to persist through at least the end of June 2022. This supply shock may lead health care systems to experience an acute imaging crisis, given that many affected facilities have contrast agent supplies that are anticipated to last only a week or two under normal operating conditions. To maximize the opportunity to continue to provide optimal care for patients with emergent or life-threatening imaging indications and thereby minimize the overall impact on patient care, practice leaders will need to quickly assess their contrast material inventories, prioritize examination indications, and reduce their expected short-term usage of ICM. This Clinical Perspective reviews ICM conservation techniques that the Yale School of Medicine has deployed or is considering deploying, depending on the severity and length of the supply shortage.

Adapting the modified barium swallow: modifications to improve safety in the setting of airborne respiratory illnesses like COVID-19.

No guidance exists on how to safely perform modified barium swallows (MBS) in the midst of the COVID-19 pandemic or other communicable airborne respiratory infections (C-ARI). MBS has the potential to become an aerosol generating procedure (AGP) as it may trigger a cough or necessitate suctioning which may result in transmission of C-ARI putting patients and health care workers at risk. Regulations and best practices from international and US governmental and commercial agencies were reviewed. This review led to the multidisciplinary development of best practices of the safety measures and structural requirements to avoid transmission of SARS-CoV-2 or other C-ARIs when performing MBS. Implementation of these best practices resulted in structural changes to the fluoroscopy suite and protocol workflows. This enabled patients with COVID-19 to undergo MBS while maintaining patient and staff safety including mitigation of potential risk of onward transmission of SARS-CoV-2 to other patients. With proper modifications, MBS can be safely performed on patients with C-ARI such as COVID-19 while maintaining patient and health care worker (HCW) safety.

Current state of radiology report release in electronic patient portals.

OBJECTIVE: The aim of our study is to evaluate the current practice patterns of radiology report release into electronic patient portals. METHODS: A survey to assess details of radiology report release was distributed to members of The Association of Administrators in Academic Radiology across the United States. Numerical analysis was used to calculate the frequencies and percentages for the clinical site, frequency and pattern of patient portal use were calculated. Statistical analysis determined the percentages and frequencies for the clinical site, frequency and pattern of patient portal use, as well as statistical differences. RESULTS: A total of 31 (response rate = 28%, 31/108) at least partially completed surveys were received. Most (29/31, 94%) sites reported having a patient portal available with 80% (12/15) reporting < 50% patient utilization. There were no significant (p > 0.05) geographical differences noted in percentage utilization. Seventy-eight percent (21/27) of sites reported some form of automatic radiology report release into their portal. Mean delay was 4 days (range 0-7) from report completion to portal release. No correlation (r = 2) was seen between percentage of patient utilization of portals and timing of radiology report release. CONCLUSION: Most academic centers across the country have patient portals, however, most of these centers report less than 50% utilization of the portals by patients. While variability in radiology report release in patient portals was noted, the majority (78%) of academic medical centers have some form of automatic report release with average delay of 4 days between report completion to portal release.

Creating a Radiology Call Center Hotline and "HOT" Sites: Centralizing Radiology Questions and Cohorting Out-patient Care During the COVID-19 Pandemic.

INTRODUCTION: Amidst COVID-19 crisis, confusion exists over current radiology operations due to influx of new data and new protocols. In order to decrease confusion and reduce imaging facility related COVID-19 transmissions, we created a dedicated radiology COVID-19 call center and dedicated out-patient COVID-19 imaging sites (referred to "HOT" sites). MATERIALS AND METHODS: We created a central radiology call center hotline, staffed by our radiology technologists, to answer all radiology questions related to COVID-19 and help with scheduling exams. All out-patient x-ray exams became mandatory to schedule through the call center so proper COVID-19 screening could occur. If positive for COVID-19 symptoms, they are sent to "HOT" sites. Various statistical analyses were performed. RESULTS: A total of 2548 calls were received over 7 weeks with linear increase in calls during this period (R 2 = 0.17, P = 0.003). Most common reasons for calling were related to scheduling (n = 2336, 92%) and radiology operations (n = 145, 6%). At our main "HOT" site, from a total of 371 separate patient encounters by date of study, 72 patient encounters (19%) were COVID-19 positive at time of exam. DISCUSSION: This project provides efficient and reassuring radiology operations during an emergency situation by providing a single reliable point of contact and a source of truth for all facets of radiology. In doing so, we facilitate high quality patient centered care while protecting the health of our patients and staff.

Transitioning From Peer Review to Peer Learning: Report of the 2020 Peer Learning Summit.

Since its introduction nearly 20 years ago, score-based peer review has not been shown to have meaningful impact on or be a valid measurement instrument of radiologist performance. A new paradigm has emerged, peer learning, which is a group activity in which expert professionals review one another's work, actively give and receive feedback in a constructive manner, teach and learn from one another, and mutually commit to improving performance as individuals, as a group, and as a system. Many radiology practices are beginning to transition from score-based peer review to peer learning. To address challenges faced by these practices, a 1-day summit was convened at Harvard Medical School in January 2020, sponsored by the ACR. Several important themes emerged. Elements considered key to a peer-learning program include broad group participation, active identification of learning opportunities, individual feedback, peer-learning conferences, link with process and system improvement activities, preservation of organizational culture, sequestration of peer-learning activities from evaluation mechanisms, and program management. Radiologists and practice leaders are encouraged to develop peer-learning programs tailored to their local practice environment and foster a positive organizational culture. Health system administrators should support active peer-learning programs in the place of score-based peer review. Accrediting organizations should formally recognize peer learning as an acceptable form of peer review and specify minimum criteria for peer-learning programs. IT system vendors should actively collaborate with radiology organizations to develop solutions that support the efficient and effective management of local peer-learning programs.

Impact of Radiologist-Driven Change-Order Requests on Outpatient CT and MRI Examinations.

PURPOSE: To assess impact of electronic medical record-embedded radiologist-driven change-order request on outpatient CT and MRI examinations. METHODS: Outpatient CT and MRI requests where an order change was requested by the protocoling radiologist in our tertiary care center, from April 11, 2017, to January 3, 2018, were analyzed. Percentage and categorization of requested order change, provider acceptance of requested change, patient and provider demographics, estimated radiation exposure reduction, and cost were analyzed. P < .05 was used for statistical significance. RESULTS: In 79,310 outpatient studies in which radiologists determined protocol, change-order requests were higher for MRI (5.2%, 1,283 of 24,553) compared with CT (2.9%, 1,585 of 54,757; P < .001). Provider approval of requested change was equivalent for CT (82%, 1,299 of 1,585) and MRI (82%, 1,052 of 1,283). Change requests driven by improper contrast media utilization were most common and different between CT (76%, 992 of 1,299) and MRI (65%, 688 of 1,052; P < .001). Changing without and with intravenous contrast orders to with contrast only was most common for CT (39%, 505 of 1,299) and with and without intravenous contrast to without contrast only was most common for MRI (26%, 274 of 1,052; P < .001). Of approved changes in CT, 51% (661 of 1,299) resulted in lower radiation exposure. Approved changes frequently resulted in less costly examinations (CT 67% [799 of 1,198], MRI 48% [411 of 863]). CONCLUSION: Outpatient CT and MRI orders are deemed incorrect in 2.9% to 5% of cases. Radiologist-driven change-order request for CT and MRI are well accepted by ordering providers and decrease radiation exposure associated with imaging.

Social Distancing with Portable Chest Radiographs During the COVID-19 Pandemic: Assessment of Radiograph Technique and Image Quality Obtained at 6 Feet and Through Glass.

PURPOSE: To develop a technique that allows portable chest radiography to be performed through the glass door of a patient's room in the emergency department. MATERIALS AND METHODS: A retrospective review of 100 radiographs (50 [mean age 59.4 ± 17.3, range 22-87; 30 women] performed with the modified technique in April 2020, randomized with 50 [mean age 59 ± 21.6, range 19-100; 31 men] using the standard technique was completed by three thoracic radiologists to assess image quality. Radiation exposure estimates to patient and staff were calculated. A survey was created and sent to 32 x-ray technologists to assess their perceptions of the modified technique. Unpaired Ttests were used for numerical data. A P value < .05 was considered statistically significant. RESULTS: The entrance dose for a 50th percentile patient was the same between techniques, measuring 169 µGy. The measured technologist exposure from the modified technique assuming a 50th percentile patient and standing 6 feet to the side of the glass was 0.055 µGy, which was lower than standard technique technologist exposure of 0.088 µGy. Of the 100 portable chest radiographs evaluated by three reviewers, two reviewers rated all images as having diagnostic quality, while the other reviewer believed two of the standard images and one of the modified technique images were non-diagnostic. A total of 81% (26 of 32) of eligible technologists completed the survey. Results showed acceptance of the modified technique with the majority feeling safer and confirming conservation of PPE. Most technologists did not feel the modified technique was more difficult to perform. CONCLUSIONS: The studies acquired with the new technique remained diagnostic, patient radiation doses remained similar, and technologist dose exposure were decreased with modified positioning. Perceptions of the new modified technique by frontline staff were overwhelmingly positive.

Magnetic Resonance Imaging Features of Endometrial Polyps: Frequency of Occurrence and Interobserver Reliability.

OBJECTIVE: This study aimed to evaluate magnetic resonance imaging (MRI) features and interobserver agreement of endometrial polyps. METHODS: After institutional review board approval, our database was searched for women older than 18 years who underwent MRI pelvis and pelvic surgical intervention from 2012 to 2016. Seventy-two patients with polyps and 75 controls composed the study cohort. Two radiologists evaluated the MRIs retrospectively for polyps. Polyp characteristics and enhancement were assessed. RESULTS: Sensitivity and specificity of readers 1 and 2 were 59.7% and 88.0%, and 44.4 and 96.0%, respectively. There was moderate agreement for presence of polyps (κ = 0.556, P ≤ 0001), T2 fibrous core, and intratumoral cysts, with slight agreement for T2 signal and enhancement. Polyp size moderately correlated with pathology (κ = 0.465 [P = 0.025] for reader 1, κ = 0.562 [P = 0.029] for reader 2). The most common enhancement was same as myometrium. CONCLUSION: Magnetic resonance imaging is moderately sensitive for detecting endometrial polyps, demonstrating features that are not sensitive but can be specific, with moderate interobserver agreement.

What Patients Want to Know about Imaging Examinations: A Multiinstitutional U.S. Survey in Adult and Pediatric Teaching Hospitals on Patient Preferences for Receiving Information before Radiologic Examinations.

Purpose To identify what information patients and parents or caregivers found useful before an imaging examination, from whom they preferred to receive information, and how those preferences related to patient-specific variables including demographics and prior radiologic examinations. Materials and Methods A 24-item survey was distributed at three pediatric and three adult hospitals between January and May 2015. The χ2 or Fisher exact test (categorical variables) and one-way analysis of variance or two-sample t test (continuous variables) were used for comparisons. Multivariate logistic regression was used to determine associations between responses and demographics. Results Of 1742 surveys, 1542 (89%) were returned (381 partial, 1161 completed). Mean respondent age was 46.2 years ± 16.8 (standard deviation), with respondents more frequently female (1025 of 1506, 68%) and Caucasian (1132 of 1504, 75%). Overall, 78% (1117 of 1438) reported receiving information about their examination most commonly from the ordering provider (824 of 1292, 64%), who was also the most preferred source (1005 of 1388, 72%). Scheduled magnetic resonance (MR) imaging or nuclear medicine examinations (P < .001 vs other examination types) and increasing education (P = .008) were associated with higher rates of receiving information. Half of respondents (757 of 1452, 52%) sought information themselves. The highest importance scores for pre-examination information (Likert scale ≥4) was most frequently assigned to information on examination preparation and least frequently assigned to whether an alternative radiation-free examination could be used (74% vs 54%; P < .001). Conclusion Delivery of pre-examination information for radiologic examinations is suboptimal, with half of all patients and caregivers seeking information on their own. Ordering providers are the predominant and preferred source of examination-related information, with respondents placing highest importance on information related to examination preparation. © RSNA, 2018 Online supplemental material is available for this article.

Proctoring of New Emergency Radiologists to Promote Clinical Excellence and Ensure Quality of Care.

PURPOSE: The authors' institution provides 24/7 attending radiologist final interpretations for all emergency, urgent, and inpatient studies. As a supplement to the existing emergency radiology faculty, the institution relies on two groups of radiologists to provide final imaging interpretations after hours: radiology fellows (RFs) and newly hired subspecialty radiologists (NRs). For both groups, subspecialty services provide overreads the following day to improve the skills of the staff members and ensure clinical excellence. The purpose of this study was to compare the clinical significance and rate of discrepancies between RFs and NRs. METHODS: A retrospective review of all overreads from July 1, 2012, to June 30, 2015, was performed. Discrepancy rates for RFs and NRs were calculated. Error significance for cases requiring addenda was categorized as follows: acute, likely malignant, indeterminate, unlikely to be of clinical significance, insignificant typographic error, or significant typographic error. RESULTS: In total, 10,796 studies were rechecked, of which 1.9% (n = 205) required addenda, 3.6% (n = 384) were deemed addendum-optional, and 94.5% (n = 10,207) required no comments. There was no significant difference in cases requiring addenda (RFs, 1.7% [119 of 6,847]; NRs, 2.2% [86 of 3,949]; P = .11). Of the 205 cases requiring addenda, 21.0% (n = 43) were deemed to be acute, 4.9% (n = 10) likely malignant, 28.3% (n = 58) indeterminate, 32.7% (n = 67) unlikely to be of clinical significance, and 13.1% (n = 27) secondary to typographic errors (66.7% [n = 18] deemed to be significant). CONCLUSIONS: After-hours coverage with RFs and NRs allows high-quality final, actionable interpretations with low discrepancy rates and no significant difference between both groups for addendum-needed cases. The program strikes a balance between the need for timely interpretations and the need to continually monitor and improve the quality of interpretations through subspecialist feedback.

Is there an added value of a hepatobiliary phase with gadoxetate disodium following conventional MRI with an extracellular gadolinium agent in a single imaging session for detection of primary hepatic malignancies?

PURPOSE: To determine added value of hepatobiliary phase (HBP) using gadoxetate disodium compared to MRI with extracellular gadolinium-based contrast agent (GBCA) for detection of primary hepatic malignancies in a single imaging session. MATERIALS AND METHODS: IRB approved this HIPAA compliant retrospective study. Within 90 days of resection or liver transplant, thirty patients underwent MRI with extracellular GBCA followed by separate injection of gadoxetate for HBP. Two sets of images were reviewed: Set #1-unenhanced and enhanced images with an extracellular GBCA and set #2-with addition of HBP. Data were analyzed in two groups, cases with hepatocellular carcinoma (HCC) only and cases with either HCC and/or cholangiocarcinoma. Observer diagnostic accuracy (Az), sensitivity, and specificity were calculated. RESULTS: 14/30 subjects had HCC (46%, CI 28-66%), 2/30 (2%, CI 1-22%) cholangiocarcinoma, and 14/30 (46%, CI 28-66%) no malignancy. There was no significant change in A z value with addition of gadoxetate in the detection of HCC (range 0.84-0.97 set #1 and 0.85-0.97 set #2, p > 0.05). Sensitivity and specificity showed no significant differences (p > 0.05) between the image sets for all readers. When stratified by lesion size, there was no significant difference in accuracy, sensitivity, or specificity for any reader (p > 0.05). CONCLUSION: When compared to extracellular GBCA, gadoxetate HBP imaging does not result in a significant difference in accuracy or sensitivity in diagnosis of HCC or cholangiocarcinoma and may result in a decrease in specificity.