24/7/365 Neuroradiologist Coverage Improves Resident Perception of Educational Experience,Referring Physician Satisfaction,and Turnaround Time

PurposeTo quantitatively and qualitatively assess the impact of attending neuroradiology coverage on radiology resident perceptions of the on-call experience, referring physician satisfaction, and final report turnaround times.Materials and Methods24/7/365 attending neuroradiologist coverage began in October 2016 at our institution. In March 2017, an online survey of referring physicians, (emergency medicine, neurosurgery, and stroke neurology) and radiology residents was administered at a large academic medical center. Referring physicians were queried regarding their perceptions of patient care, report accuracy, timeliness, and availability of attending radiologists before and after the implementation of overnight neuroradiology coverage. Radiology residents were asked about their level of independence, workload, and education while on-call. Turnaround time (TAT) was measured over a 5-month period before and after the implementation of overnight neuroradiology coverage.ResultsA total of 28 of 64 referring physicians surveyed responded, for a response rate of 67%. Specifically, 19 of 23 second (junior resident on-call) and third year radiology residents (senior resident on-call) replied, 4 of 4 stroke neurology fellows replied, 8 of 21 neurosurgery residents, and 16 of 39 emergency medicine residents replied. Ninety-five percent of radiology residents stated they had adequate independence on call, 100% felt they have enough faculty support while on call, and 84% reported that overnight attending coverage has improved the educational value of their on-call experience. Residents who were present both before and after the implementation of TAT metrics thought their education, and independence had been positively affected. After overnight neuroradiology coverage, 85% of emergency physicians perceived improved accuracy of reports, 69% noted improved timeliness, and 77% found that attending radiologists were more accessible for consultation. The surveyed stroke neurology fellows and neurosurgery residents reported positive perception of the TAT, report quality, and availability of accessibility of attending radiologist.ConclusionsIn concordance with prior results, overnight attending coverage significantly reduced turnaround time. As expected, referring physicians report increased satisfaction with overnight attending coverage, particularly with respect to patient care and report accuracy. In contrast to some prior studies, radiology residents reported both improved educational value of the on-call shifts and preserved independence. This may be due to the tasking the overnight neuroradiology attending with dual goals of optimized TAT, and trainee growth. Unique implementation including subspecialty trained attendings may facilitate radiology resident independence and educational experience with improved finalized report turnaround.     

Radiology resident interpretations of on-call imaging studies: the incidence of major discrepancies

RATIONALE AND OBJECTIVES: To determine the incidence of radiology resident preliminary interpretation errors for plain film, body computed tomography, and neuroradiology (neuro)computed tomographic examinations read on call. MATERIALS AND METHODS: We retrospectively reviewed the data in a prospectively acquired resident quality assurance (QA) database dating between January 2000 and March 2007. The database comprises all imaging studies initially interpreted by an on-call resident and later reviewed by a board-certified attending radiologist who determined the level of discrepancy between the two interpretations according to a graded scale from 0 (no discrepancy) to 3 (major discrepancy). We reviewed the data with respect to resident training level, imaging modality, and variance level. Statistical analysis was performed with chi(2) test, alpha = 0.05. We compared our results with other published series studying resident and attending accuracy. RESULTS: A total of 141,381 cases were entered into the database during the review period. Of all examinations, 95.7% had zero variance, 3.3% minor variance, and 1.0% major variance. There was a slight, statistically significant increase in overall accuracy with increased resident year from 95.4% of examinations read by first-year residents (R1s) to 96.1% by fourth-year resident (R4s) (P < .0001). Overall percentages of exams with major discrepancies were 1.0% for R1s, 1.1% for second-year residents, 1.0% for third-year residents, and 0.98% for R4s. CONCLUSIONS: The majority of preliminary resident interpretations are highly accurate. The incidence of major discrepancies is extremely low and similar, even with R1s, to that of attending radiologists published in other studies. A slight, statistically significant decrease in the error rate is detectable as residents gain experience throughout the 4 years of residency.     

Evaluation of clinical experience in a radiology residency program with quantitative profiling: rationale,methods, and application

RATIONALE AND OBJECTIVES: The author developed a technique for residency program evaluation, called "quantitative profiling," that is based on computer retrieval of radiologic reports. The hypothesis was that it would provide insights into the contributions of residents to clinical service, measures of resident experience and productivity for program evaluation, and benchmarks for comparison. MATERIALS AND METHODS: The radiology residency program of a major teaching hospital was studied retrospectively from 1989 to 1997. The number of radiologic reports signed by individual residents and faculty members was retrieved. The clinical experience of the 1993-1997 cohort of residents was described according to subspecialty area and modality. RESULTS: Residents signed 46.5% of all reports, with a mean total of 14,445 reports +/- 1,292 per resident during the entire residency. The distribution of examinations was as follows: thoracic, 42.1%; musculoskeletal, 26.1%; abdominal, 13.4%; sonography, 8.7%; neuroradiology, 4.3%; nuclear, 2.4%; breast, 1.6%; and vascular, 1.4%. The most frequently reported results were for one-view chest radiography. CONCLUSION: Quantitative profiling can help track the range and progress of resident experience, help determine the deployment of residents, and provide empirical data upon which decisions to modify residency programs may be based.     

Significant on-call misses by radiology residents interpreting computed tomographic studies: Perception versus cognition

The purpose of this study was to evaluate the etiology of significant false-negative computed tomographic (CT) interpretations by radiology residents on-call. Over a 1-year period, significant on-call false-negative CT interpretations were analyzed to determine whether errors were perceptual (i.e., the resident did not see the finding or findings) or cognitive (i.e., the resident did not recognize the implications or misinterpreted a finding or findings). Significant misses were defined as errors that delayed surgical treatment or misdirected management in a potentially life-threatening manner.A total of 12 significant false-negative interpretations occurred over a 1-year period. All head CT misses (extraaxial hemorrhage, pneumocephalus, contusion, subarachnoid hemorrhage due to ruptured aneurysm) were perceptual errors. Misses on thoracic, abdominal, and pelvic CT scans (2 abscesses, abdominal aortic aneurysm rupture, superior vena cava perforation due to catheter placement, ischemic bowel, liver laceration, hypoperfusion syndrome, appendicitis) were mixed (4 cognitive and 4 perceptual errors).Since the diagnostic possibilities of emergency head CT scans are limited, residents missed only subtle, perceptual manifestations and had little difficulty interpreting findings when they were correctly recognized. The gamut of diagnostic possibilities in the thorax, abdomen, and pelvis was more challenging to residents on-call; errors in both perception and interpretation arose with equal frequency, and the significant error rate was higher than that for head CT interpretation. Junior residents, who make most of the significant on-call errors, commonly feel overwhelmed in attempting to assimilate the knowledge required to take call. Prepartion needs to be extensive, yet it should be focused on areas that will engender optimal impact on after-hours performance. When preparing residents to interpret on-call CT studies, perceptual manifestations of neuroradiology should be emphasized, whereas a more comprehensive approach to thoracic, abdominal, and pelvic disorders needs to be stressed.Presented at the 8th Annual Meeting of the American Society of Emergency Radiology, New Orleans, March 20, 1997     

On-call services provided by radiology residents in a university hospital environment.

OBJECTIVE: To better understand the consultative role of the radiology resident after hours. METHODS: Data were collected prospectively from Mar. 15, 1999, to Jan. 5, 2001, during on-call coverage hours at our university hospital. Urgent radiologic examinations for which the on-call resident rendered a preliminary interpretation were included in our analysis, with the following entered into a database: patient demographics, consultative time and weekday, imaging modality, consulting clinical service and indication for each study. RESULTS: A total of 1784 studies were performed on 1451 patients; most were requested by the emergency department (844 cases [47.3%]). The mean number of radiographic studies performed was 20.1 (standard error of the mean [SEM] 1.1) per weekday (n = 44) and 49.4 (SEM 1.8) per weekend day or holiday (n = 18). There were 1227 (68.8%) computed tomographic (CT), 338 (18.9%) ultrasonographic, 98 (5.5%) plain radiograph, 63 (3.5%) nuclear medicine, 21 (1.2%) interventional, 20 (1.1%) fluoroscopic and 17 (1.0%) magnetic resonance imaging examinations. The 3 most common studies were CT of the head in 692 cases, CT of the abdomen in 230 and venous Doppler ultrasonography in 158. CONCLUSIONS: Radiology residents are performing a diverse and increasing number of emergent diagnostic examinations after hours. It is therefore important that radiology departments are aware of these consultative needs to best ensure that appropriate resident skills are developed to meet these demands.     

Part I: preparing first-year radiology residents and assessing their readiness for on-call responsibilities

RATIONALE AND OBJECTIVES: The aim of the study is to evaluate the effectiveness of an Emergency Radiology (ER) Core Curriculum training module and a Digital Imaging and Communications in Medicine (DICOM)-based interactive examination system to prepare first-year (postgraduate year 2 [PGY-2]) radiology residents and assess their readiness for taking overnight radiology call. MATERIALS AND METHODS: Institutional review board approval was obtained, and the study was compliant with Health Insurance Portability and Accountability Act (HIPAA) regulations. A dedicated month-long ER curriculum was designed to prepare new radiology residents for overnight radiology call that includes interpretation of off-hour urgent and emergent studies without immediate direct attending supervision. Lectures of the curriculum, provided by department staff, were based on the American Society of Emergency Radiology core curriculum. The lecture series was implemented after PGY-2 residents had completed formal introductory resident rotations during their first 6 months of training. A DICOM-based interactive computer-based testing module was developed and administered at the end of the lecture series. The module consisted of 19 actual emergency department cases with entire series of images, simulating an on-call setting. Tests were scored by two staff members blinded to resident identifying information. Upper-level residents also were tested, and comparison was made between first-year and upper-level resident test scores to determine the effectiveness of the test in determining first-year resident preparedness for call. Statistical analysis of results was performed by using t-test (P < .05). RESULTS: All residents in the residency program present during the month (nine PGY-2, six PGY-3, seven PGY-4, seven PGY-5 residents) attended the lecture series and finished the testing module at the end of the lecture series. Of 19 actual emergency cases on the testing module, five cases were neuroradiology, three cases were thoracic imaging, eight cases were body imaging, and three cases were musculoskeletal. PGY-2 residents scored an average of 73.0% (range, 63.2%-81.6%) of total points possible. PGY-3 residents scored an average of 76.8% (range, 68.4%-86.8%); PGY-4 residents scored an average of 77.4% (range, 65.8%-100%), and PGY-5 residents scored an average of 81.2% (range, 68.4%-94.7%). There was no statistically significant difference in scores according to level of training. CONCLUSION: First-year radiology residents who underwent 6 months of formal radiology training followed by an intensive ER lecture series before taking overnight call had scores similar to upper-level colleagues on an interactive computer-based ER simulation module.     

Emergency radiology testing,teaching, and training

Conclusion This article summarizes the training and teaching of radiology residents before they attempt unsupervised emergency call, as reported in the radiologic literature. It is hoped that this report will prompt a serious evaluation of the responsibilities of radiology residents assigned to the emergency center and a reconsideration of the radiologic training and experience provided to radiology residents before they are required to assume these responsibilities. Clearly, education and training in radiology appropriate to the responsibilities expected of the on-call emergency radiology resident are required to assure optimum patient care.     

Preliminary Reports in the Emergency Department: Is a Subspecialist Radiologist More Accurate Than a Radiology Resident?

RATIONALE AND OBJECTIVES: To determine whether emergency department (ED) preliminary reports rendered by subspecialist attending radiologists who are reading outside their field of expertise are more accurate than reports rendered by radiology residents, and to compare error rates between radiologists and nonradiologists in the ED setting. MATERIALS AND METHODS: The study was performed at a large academic medical center with a busy ED. An electronic preliminary report generator was used in the ED to capture preliminary interpretations rendered in a clinical setting by radiology residents, junior attendings (within 2 years of taking their oral boards), senior attendings, and ED clinicians between August 1999 and November 2004. Each preliminary report was later reviewed by a final interpreting radiologist, and the preliminary interpretation was adjudicated for the presence of substantial discordances, defined as a difference in interpretation that might immediately impact the care of the patient. Of the 612,890 preliminary reports in the database, 65,780 (11%) met inclusion criteria for this study. A log-linear analysis was used to assess the effects of modality and type of author on preliminary report error rates. RESULTS: ED clinicians had significantly higher error rates when compared with any type of radiologist, regardless of modality. Within the radiologists, residents and junior attendings had lower error rates than did senior attendings, but the differences were not statistically significant. CONCLUSION: Subspecialized attending radiologists who interpret ED examinations outside their area of expertise have error rates similar to those of radiology residents. Nonradiologists have significantly higher error rates than radiologists and radiology residents when interpreting examinations in the ED.     

The “night stalker” effect: Are quality improvements with a dedicated night call rotation sustained?

The authors assessed whether the addition of a second-year diagnostic radiology resident assigned to cover the night shift at a major urban university hospital has a sustained effect on the number and clinical significance of “missed” radiologic findings. Radiographs interpreted overnight in the emergency department by radiology residents between January 1992 and December 1992 were reviewed daily by emergency radiology attending staff. A list of patients for whom there was a modification in the final radiologic interpretation was given to the emergency department physicians, who reviewed each case, scored the urgency of patient recall, and estimated the likelihood of patient morbidity attributable to the miss. The relative performance of after-hours residents was compared on the five nights per week with the dedicated night resident vs. the two nights per week without the dedicated night resident (control group). Of 22,295 after-hours examinations performed during the study period, 304 (1.36%) misses were recorded, nearly identical to the miss rate for the preceding 6 months. The percentage per examination interpreted (and number) of missed cases stratified by recall score for the control and dedicated night resident groups, respectively, were: (a) immediate, 0.62% (34) and 0.29% (49); (b) within 48 hours, 0.31% (17) and 0.32% (54); (c) no recall, 0.71% (24) and 0.29% (39); (d) finding already recognized by emergency department physicians, 0.44% (24) and 0.23% (39); total, 2.09% (114) and 1.13% (190). The difference in total discordance rates is statistically significant (P < 1 × 10⁻¹⁵). Our previously reported improvement in the quality of after-hours radiographic interpretation due to the addition of a dedicated night shift resident is sustained in a new group of residents. This confirms that the improvement is real and not a manifestation of the measurement methods.     

Coverage of emergency after-hours ultrasound cases: survey of practices at U.S. Teaching hospitals

RATIONALE AND OBJECTIVES: Diagnostic ultrasound examinations may be performed after-hours by physicians if technologists are not available or cases are complex. Our experience suggested there is wide variability in how ultrasound coverage is provided after-hours, which motivated us to conduct a formal survey of teaching programs around the country. METHODS: Four hundred five members of the Association of Program Directors in Radiology were contacted by e-mail and sent a link to a five-part questionnaire posted on the Web. Respondents were asked whether ultrasound cases after-hours are performed in their institutions by radiology residents, technologists on the premises after-hours, technologists on-call, or some combination. Data on the type of program, number of beds in the primary hospital, number of residents in the program, and geographic location of the program were recorded. Responses were automatically written to a data file stored on a Web server and the imported into an Excel spreadsheet for data analysis. A chi(2) analysis was performed to assess associations among the variables and statistical significance. RESULTS: A total of 79 programs responded to the survey. Of those, 32% provided coverage with ultrasound technologists on call, 24% by ultrasound technologists on the premises, 13% provided combination coverage, and 10% provided coverage solely with residents on call. There was no association among number of residents in the program, location of the program, or type of program (university, community, or affiliated) and type of coverage provided. CONCLUSION: There is wide variability in methods for providing coverage of after-hours ultrasound cases. However, on-site or on-call coverage of emergency cases by technologists did not appear to depend significantly on program location, program type, or program size.     

Results of and comments on the 2000 survey of the American Association of Academic Chief Residents in Radiology

RATIONALE AND OBJECTIVES: The American Association of Academic Chief Residents in Radiology (A3CR2) annually surveys radiology residency programs on issues related to training. The objective is to highlight national similarities, differences, and trends to help programs establish standards and improve residency training. MATERIALS AND METHODS: Questionnaires were mailed to 180 accredited diagnostic radiology residency training programs in the United States. The survey covered the usual general topics and more specific topics considered every 4 years; for 2000 the latter were on-call issues and the chief residency year. RESULTS: Completed surveys were returned from 63 programs (35%). Important findings included increased caseload and call commitments, especially for smaller programs. Resident salaries appear to have increased more than the consumer price index. Nonemergent after-hour coverage and teleradiology are now a large part of the resident work practice. Women continue to be underrepresented, with a trend downward. Chief residents are more involved in organizing preparation for board examinations and have greater office facilities and more administrative duties. CONCLUSION: This survey provided useful insights. All levels of residency face increased workloads. On-call hours have not changed, but the work has intensified and the use of teleradiology has increased. Many programs have adopted a "night-float" system, and nonemergent after-hours coverage should be considered in any program evaluation. Continued vigilance and sustained efforts are required to ensure that radiology is considered as a specialty by both men and women. With increased demands on attending physicians' time, chief residents may need to take on more administrative responsibilities.     

Radiology resident interpretation of on-call CT pulmonary angiograms

RATIONALE AND OBJECTIVES: To evaluate the interpretation of computed tomographic pulmonary angiograms performed outside of regular reporting hours, comparing the initial interpretation by the radiology resident to the attending radiologist. MATERIALS AND METHODS: Records for 840 consecutive computed tomographic pulmonary angiograms (CTPA) performed outside of regular reporting hours at two tertiary referral centers from January 1, 2004-December 31, 2005 were reviewed. The preliminary interpretation by the on-call radiology resident was compared to the subsequent final report issued by a subspecialty trained chest radiologist. Studies were stratified as positive, negative, or equivocal for pulmonary embolus. Cases with discordant interpretations or negative CTPA were reviewed to determine impact on clinical outcome. Patients were followed up to 12 months after CTPA to document any subsequent thromboembolic event. RESULTS: Sixteen percent (131/840) of CTPAs were reported positive by the staff radiologist. There was agreement in 90% (752/840) of studies (P = .76, 95% confidence interval, 0.71-0.81) with 86% (114/133) agreement for studies interpreted as positive by residents, 95% (582/612) for studies interpreted as negative by residents, and 63% (60/95) for studies interpreted as equivocal by residents. Studies of optimal quality had higher interobserver agreement than studies of suboptimal quality (P < .0001). In-patient studies were more likely to be positive than emergency room patients (20% vs. 13%) (P = .004). No adverse clinical outcomes were attributed to discordant interpretations. CONCLUSIONS: Radiology residents provide a high level interpretation of on-call CTPA studies, achieving good concordance with the attending radiologists' assessment.     

A computer-based radiology simulator as a learning tool to help prepare first-year residents for being on call

RATIONALE AND OBJECTIVES: The start of call is a stressful time for radiology residents. Traditional teaching methods are not ideal for call preparation because they are radically different than the task performed on call. The purpose of this study is to determine if a computer-based radiology simulator would have an effect on resident confidence level or diagnostic abilities. MATERIALS AND METHODS: A simulator was created to mimic the picture archive and communication system (PACS) at our hospital. Typical call-level cases were selected, anonymized, and entered into the database. The first-year residents were randomly split into a control group and a study group that used the simulator. Each resident took a survey 1 month before and after beginning call to measure his or her subjective feeling of preparedness and nervousness. Objective measures were also obtained through the use of discordance levels from on-call cases. RESULTS: Seventy-one cases were entered into the simulator. Of the 12 residents in the first-year class, 7 were placed in the study group and 5 in the control group. The residents in both groups claimed they felt more prepared and less nervous 1 month after starting call. The differences at survey were not significant, but the residents in the study group trended toward feeling more prepared and less nervous. There was no statistical difference in the discordance rates for on-call cases between the two groups. CONCLUSIONS: Although statistical significance was not reached between the users of the radiology simulator and the control group, there was a subjective feeling that the simulator was useful for call preparation and as an interactive learning tool. A larger sample study group size may show statistical significance.     

Residency training as technology matures a survey of radiology residents' training experiences

RATIONALE AND OBJECTIVES: The aim of the study is to assess radiology resident training experience in cardiac magnetic resonance imaging (MRI), positron emission tomography (PET), obstetrical (OB) ultrasound (US), carotid US, and barium esophagram. MATERIALS AND METHODS: One hundred eighteen radiology residents completed surveys. Surveys assessed resident year of residency training, hospital size, program affiliation with an academic institution, state, performance of the examinations listed, number of examinations performed per week, and number of weeks spent on rotations for each modality. The study was approved by the institutional review board and was Health Insurance Portability and Accountability Act (HIPAA) compliant. t-Test and chi-square test were performed, and results were analyzed for statistical significance. RESULTS: Most (94 respondents; 80%) respondents were third-year residents, 101 residents (86%) stated their program was affiliated with an academic institution, 92 residents (78%) performed cardiac MRI, 104 (88%) performed PET, 84 (71%) performed OB US, 71 (60%) performed carotid US (one did not respond), and all performed esophagrams (although one did not respond). Only performance of cardiac MRI and PET correlated positively with a larger average hospital size (P < .01). Residents at an academically affiliated program were significantly more likely to perform cardiac MRI (P < .05). Geographic region significantly affected likelihood of performance of cardiac MRI only. CONCLUSION: Such factors as hospital size, academic institution affiliation, and geography affect radiology resident training, particularly for such maturing applications as cardiac MRI and PET. This information may be useful in attempts to standardize radiology residency training.     

Resident vs. attending interpretation of on-call studies: clinical impact

Purpose: This study was performed to determine whether significant changes to patient treatment plan or outcome result from discrepancies between on-call radiology residents and follow-up attending radiologists in their interpretation of examinations. Methods: For 70 days we recorded on-call radiology residents' readings of all computed tomography and ultrasound examinations performed in our institution and the follow-up attending radiologists' readings of these same examinations. A chart review was performed to determine whether interpretation discrepancies changed the treatment plan and clinical outcome. Results: Eight-hundred thirty-four examinations met the study guidelines. The overall discrepancy rate was 5.16 %. Of these discrepancies, 6.98 % affected the treatment plan (0.36 % of all 834 studies) and none affected the clinical outcome. Conclusion: Where there is a discrepancy between interpretation of computed tomography and ultrasound after hours by on-call radiology residents and follow-up readings by attending radiologists, this discrepancy has no significant effect on the immediate or long-term care of patients.     

Clinical consequences of misinterpretations of neuroradiologic CT scans by on-call radiology residents

BACKGROUND AND PURPOSE: Studies have looked at the accuracy of radiologic interpretations by radiology residents as compared with staff radiologists with regard to emergency room plain films, emergency room body CT scans, and trauma head CT scans; however, to our knowledge, no study has evaluated on-call resident interpretations of all types of neuroradiologic CT scans. Both as a part of our departmental quality control program and to address concerns of clinical services about misinterpretation of neuroradiologic CT scans by on-call radiology residents, we evaluated the frequency of incorrect preliminary interpretations of neuroradiologic CT scans by on-call radiology residents and the effect of such misinterpretations on clinical management and patient outcome. METHODS: As determined by the staff neuroradiologist the next day, all potentially clinically significant changes to preliminary reports of emergency neuroradiologic CT scans rendered by on-call radiology residents were recorded over a 9-month period. A panel of neuroradiologists reviewed and graded all the changed cases by consensus. An emergency department staff physician reviewed medical records of all submitted cases to determine clinical consequences of the misinterpretations. RESULTS: Significant misinterpretations were made in 21 (0.9%) of 2388 cases during the study period. There was a significant change in patient management in 12 of the cases, with a potentially serious change in patient outcome in two cases (0.08%). CONCLUSION: On-call radiology residents have a low rate of significant misinterpretations of neuroradiologic CT scans, and the potential to affect patient outcome is rare.     

Resident Interpretation of Emergency CT Scans in the Evaluation of Acute Appendicitis

PURPOSE: Radiology resident interpretation of computed tomographic (CT) scans at academic institutions often guides management of cases of suspected acute appendicitis in the emergency department. The purpose of this study was to compare resident and faculty interpretation of CT scans obtained for acute appendicitis. MATERIALS AND METHODS: From December 16, 1999, to July 13, 2000, CT was performed in 103 consecutive patients between the hours of 9:00 PM and 8:00 AM who were suspected of having acute appendicitis. The authors compared the residents' preliminary written interpretations with both the final reports written by the faculty and the surgical findings. The faculty interpreting the CT scans were aware of resident interpretations but were not aware that a study was being conducted. RESULTS: The final faculty interpretation and the preliminary resident interpretation were identical in 96 of the 103 patients (93%; 95% confidence interval: 87.8%, 97.2%). In only one patient was a scan originally interpreted as negative interpreted as positive by the faculty member. Clinically, the patient did not have acute appendicitis, and surgery was not perforrmed. CONCLUSION: In the diagnosis of acute appendicitis, image interpretations made by adequately trained radiology residents can be expected to closely match those of the radiology faculty, and the practice of after-hours interpretation of such studies by radiology residents is safe.     

Emergency imaging discrepancy rates at a level 1 trauma center: identifying the most common on-call resident “misses”

The focus of our research is to identify the most frequently reported on-call discrepancies at our hospital by modality and level of resident training. Our intent is to identify specific areas of concern that may be amenable to improvement through initiation of dedicated resident training in the field of emergency radiology. Our study included 648 significant discrepancies from 193,722 studies ordered through the emergency department over a 7-year period. The overall discrepancy rates were calculated for each resident level of training and modality type. Significance was determined using χ2 testing with α?=?0.05. The most common types of discrepancies were identified. The overall rate of reported discrepancies was low for all levels of training (0.23–0.42 %) with a small, but statistically significant, decrease in rate for the senior residents. Common categories of discrepancies for all residents included fractures on radiographs (XR) and computed tomography (CT), masses and hemorrhage on CT, and lung nodules and pulmonary infiltrates on radiographs. Specific discrepancies reported more frequently for new call-takers included phalangeal fractures on XR as well as white matter disease, hepatic lacerations, pyelonephritis, peritoneal fluid, lymphadenopathy, and pneumothoraces on CT. It is our recommendation that radiology resident training programs ensure that the common discrepancies illustrated herein are specifically addressed as part of a dedicated emergency radiology course.     

CT pulmonary angiography for the detection of pulmonary embolism: interobserver agreement between on-call radiology residents and specialists (CTPA interobserver agreement)

PURPOSE: The aim of this study was to prospectively determine interobserver agreement between on-call radiology residents and specialists in the interpretation of computed tomographic pulmonary angiography (CTPA). METHODS: CTPA examinations obtained between January 2002 and March 2003 were interpreted by a radiology resident on call and by two radiology specialists. Agreement was assessed using percentage of agreement between interpreters and by the kappa coefficient. Sensitivity of residents' interpretations was calculated by relating them to the interpretation of Specialist 1, which served as the gold standard. RESULTS: Of the 81 CTPA examinations evaluated, there was agreement of 93% and 91% for the diagnosis of pulmonary embolism (PE) and of 97% and 85% for the exclusion of PE with Specialist 1 and 2, respectively. The concordance between residents' interpretations and those of Specialist 1 was very high (kappa=.8), and with those of Specialist 2 was high (kappa=.7). In all cases of agreement between the two specialists, there was complete agreement between the specialists' and the residents' intepretations. CONCLUSIONS: Our study showed good to very good agreement of residents' interpretations with each of the radiology specialists. Therefore, relying on the residents' preliminary interpretations during after-hour calls is reasonable.     

Radiology residents' on-call interpretation of chest radiographs for congestive heart failure

RATIONALE AND OBJECTIVES: This study was designed to evaluate the performance of radiology residents in interpreting emergency department (ED) chest radiographs for congestive heart failure and to characterize the factors associated with a subsequent amended interpretation by an attending radiologist. MATERIALS AND METHODS: We retrospectively reviewed all amended reports for ED chest radiographs between January 2004 and July 2005 and identified those with discrepant interpretations regarding the diagnosis of congestive heart failure. A total of 1.9% (476 of 24,600) of chest radiographs were amended over the study period. Forty-eight patients (75% female, mean age 66 years) whose chest radiograph was amended for the diagnosis of congestive heart failure and were available for review formed the study population. A control group of 35 patients (69% female, mean age 67 years) were individually matched to a convenience subset of patients by age, gender, clinical indication, and radiographic projection. Chest radiographs were in the anteroposterior projection in 62% (30 of 48) of study patients and 60% (21 of 35) of controls. A blinded expert panel of three board-certified cardiothoracic radiologists jointly reviewed each chest radiograph for the presence or absence of congestive heart failure and its specific radiographic findings. RESULTS: The expert panel diagnosed congestive heart failure in 19% (9 of 48) of study patients and in 23% (8 of 35) of controls (P = .65). When present, congestive heart failure was mild to moderate in severity in both the study and control groups (P = 1.00). There was a significant difference in the expert panel agreement between the attending versus the resident interpretation (65% versus 35%, P = .008), for the study group. This resulted in fair agreement (kappa = 0.29) between the expert panel and the attending interpretation and no agreement (kappa = -0.29) between the expert panel and the resident interpretation. In contrast, the expert panel agreed with the joint resident/attending interpretation in 83% (29 of 35) of controls, yielding substantial agreement (kappa = 0.72). CONCLUSION: Interpretation of chest radiographs for congestive heart failure by radiology residents has a low error rate. The majority of chest radiographs with discrepant resident and attending interpretations were portable films of female patients with subtle radiographic findings of congestive heart failure, and were inherently difficult to interpret.