Patient satisfaction reporting for patellofemoral arthroplasty is significantly lacking: a systematic review

Background: Patellofemoral Arthroplasty (PFA) has been shown to be successful in restoring knee function and quality of life in patients with the isolated patellofemoral disease. Patient satisfaction has been suggested as an indicator of the quality of elective orthopedic operations, although there remains no standardized method to collect and evaluate satisfaction. The present study offers a systematic review of the available literature concerning patient satisfaction following PFA to assess common methodologies for reporting patient satisfaction.

Methods: A query of the Medline database produced 116 articles that were reviewed for inclusion in the review. The following inclusion criteria were used to identify suitable articles: English language, clinical outcomes study related to PFA, and patient-reported satisfaction as an outcome measure.

Results: Seven studies met inclusion criteria and were eligible for review. The highest level of evidence was level-III. The study publication dates ranged from 2009 to 2016, with six published in 2015 & 2016. In total, 320 PFAs were performed on 267 patients. Four articles reported the proportion of included patients who had previous knee surgeries (range: 20–60%). Three studies used ordinal scales to rate patient satisfaction. Four studies (57.1%) reported the numeric proportion of patients satisfied following PFA, which ranged from 76% to 96.5%. Two studies used Visual Analog Scale methods. For these two studies, one of them reported the mean satisfaction score as 7.5/10, and the other reported a median of 90/100.

Conclusions: The available literature on patient satisfaction after PFA was found to be limited, with low-quality evidence and variable methodology.     

Transfer Patient Imaging: Assessment of the Impact of Discrepancies Identified by Emergency Radiologists

PurposeAdvanced imaging examinations of emergently transferred patients (ETPs) are overread to various degrees by receiving institutions. The practical clinical impact of these second opinions has not been studied in the past. The purpose of this study is to determine if emergency radiology overreads change emergency medicine decision making on ETPs in the emergency department (ED).MethodsAll CT and MRI examinations on patients transferred to a level I trauma center during calendar year 2018 were routinely overread by emergency radiologists and discrepancies with the outside report electronically flagged. All discrepant reports compared with the outside interpretations were reviewed by one of four emergency medicine physicians. Comparing the original and final reports, reviewers identified changes in patient management that could be attributed to the additional information contained in the final report. Changes in patient care were categorized as affecting ED management, disposition, follow-up, or consulting services.ResultsOver a 12-month period, 5,834 patients were accepted in transfer. Among 5,631 CT or MRI examinations with outside reports available, 669 examinations (12%) had at least one discrepancy in the corresponding outside report. In 219 examinations (33%), ED management was changed by discrepancies noted on the final report; patient disposition was affected in 84 (13%), outpatient follow-up in 54 (8%), and selection of consulting services in 411 (61%), and ED stay was extended in 544 (81%). Discrepant findings affected decision making in 613 of 669 of examinations (92%).ConclusionEmergency radiology overreading of transferred patients’ advanced imaging examinations provided actionable additional information to emergency medicine physicians in the care of 613 of 669 (92%) examinations with discrepant findings. This added value is worth the effort to design workflows to routinely overread CT and MRI examinations of ETPs.     

The yield of CT pulmonary angiograms to exclude acute pulmonary embolism

There is accumulating evidence regarding the overuse of computed tomography pulmonary angiography (CTPA) to exclude pulmonary embolism (PE). We evaluated the yield of CTPA studies performed at our tertiary care hospital between April 2008 and March 2010 for emergency patients (ED), inpatients (INPT), and intensive care unit inpatients (ICU). For each patient group, we also compared CTPA positivity rates among the following: daytime and on-call studies, 1 year before and after institution of an Emergency Radiology division, interpreting thoracic and non-thoracic radiologists, and individual emergency physicians. Patients with a history of PE and indeterminate studies were excluded. The diagnosis of PE was based on the radiology report. D-dimer values obtained within 24 h prior to CTPA were recorded. A total of 3,571/4,757 CTPA studies satisfied the inclusion criteria. The fraction of positive studies was 252/1,677 (15.0 %) ED, 255/1,548 (16.5 %) INPT, and 62/346 (17.9 %) ICU. There was no difference in yield between patient groups, daytime vs. on-call studies, before vs. after instituting an emergency radiology division, and thoracic vs. non-thoracic radiologists (p?>?0.05). For individual emergency physicians, the mean CTPA positivity rate was 15.4 % but varied considerably (σ?=?8.5 %, range, 0–38.5 %). In comparison to other recent studies, our yield of ED CTPA is relatively high but varied widely among individual emergency physicians. While the reasons for such differences require further investigation, our results reinforce the importance of a strong clinical assessment in the work-up of suspected PE.     

Percutaneous cholecystostomy for acute cholecystitis: ten-year experience

PurposeTo review the clinical course of patients with acute cholecystitis treated by percutaneous cholecystostomy, and to identify risk factors retrospectively that predict outcome.Materials and MethodsA total of 106 patients diagnosed with acute cholecystitis were treated by percutaneous cholecystostomy during a 10-year period. Seventy-one (67%) presented to the emergency department (ED) specifically for acute cholecystitis, and 35 (23%) were inpatients previously admitted for other conditions. Outcomes of the two groups were compared with respect to severity of illness, leukocytosis, bile culture, liver function tests, imaging features, time intervals from onset of symptoms to medical and percutaneous intervention, and whether surgical cholecystectomy was later performed.ResultsOverall, 72 patients (68%) showed an improvement clinically, whereas 34 (32%) showed no improvement or a clinically worsened condition after cholecystostomy. Patients who presented to the ED primarily with acute cholecystitis fared better (84% of patients showed improvement) than inpatients (34% showed improvement; P < .0001). Gallstones were identified in 54% of patients who presented to the ED, whereas acalculous cholecystitis was more commonly diagnosed in inpatients (54%). Patients with sepsis had worse outcomes overall (P < .0001). Bacterial bile cultures were analyzed in 95% of patients and showed positive results in 52%, with no overall effect on outcome. There was no correlation between the time of onset of symptoms until antibiotic therapy or cholecystostomy in either group. Long-term outcomes for both groups were better for those who later underwent cholecystectomy (P < .0001).ConclusionsOutcomes after percutaneous cholecystostomy for acute cholecystitis are better when the disease is primary and not precipitated by concurrent illness.     

Decreasing Duplicative Imaging: Inpatient and Emergency Medicine Abdominal Ultrasound Within 72 Hours of Abdominal CT

PurposeThe aim of this project was to reduce abdominal ultrasound examinations in patients who had undergone abdominal CT within 72 hours previously.MethodsA best practice advisory (BPA) was created in the electronic medical record to advise against the use of abdominal ultrasound in adult inpatients and emergency department patients who had undergone abdominal CT within the preceding 72 hours. Acceptable acknowledgment reasons to proceed with the order were made available if providers chose to override. Frequency of BPA firing and subsequent ordering behavior were evaluated 6 months after integration of the BPA into the electronic medical record. Chart review was conducted for 100 patients whose orders were placed through an override of the alert to determine if the ultrasound study added value and for all patients whose ultrasound studies were canceled to confirm that patient care was not compromised by omitting the ultrasound study.ResultsIn the first 6 months, a total of 614 inpatient and emergency department abdominal ultrasound orders triggered the BPA. A total of 16% of orders (n = 96) were canceled by the provider after the BPA, reflecting 518 overrides. The majority of retained orders were to evaluate the gallbladder (44% [227 of 518]). Chart review confirmed utility for gallbladder imaging and that the canceled ultrasound examinations would not have contributed value to patients’ care.ConclusionsA recently performed abdominal CT scan may obviate the need for inpatient and emergency department abdominal ultrasound, particularly in the setting of hospital-acquired acute kidney injury. A BPA resulted in only 16% of orders’ being canceled, whereas chart review revealed a much larger opportunity to avoid duplicative imaging.     

Plain abdominal radiography in acute abdominal pain—is it really necessary?

The aims of this study are to audit the ordering of abdominal radiographs (AXR) in the emergency department (ED) and evaluate the current practices, knowledge and attitudes of emergency physicians with regard to ordering AXRs in patients presenting with acute abdominal pain. A retrospective study was undertaken at an ED of a tertiary hospital in Tasmania using clinical notes on patient presenting with acute abdominal pain who underwent an AXR. The study also included a short questionnaire, which assessed emergency physicians’ knowledge of current imaging guidelines and clinical practice when ordering an AXR. During the study period, 108 patients satisfied the selection criteria, and the AXR was reported as normal in 76 % (n?=?82; p value <0.05), non-specific in 12 % (n?=?13; p value <0.05) and abnormal in 12 % (n?=?13; p value <0.05) of patients. Of those patients, 25 % (n?=?27) of the AXRs did not meet indications listed in the Diagnostic Imaging Pathways published by the Western Australia Department of Health and were found not to benefit patient care. Of the 19 doctors who completed the survey, only 16 % (n?=?3) were aware of any clinical guidelines for imaging in this setting. Current guidelines should be followed when ordering imaging for patients with acute abdominal pain to minimise unnecessary patient radiation exposure, avoid delays in diagnosis and definitive patient management, reduce costs and therefore increase efficiency in ED.     

The impact of introducing a no oral contrast abdominopelvic CT examination (NOCAPE) pathway on radiology turn around times,emergency department length of stay,and patient safety

This investigation evaluates the impact of the no oral contrast abdominopelvic CT examination (NOCAPE) on radiology turn around time (TAT), emergency department (ED) length of stay (LOS), and patient safety metrics. During a 12-month period at two urban teaching hospitals, 6,409 ED abdominopelvic (AP) CTs were performed to evaluate acute abdominal pain. NOCAPE represented 70.9 % of all ED AP CT examinations with intravenous contrast. Data collection included patient demographics, use of intravenous (IV) and/or oral contrast, order to complete and order to final interpretation TAT, ED LOS, admission, recall and bounce back rates, and comparison and characterization of impressions. The NOCAPE pathway reduced median order to complete TAT by 32 min (22.9 %) compared to IV and oral contrast AP CT examinations (traditional pathway) (P?P?P?=?0.003). Recall and bounce back rates were 3.2 %, and only one patient had change in impression after oral contrast CT was repeated. The NOCAPE pathway is associated with decreased radiology TAT and ED LOS metrics. The authors suggest that NOCAPE implementation in the ED setting is safe and positively impacts both radiology and emergency medicine workflow.     

Has NICE guidance changed the management of the suspected scaphoid fracture: A survey of UK practice

IntroductionDespite scaphoid fractures being relatively uncommon pro-active treatment of suspected fractures has been seen as a risk management strategy. The poor positive predictive value of X-rays has led to published guidelines advocating MRI as a first-line or early imaging tool. It is unclear whether UK hospitals have been able to introduce early scanning and this national survey sought to establish the current management strategies for patients with a suspected scaphoid fracture.MethodAn electronic survey of UK emergency departments (ED) was conducted to establish the initial and follow up strategies for patients with negative imaging. Comparison of first and second-line imaging modalities was undertaken together with review of the clinical speciality responsible for ongoing management.Results166 UK NHS Trusts were identified with emergency department facilities of which 66 (39.8%) responded. All sites perform an X-ray as the initial examination. For those with a negative examination ED follow up was the most common approach (54.6%), although many sites refer patients to other specialities including orthopaedics (39.4%) for follow up. The data demonstrated inconsistencies in the number of follow-up episodes and the different imaging investigations utilised. Frustration with the challenges presented by this patient cohort was evident.ConclusionThe suspected scaphoid fracture represents an ongoing challenge to the NHS with many resource intensive pathways reliant on access to complex imaging investigations.Implications for practiceOur study identified that UK Emergency Departments have limited early access to complex imaging for scanning of the scaphoid. A range of strategies are used for follow up of suspected scaphoid fractures and these are resource intensive. Overtreatment of patients with suspected scaphoid fracture is used as a risk management approach.     

Appropriateness of Computed Tomography and Ultrasound for Abdominal Complaints in the Emergency Department

ObjectiveThe purpose of this study was to evaluate the appropriateness of ultrasound (US) and computed tomography (CT) examinations ordered in the emergency department (ED) for abdominal complaints.Materials and MethodsWe reviewed 154 CTs and 154 US orders for appropriateness using evidence-based recommendations by the American College of Radiology. The sample was powered to show a prevalence of inappropriate orders of 25% with a margin of error of 7.5%. Findings in the final reports were compared to the initial clinical diagnosis classified in 4 categories: normal, compatible with initial diagnosis, alternative diagnosis, and inconclusive. We also evaluated the frequency in which a second imaging modality was ordered on the same visit.ResultsA total of 135 CT and 143 US examinations had complete clinical information to allow evaluation of order appropriateness. The rate of inappropriate orders was 36.3% for CT and 84.4% for US. The final report of appropriate orders was significantly more likely to demonstrate findings compatible with the initial diagnosis for both CT (76.7% vs 20.4%, P < 0.0001) and US (38.9% vs 14.4%, P = 0.0093). Inappropriately ordered CT scans were more likely to show no abnormalities (46.9 vs 16.3%, P = 0.0001). An additional imaging order with a secondary modality was requested in 20% of the inappropriate US orders, and 8.2% of the inappropriate CT orders.ConclusionThe prevalence of inappropriate examinations in the ED was 36.3% for CT and 84.4% for US. Appropriately ordered exams were more likely to yield imaging findings compatible with the initial diagnosis for both modalities.     

Tomografía computarizada cerebral solicitada desde Urgencias: la realidad

ObjectivesTo evaluate the most common reasons for requesting brain CT studies from the emergency department and to calculate the prevalence of urgent acute pathology on this population group.Material and methodsWe reviewed brain CT studies requested from the emergency department during October and November 2018. We recorded the following variables: age, sex, reason for requesting the study, CT findings, use of contrast agents and reasons for using them, and, in patients who had undergone previous head CT studies, whether the findings had changed. SPSS was used for statistical analyses.ResultsA total of 507 urgent brain CT studies were done (41.4% in men, 58.6% in women; mean age, 65.4 ± 20 years).The most common reason for requesting the study was head trauma (40.5%); only 15.6% of these studies showed acute posttraumatic intracranial lesions.The second most common reason was focal neurologic symptoms (16%); only 16% of these studies showed recent ischemic infarcts or acute bleeding.No pathological findings were reported in 43.2% of the studies.The most common abnormal finding was small vessel disease (20%).Space-occupying lesions (both benign and malignant) were found in 3.9% of all patients.ConclusionsMost brain CT studies requested from the emergency department showed no findings that would modify the management of the patient. Overuse of urgent brain CT increases the radiology department's workload and exposes patients to radiation unnecessarily.     

Tromboembolismo pulmonar agudo: adecuación del manejo de pacientes según las guías de práctica clínica en el servicio de urgencias

Background and aimsTo evaluate the frequency of acute pulmonary embolism, the use of clinical probability scores, and the appropriateness of the management of patients for whom computed tomography angiography (CTA) was requested from the emergency department for suspected acute pulmonary embolism.Materials and methodsThis was a retrospective observational study of CTA studies requested from the emergency department to rule out acute pulmonary embolism. We analyzed clinical variables and the explicit use of clinical probability scores. We determined the appropriateness of management according to the Wells Score and Geneva Score and the simplified versions of these two scores, calculated retrospectively.ResultsWe included 534 patients (52.8% women; mean age, 73 years). The frequency of acute pulmonary embolism was 23.0% and the Wells Score was explicitly used in 15.2%. The appropriateness of the management varied depending on the clinical probability score used to assess it (54.5%-75.8%) and on whether the standard D-dimer or age-adjusted D-dimer was used.ConclusionsThe failure to use the Wells Scores in all cases does not necessarily imply inappropriate management, and the performance of global clinical judgment can be similar to that of clinical probability scores; however, specific studies are necessary to confirm this hypothesis.     

Revision following patello-femoral arthoplasty

Purpose

To describe the population of patients undergoing patello-femoral arthroplasty (PFA) revision and the reasons for which these implants are being revised. To compare this information with the observed failure patterns described in other national registries and with those seen for total knee replacement (TKR).

Methods

Using data accessed from the National Joint Registry for England and Wales, we identified 4634 primary PFA implanted between 1 April 2003 and 30 June 2010. As of 1 July 2010, 195 PFAs had been revised. The epidemiology of PFA revision is described with specific emphasis upon the reasons for revision.

Results

The median age at revision was 61 years (145 F:50 M). Revision occurred at a median of 2.0 years following primary surgery. Sixty of the 98 centres (61%) performing PFA revisions undertook only one such procedure. The 195 revisions were undertaken by 140 different consultants. Unexplained pain was the reason for revision in 46% of cases where a reason was stated. Progression of tibio-femoral arthritis was seen in only 14% of cases. Undiagnosed pain remained the most common reason for revision irrespective of patient age and time to revision, and was twice as common for PFA revision when compared to a matched group of failed TKR (43% vs. 19%, P < 0.001).

Conclusions

Unexplained pain is the principal indication for early revision of the failing PFA. The high proportion of revisions performed for unexplained pain raises questions about the adequacy of surgical selection for patients undergoing PFA.

Level of evidence

Retrospective comparative study, Level III.     

Recommendations for additional imaging on emergency department CT examinations: comparison of emergency- and organ-based subspecialty radiologists

Purpose

Past studies have identified a high frequency of recommendations for additional imaging (RAI) for computed tomography (CT) studies performed in an emergency department (ED), thereby potentially contributing to increased imaging utilization and costs. The purpose of this study was to compare rates of RAI within the ED setting between ED-based and organ-based subspecialty radiologists.

Methods

We identified 600 ED CT studies, comprising 200 head, chest, and abdominal CT studies, split equally between cases reviewed by ED-based and organ-based radiologists. Frequency of RAI for the three examinations was compared between these subspecialty groups.

Results

Frequencies of RAI were 21.5 %, 13.5 %, and 5.5 % for CT examinations of the chest, abdomen, and brain, respectively. There was a significantly higher frequency of RAI for chest CT studies interpreted by chest radiologists than by ED radiologists (28.0 % vs. 15.0 %, respectively, p?=?0.036), largely due to a higher rate of RAI for incidentally detected lung nodules and masses as well as other pulmonary parenchymal abnormalities by chest radiologists. There was no significant difference in RAI on brain or abdominal CT studies between the two groups (p?=?0.426–1.0). However, on abdominal studies, only ED-based radiologists provided RAI for abnormalities of the bowel or uterus, while only organ-based radiologists provided RAI for pancreatic abnormalities. Only 25.6 % of RAI were subsequently performed at our institution.

Conclusion

For chest CT studies performed at the authors' institution, differences in management of incidental pulmonary nodules contributed to a significantly higher frequency of RAI by chest radiologists than by ED-based radiologists. Further investigation of the impact of these differences on cost and patient outcomes is warranted.     

Retrospective Analysis of Emergency Computed Tomography Imaging Utilization at an Academic Centre: An Analysis of Clinical Indications and Outcomes

PurposeTo explore resource utilization through evaluation of computed tomography (CT) imaging trends in the emergency department by examining common indications/outcomes for imaging in this setting.MethodsA retrospective analysis of clinical indications/outcomes for all CT imaging in 3 emergency departments over a 1-year period was conducted. Scans were divided by body part and the most common indications for each type of scan were determined. Clinical outcomes from each study were extracted from final interpretations by the reporting radiologist.ResultsA total of 4556 CT scans were performed in the emergency department over a 1-year period. A total of 3.6% of all-comers to our emergency departments underwent CT scan as part of their investigation. There were 2107 head CTs (46%), 1296 (28%) abdominal CTs, 468 (10%) CTs of the chest, 408 (9%) CTs of the neck/spine, and 101 (2%) extremity CTs performed. The most common clinical indication for performing a CT head was focal neurological defect comprising 1534 (73%) of all CT heads. Twenty-four percent of abdominal CTs were for investigation of right lower quadrant pain, followed by flank pain (19%). Chest pain and shortness of breath were the most common indications for CTs of the chest (315 [75%]) with 10% of these examinations for this indication positive for pulmonary embolism. Trauma was the most common indication for neck CTs (296 [73%]) and extremities (70 [69%]). Nil acute was the most common final interpretation in all categories (79% CT heads, 75% neck CTs, 38% abdominal CTs, 43% chest CTs).ConclusionsNil acute was the most common diagnosis; however, serious clinical outcomes were identified 40% of the time. Cross-sectional imaging remains an integral tool for triage and diagnosis in this environment as the cost of missing a diagnosis in this setting has a great impact on patient care.     

Secondary cardiac risk stratifying tests after coronary computed tomography angiography in emergency department patients

BackgroundSeveral large trials demonstrated that coronary computed tomography angiography (CTA) in a triage strategy could lead to increased secondary cardiac risk stratifying testing (SCRST). Whether this is true for routine clinical care remains unclear. We measured SCRSTs after coronary CTA was implemented in our emergency department (ED) practice by CTA result, and if locally existing management recommendations for a structured post CTA diagnostic strategy were followed.MethodsThis single site retrospective cohort study included all our ED patients who received coronary CTA between October 1, 2012 and September 30, 2016. SCRST's included functional cardiac tests and invasive coronary angiography (ICA), performed during the ED coronary CTA visit or related admission.ResultsA total of 1916 subjects were included with a mean age of 52.9 ± 10.8 years. Of their coronary CTAs, 179 were positive (severe stenosis, occlusion or ventricular wall motion abnormalities; 9.3%), 105 intermediate (moderate stenosis; 5.5%), 1611 negative (no to mild obstructive CAD; 84.1%) and 21 non-diagnostic (1.1%). SCRSTs were performed in 237 (overall 12.4%, noninvasive in 5.6%, ICA in 6.7%). After positive coronary CTA, 73.7% of subjects received SCRSTs. For intermediate, negative and non-diagnostic CTAs this was 72.4%, 1.1% and 47.6% respectively. Management conformed to local management recommendations in 96.2% of cases.ConclusionIn spite of previous trials, rates of secondary cardiac risk stratifying tests after routine clinical ED coronary CTA are low, especially in patients with negative coronary CTA. Structured management guidelines for post coronary CTA, and adherence to these guidelines, appear essential.     

Utility of ultrasound after a negative CT abdomen and pelvis in the emergency department

PurposeThe purpose of this study is to assess the utility of an abdominal and/or pelvic ultrasound (US) performed within 24 h after a negative CT of the abdomen and pelvis (CTAP) in the emergency department (ED). The secondary endpoint is to assess whether there is a significant increase in length of stay (LOS) in the ED due to immediate US reimaging.MethodWe reviewed the imaging reports of 335 patients over the course of 3 years in our ED who had an US within 24 h after a negative CTAP. We then assessed type of US and whether the US showed any acute findings. We also evaluated LOS in the ED.ResultsOut of 335 patients, there were only three US cases suspicious for acute surgical pathology (3/335 or 0.9%). On 30-day clinical follow-up, only one of the three cases was confirmed as cholecystitis on pathology. The most common non-surgical findings on US not initially reported on CTAP were ovarian cysts (29/83) and gallstones (9/83). Additionally, the LOS for patients who received both a CTAP and US was 119 min longer than patients who only received a CTAP.ConclusionUS abdomen and/or pelvis reimaging within 24 h following a negative CTAP is unlikely to change surgical management in the acute setting. US reimaging can still be useful in diagnosing non-surgical pathology, which could serve to explain the patient's pain. US reimaging after negative CTAP is associated with an average increase in the ED LOS.     

Computed tomography for detection of septic foci: Retrospective analysis of patients presenting to the emergency department

ObjectiveSepsis is defined as organ dysfunction due to severe infection. Septic patients face a significant mortality risk. Thus, timely recognition with prompt focus identification and control are essential. This study aims to determine the current role of computed tomography (CT) in the diagnostic workup of septic patients.MethodsWe retrospectively identified 357 patients in the emergency department (ED) of a large university center with suspected sepsis in a two-year period. A total of 132 patients underwent CT scanning within 72 h of admission. Patients were characterized by clinical and laboratory findings. CT reports were categorized and matched with clinical data.ResultsOf 357 ED patients with suspected sepsis, 37.0% (132/357) underwent CT imaging within 72 h. The most commonly identified septic foci in CT were chest 38.6% (49/127), abdomen 22.0% (28/127) and genitourinary tract 20.5% (26/127) in descending order. The focus detection rate was 76.5% per patient with a concurrent number-needed-to-scan of 1.31. Contrast medium administration in CT did not improve focus detection rate (p = 0.631) or diagnostic confidence in this patient population (p = 0.432). CT had a positive predictive value of 81.82% (CI 76.31 to 86.28%) in predicting the focus of the discharge diagnosis. Follow-up imaging in patients with unclear focus reveals a new focus in 39.5% of patients.ConclusionsOur investigation of the role of CT in ED patients with suspected sepsis indicated a high positive predictive value for CT with regard to the discharge diagnosis. Repeat imaging may help identify further septic foci in a subgroup with persistently unclear focus. Use of contrast medium seems less relevant for focus detection than expected, as it did not increase diagnostic confidence.     

Diagnostic Emergency Imaging Utilization at an Academic Trauma Center From 1996 to 2012

PurposeThe aim of this study was to retrospectively review the growth rate in emergency radiology volume at an urban academic trauma center from 1996 to 2012.MethodsThe authors reviewed aggregated billing data, for which the requirement for institutional review board approval was waived, from 1,458,230 diagnostic radiologic examinations ordered for emergency department (ED) visits from 1996 to 2012. The growth rate was calculated as the average annual percentage change in imaging examinations per ED visits. The growth rates between 1996 to 2003 and 2004 to 2012 were statistically compared using a t test.ResultsED patient visits showed continual growth at an average of 3% per year. Total imaging per ED visit grew from 1996 to 2003 at 4 ± 4% per year but significantly decreased from 2004 to 2012 at −2 ± 3% per year (P = .01). By modality, statistically significant decreased growth was observed in CT and MRI from 2004 to 2012. Ultrasound and x-ray showed unchanged growth from 1996 through 2012. ED physician ultrasound data available for 2002 to 2011 also showed increased growth.ConclusionsWhen adjusting ED imaging volume by ED visits, significantly decreased growth of overall ED imaging, specifically CT and MRI, was observed during the past 9 years. This may be due to slowing of new imaging indications, improved awareness of practice guidelines, and increased use of ultrasound. Although the national health care discussion focuses on continual imaging growth, these results demonstrate that long-term stability in ED imaging utilization is achievable.     

Clinical impact of computed tomography in the emergency department in nontraumatic chest and abdominal conditions

Aim

To evaluate the clinical impact of CT scan in modifying the clinical management in patients referred to the emergency department.

Methods

We prospectively evaluated 300 patients (177 males, 63?±?18 years old) admitted in the emergency department (ED) of a single institution, who underwent a CT examination for thoracic and/or abdominal complains. Demographic and clinical data were collected. Hypothesized outcome prior to CT scan and final management (i.e., discharge, short observation in the ED, hospitalization, and department of admission) were compared.

Results

After CT examination, a major variation in diagnosis occurred in 37% of cases and clinical management changed in 43%, occurring in 51% of patients who underwent abdominal CT, in 40% of chest CT, and in 29% of chest/abdominal CT (P?=?0.015). Department of hospitalization changed in 26% of cases (P?<?0.001). Clinical impact of CT scan was significantly associated (P?=?0.001) with the color code at admission. In particular, the more severe was the clinical condition, the lower was the variation of management after CT examination.

Conclusions

This work confirms the crucial role of CT examination in the management of nontraumatic patients admitted to the ED, both in terms of better clarifying the diagnosis and in influencing the clinical management.

     

Role of complementary Ct chest in patients presenting with acute abdominal symptoms during covid-19 pandemic: a UK experience

BackgroundIn March 2020, the UK Intercollegiate General Surgery Guidance on COVID-19 recommended that patients undergoing emergency abdominal CT should have a complementary CT chest for COVID-19 screening.PurposeTo establish if complementary CT chest was performed as recommended, and if CT chest influenced surgical intervention decision. To assess detection rate of COVID-19 on CT and its correlation with RT-PCR swab results. To determine if COVID-19 changes is reliably detected within the lung bases which are usually imaged in standard abdominal CT.MethodsPatients with acute abdominal symptoms presenting to a single institution between 1st and 30th April 2020 who had abdominal CT and complementary CT chest were retrospectively extracted from Computerised Radiology Information System. CT COVID-19 changes were categorised according to British Society of Thoracic Radiology reporting guidance. Patient demographics (age and gender), RT-PCR swab results and management pathway (conservative or intervention) were recorded from electronic patient records. Statistical analyses were performed to evaluate any significant association between variables. p values ≤0.05 were regarded as statistically significant.ResultsCompliancy rate in performing complementary CT chest was 92.5% (148/160). Thirty-five patients (35/148,23.6%) underwent intervention during admission. There was no significant association (p = 0.9085) between acquisition of CT chest and management pathway (conservative vs intervention). CT chest had 57% sensitivity (CI 18.41% to 90.1%) and 100% specificity (CI 92% to 100%) in COVID-19 diagnosis. Three of ten patients who had classic COVID-19 changes on CT chest did not have corresponding changes in lung bases.ConclusionCompliance with performing complementary CT chest in acute abdomen patients for COVID-19 screening was high and it did not influence subsequent surgical or interventional management.