Intravenous Contrast Extravasation During CT: A National Data Registry and Practice Quality Improvement Initiative

PurposeEstablish 3 performance benchmarks for intravenous contrast extravasation during CT examinations: extravasation frequency, distribution of extravasation volumes, and severity of injury. Evaluate the effectiveness of implementing practice quality improvement (PQI) methodology in improving performance for these 3 benchmarks.MethodsThe Society of Abdominal Radiology and ACR developed a registry collecting data for contrast extravasation events. The project includes a PQI initiative allowing for process improvement.ResultsAs of December 2013, a total of 58 radiology practices have participated in this project, and 32 practices have completed the 2-cycle PQI. There were a total of 454,497 contrast-enhanced CT exams and 1,085 extravasation events. The average extravasation rate is 0.24%. The median extravasation rate is 0.21%. Most extravasations (82.9%) were between 10 mL and 99 mL. The majority of injuries, 94.6%, are mild in severity, with 4.7% having moderate and 0.8% having severe injuries.Data from practices that completed the PQI process showed a change in the average extravasation rate from 0.28% in the first 6 months to 0.23% in the second 6 months, and the median extravasation rate dropped from 0.25% to 0.16%, neither statistically significant. The distribution of extravasation volumes and the severity of injury did not change between the first and second measurement periods.ConclusionsNational performance benchmarks for contrast extravasation rate, distribution of volumes of extravasate, and distribution of severity of injury are established through this multi-institutional practice registry. The application of PQI failed to have a statistically significant positive impact on any of the 3 benchmarks.     

Image Quality Improvement after Implementation of a CT Accreditation Program

Objective

The purpose of this study was to evaluate any improvement in the quality of abdominal CTs after the utilization of the nationally based accreditation program.

Materials and Methods

Approval was obtained from the Institutional Review Board, and informed consent was waived. We retrospectively analyzed 1,011 outside abdominal CTs, from 2003 to 2007. We evaluated images using a fill-up sheet form of the national accreditation program, and subjectively by grading for the overall CT image quality. CT scans were divided into two categories according to time periods; before and after the implementation of the accreditation program. We compared CT scans between two periods according to parameters pertaining to the evaluation of images. We determined whether there was a correlation between the results of a subjective assessment of the image quality and the evaluation scores of the clinical image.

Results

The following parameters were significantly different after the implementation of the accreditation program: identifying data, display parameters, scan length, spatial and contrast resolution, window width and level, optimal contrast enhancement, slice thickness, and total score. The remaining parameters were not significantly different between scans obtained from the two different periods: scan parameters, film quality, and artifacts.

Conclusion

After performing the CT accreditation program, the quality of the outside abdominal CTs show marked improvement, especially for the parameters related to the scanning protocol.     

PACS中医学影像质量控制系统的研究与设计

目的解决PACS系统使用而带来的质量保证问题。方法研究设计用于影像设备和图像采集网关之间的医学影像质量控制系统。结果医学影像质量控制系统可以部分解决PACS的质量保证问题。结论医学影像质量控制系统可以在最大程度上做到对错误影像或低质量影像早发现、早修改,从而进一步提高PACS中医学信息和医学影像的准确性。     

2015 AMCLC Open-Microphone Session: Improving the IQ (Information Quality) of What We Do

Each year an open-microphone session is hosted by the Council Steering Committee. The committee invited an expert panel to discuss the use of effective communication in appropriate procedure selection and methods and resources to communicate the results of procedures performed in an actionable and clear manner to referring clinicians and patients, as well as downstream data systems. The ACR is actively encouraging radiologists to leverage existing and new technologies to increase their visibility in the health care system. Key features in Imaging 3.0 are results reporting through actionable reports, decision support for results reporting, guidelines for recommendations, tools for actionable reports, and tracking a radiologist’s recommendations. The final radiology report is an essential product of our service, but it is increasingly clear that the noninterpretive components of our profession will add the most value to patient care. The radiology report is not the only evidence of our work. Nonetheless, the information quality and content of the radiology report can and must be improved so that it can add value and clinical usefulness toward excellent patient care. We must use appropriate tools and “best knowledge” to deliver actionable and value-added high-quality reports.     

Implementation and Results of a Percutaneous Renal Allograft Biopsy Protocol to Reduce Complication Rate

Percutaneous renal transplant biopsy (PRTB) is the gold standard for evaluating allograft rejection after renal transplant. Hemorrhage is the predominant complication. We describe the implementation of a standardized protocol for PRTB at a single institution, with the aim of reducing bleeding complications. Utilizing the plan-do-study-act model for quality improvement, we created and deployed a protocol centered on controlling patient’s hypertension, platelet function, and anticoagulation status. The 4-year study encompassed a total of 880 PRTBs, before and after implementation of the protocol. Total complication rate, which was 5.8% in the 2 years leading up to implementation of the protocol, was reduced to 2.9% after the protocol was introduced (P = .04). A standardized approach to PRTB can potentially lower complication rates; we present a framework for implementating a quality improvement protocol at other institutions.     

The Success and Failure of a Radiology Quality Metric: The Case of OP-10

PurposeMedical quality metrics can serve various functions, including promoting quality improvement efforts within a medical system, and providing a basis for comparing quality among institutions. OP-10, an imaging efficiency quality measure based on the number of CT scans of the abdomen performed both with and without contrast is broadly used and publically reported, but it has not been investigated in actual practice.MethodsIn this project, we report on both a successful quality improvement effort built around measurement of OP-10, and on the identified potential limitations of OP-10 itself for comparing among institutions. We performed two quality improvement interventions in 2012 and 2014 directed at OP-10, encompassing building of institutional practice standards via creating multidisciplinary consensus, educating radiologists and clinicians, revising CT protocols, and providing performance measurement and feedback. Results were extracted from the radiology information system and analyzed using interrupted time series segmented regression and statistical process control charts.ResultsThe proportion of inappropriate abdominal CT scans with and without contrast under OP-10 decreased, from 3,041 of 13,855 (21.9%) to 691 of 6,006 (11.5%) (P < .0001). However, 262 of 691 (37.8%) of the CT scans labeled as potential overuse by OP-10 could be considered appropriate under national guidelines. These discordant cases clustered in specific clinical areas (eg, urology and hepatology), indicating potential for bias against centers that serve referral populations in these areas.ConclusionsWe conclude that OP-10 can be useful to drive internal quality improvement efforts but is potentially biased when used for interinstitutional comparisons.     

Ultrasound detection of bone erosions in rheumatoid arthritis: a comparison to routine radiographs of the hands and feet

Purpose To determine if ultrasound (US) of selected joints in the hands and feet can detect more erosions than radiography and establish the presence of erosive disease in patients with rheumatoid arthritis (RA).Methods Eighty joints in ten patients with RA and 40 joints in five healthy control subjects, who were age, gender and ethnicity-matched to the patients with arthritis, were prospectively studied with radiographs and sonography. Conventional radiographs of the hands and feet were obtained. US examinations of the 2nd and 5th metacarpal-phalangeal (MCP) joints of the hands, and the 1st and 5th metatarsal-phalangeal (MTP) joints of the feet were performed. Radiographs and US exams were independently graded for the presence of erosions.Results None of the control subjects had erosions. US detected erosions in 17/80, and radiographs detected erosions in 6/80 joints assessed with both modalities. US detected all erosions seen by radiographs in these selected joints. Erosive disease was present in the radiographs of seven of ten RA patients. US established erosive disease in eight of ten RA patients. US determined erosive disease in two of the three patients without radiographic erosions.Conclusions US of the MTP and MCP joints in RA can detect erosions not seen with radiography and may be complementary to radiography in establishing the presence of erosive disease in early RA.     

Radiology Patient Outcome Measures: Impact of a Departmental Pay-for-Performance Initiative on Key Quality and Safety Measures

ObjectiveAssess impact of a multifaceted pay-for-performance (PFP) initiative on radiologists’ behavior regarding key quality and safety measures.MethodsThis institutional review board–approved prospective study was performed at a large, 12-division urban academic radiology department. Radiology patient outcome measures were implemented October 1, 2017, measuring report signature timeliness, critical results communication, and generation of peer-learning communications between radiologists. Subspecialty division-wide and individual radiologist targets were specified, performance was transparently communicated on an intranet dashboard updated daily, and performance was financially incentivized (5% of salary) quarterly. We compared outcomes 12 months pre- versus 12 months post-PFP implementation. Primary outcome was monthly 90th percentile time from scan completion to final report signature (CtoF). Secondary outcomes were percentage timely closed-loop communication of critical results and number of division-wide peer-learning communications. Statistical process control analysis and parallel coordinates charts were used to assess for temporal trends.ResultsIn all, 144 radiologists generated 1,255,771 reports (613,273 pre-PFP) during the study period. Monthly 90th percentile CtoF exhibited an absolute decrease of 4.4 hours (from 21.1 to 16.7 hours) and a 20.9% relative decrease post-PFP. Statistical process control analysis demonstrated significant decreases in 90th percentile CtoF post-PFP, sustained throughout the study period (P < .003). Between 95% (119 of 125, July 1, 2018, to September 30, 2018) and 98.4% (126 of 128, October 1, 2017, to December 31, 2017) of radiologists achieved >90% timely closure of critical alerts; all divisions exceeded the target of 90 peer-learning communications each quarter (range: 97-472) after January 1, 2018.DiscussionImplementation of a multifaceted PFP initiative using well-defined radiology patient outcome measures correlated with measurable improvements in radiologist behavior regarding key quality and safety parameters.     

Trauma-Informed Radiation Therapy: Implementation and Evaluation of a Sensitive Practice Tool for Female Patients Undergoing Radiotherapy for Breast Cancer

PurposeFor childhood sexual abuse survivors, cancer care can be retraumatizing because of perceived similarities to the original sexual violence. The authors’ group designed and implemented a sensitive practice tool (SPT) and evaluated the feasibility of the tool in female patients receiving breast radiation.MethodsThe SPT was offered as a “universal precaution” to patients with breast cancer as part of standard clinical care. Patients were given the SPT, which included an instructional video about radiotherapy and a survey about triggers and preferences. The survey results were provided to radiation therapists and used to personalize patients’ care. A retrospective chart review and quality improvement survey of therapists were performed.ResultsOf 739 eligible patients, 493 (66.7%) completed the SPT from November 2013 to June 2019. Among respondents, 281 (57.0%) reported potential triggers, 395 (80.1%) reported distress management preferences, and 59 (12.0%) requested psychosocial referrals. Mean patient satisfaction was high, and a majority of patients were likely to recommend the SPT to other patients (85.3%). Among radiation therapists (n = 13), 100% reported that the SPT made it easier to customize or individualize patient care. Trauma disclosure was not significantly associated with increased frequency of trigger endorsement (P = .07) but was associated with increased endorsement of distress management preferences (P = .02) and psychosocial referral requests (P < .001).ConclusionsThe reported experience with the SPT in the breast radiotherapy setting demonstrated that potential triggers and distress management preferences among patients are common and that patient satisfaction with the SPT is high, yielding clinically meaningful and actionable sensitive practice information.     

Science to Practice: IT Solutions to Drive Standardized Report Recommendations for Abdominal Aortic Aneurysm Surveillance

Inadequate imaging surveillance has been identified as the most significant contributor to abdominal aortic aneurysm (AAA) rupture. Radiologists can contribute value to patient care and reduce morbidity and mortality related to AAA by incorporating evidence-based management recommendations from the ACR and Society of Vascular Surgery into their report impression. The challenges lie in achieving 100% radiologist compliance to incorporate the recommendations and ensuring that the patient is notified by their provider, the follow-up examination is scheduled, and the patient returns for an imaging test that may be scheduled 3 to 5 years in the future. To address these barriers, radiology quality and informatics leads have harnessed IT solutions to facilitate integration of content, communication of results, and patient follow-up.     

Artificial Intelligence in Quality Improvement: Reviewing Uses of Artificial Intelligence in Noninterpretative Processes from Clinical Decision Support to Education and Feedback

The radiology workflow can be segmented into three large groups: pre-interpretative processes, interpretation, and postinterpretative processes. Each stage of this workflow represents quality improvement opportunities for artificial intelligence and machine learning. Although the focus of recent research has been targeted toward optimization of image interpretation, this article describes significant use cases for artificial intelligence in both the pre-interpretative and postinterpretative aspects of radiology. We provide examples of how current applications of AI for quality improvement purposes across the radiology workflow have been implemented and how further integration of these technologies can significantly improve clinical efficiency, reduce radiologist work burden, and ultimately optimize patient care and outcomes.     

Imaging Approach to the Diagnosis of Acute Appendicitis in a Group of Teaching Hospitals With 24/7 In-house Availability of Ultrasound Technologist: Effect of Timing of Request on Imaging Modality

Purpose

The study sought determine effect of requisition timing on the initial-choice imaging modality in appendicitis evaluation.