Patient encounter time intervals in the evaluation of emergency department patients requiring abdominopelvic CT: oral contrast versus no contrast

The aim of the study was to assess various time intervals during patient encounters involving unenhanced (NECT) versus oral-contrast-enhanced (CECT) abdominopelvic (A/P) CT performed in the emergency department (ED) on adult patients presenting with acute abdominal pain. Computerized patient order entry and administrative data as well as scans themselves were retrospectively evaluated at a high-volume (107,000 visits per annum) regional medical center urban ED for a period of 30 consecutive days. All adult patients who had CT of abdomen and pelvis for abdominal pain during the 30 days of the study period were included. Data collected included demographic information, time of registration, time of first encounter in the ED, time of CT order, clinical indication for scan, time of scan, time of disposition (i.e., discharge or admit), and final disposition. Patients were excluded if they were less than 16 years old, pregnant, or met criteria for major trauma and evaluation in the trauma suite. Patients were also excluded from analysis if they received more than one scan on the same day (3 patients). Of 183 patients, 102 underwent NECT and 81 CECT. Some of the patients who underwent NECT had urinary colic. Among patients who did not have urinary colic there is a statistically significant difference in the median time intervals between: (1) patient arrival in the ED and evaluation by a physician (NECT 57 min, CECT 84 min, P<0.001); (2) patient exam by the physician and the time the A/P CT was ordered (NECT 35 min, CECT 63 min, P<0.01); (3) receipt of the CT order and the time of the scan (NECT 104 min, CECT 172 min, P<0.001); and (4) time of arrival in ED and disposition (NECT 358 min, CECT 599 min, P<0.001). There are significant time interval differences between CECT and NECT during patient encounters involving adults presenting with abdominal pain to the ED. The differences are greater than the amount of time allotted for opacification of small bowel (90 min). Baseline data such as these may prove useful in assessing the efficacy of scan techniques and improving resource utilization.     

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.     

Radiologists in the emergency department: when and how to use multislice CT

Chest pain is a challenging clinical problem in the emergency department. Despite advances in clinical diagnosis, many patients with atypical chest pain are needlessly hospitalized and others are mistakenly discharged. Faced with the specific clinical situation in which a patient has chest pain, an initially normal or inconclusive electrocardiogram, and normal cardiac biomarkers, multislice CT has proven useful for ruling out the conditions that involve the greatest morbidity and mortality and for establishing the cause of pain. This article reviews the current usefulness of multislice CT in the diagnostic workup of patients presenting at the emergency department with chest pain. We review the technique, define the most appropriate population, describe the acquisition protocols, and discuss the advantages and disadvantages of each study protocol.     

Effect of oral contrast for abdominal computed tomography on emergency department length of stay

Computed tomography of the abdomen and/or pelvis (CTAP) is frequently used in the emergency department (ED) allowing diagnosis of a variety of conditions, but requiring a prolonged period of preparation. To determine whether not requiring oral contrast for CTAP reduces ED length of stay (LOS). Retrospective cohort of adult patients visiting an academic ED over 13 weeks around a radiology protocol change. Before the change, many CTAPs required oral contrast; thereafter, oral contrast was not required. LOS was compared before and after the change among all adult ED patients. Among patients undergoing CTAP, adjusted LOS and time to CTAP were compared using multivariate linear regression. 20,464 adult ED visits occurred over the study period, including 1,806 where a CTAP was performed. Oral contrast usage decreased from 42.5% of CTAP to 12.2% (difference 30.3%, 95% confidence interval 38.7% to 46.3%). There was no change in LOS among all ED visits. Among ED visits where a CTAP was performed, median time to CTAP decreased by 27 min and median LOS decreased by 30 min. Adjusted LOS decreased from 324 min (312–337) to 297 min (285–309). Not routinely requiring oral contrast for CTAP in the ED is associated with a half-hour reduction in LOS among all patients undergoing CTAP.     

1995年—2007年全国急诊CT的使用趋势

目的确定全国医院急诊科(ED)CT使用的趋势及相关因素。材料与方法此项研究免除行业审查委员会批准。数据来自1995年—2007年国家医院门诊医疗保健调查报     

Yield of head CT in the alcohol-intoxicated patient in the emergency department

We aimed to determine the yield of positive head computed tomography (CT) findings among suspected alcohol-intoxicated patients presenting to the emergency department (ED). Our secondary aim was to determine if elderly intoxicated patients were more likely to have an intracranial injury. We identified patients suspected of alcohol intoxication who underwent CT scanning in the ED over a 4-year period. Pre-determined data elements including demographics, diagnosis, and disposition were extracted using a pre-formatted data sheet by blinded abstractors. “Positive” CT was defined as evidence of any type of intracranial hemorrhage. A total of 2,671 subjects with suspected alcohol intoxication and a head CT were identified. Fifty out of the 2,671 (1.9%) had a positive CT. Among CT scans of elderly (≥60 years of age) subjects, 15/555 (2.7%, 95% CI = 1.4–4.1%) were positive compared with 35/2,116 (1.7%, 95% CI = 1.1–2.2%) among those <60 years of age (p = 0.11). The yield of positive head CT among alcohol-intoxicated patients was low, at 1.9%. An age cutoff of 60 years in this population did not predict a significantly higher positive rate.     

Value of contrast enhanced CT scanning in the non-trauma emergency room patient

Summary To determine the value of performing contrast CT in addition to non-contrast CT in the evaluation of acute non-traumatic central nervous system disorders, we retrospectively reviewed 322 cases originating from the emergency room at our institution. The most common indication for scanning was seizure activity (34% of total), followed by headache (30%), focal neurological deficit (10%), and altered mental status (8%). 75% of the noncontrast scans were normal. The contrast-enhanced scan revealed abnormalities not evident on the non-contrast scan in only three of these cases, and the information did not alter patient management. We concluded that in the acute setting, if a non-contrast CT is normal, a contrast study is usually unnecessary. Therefore, given the additional risks of contrast infusion, the contrast study, if needed, is generally best obtained at a later date, after more careful evaluation of the patient's history and medical records. If the non-contrast CT scan is abnormal, a contrast enhanced CT scan may be beneficial, but, again, is often not needed to direct acute patient management.     

Breast cancer: assessing the use of routine pelvic CT in patient evaluation

OBJECTIVE: The purpose of this study was to determine the benefit of routine pelvic CT in the evaluation of patients with primary breast cancer and to assess the frequency with which equivocal or abnormal findings on pelvic CT prompted the performance of additional studies or procedures that yielded results relevant to patient care. MATERIALS AND METHODS: The reports of 6628 body CT scans that included images of at least the pelvis in 2426 patients with breast cancer during a 9-year period were reviewed. The presence and sites of reported definite or probable metastases or pelvic tumors were recorded for each scan. Also, the types and results of diagnostic examinations and procedures prompted by equivocal or abnormal findings on pelvic CT were recorded. RESULTS: Pelvic metastases shown on CT were the only known site of metastasis in 13 (0.5%) of 2426 patients, and four other patients (0.2%) had new or enlarging pelvic metastases despite the presence of stable extrapelvic metastases. The pelvic metastases in these 17 patients were located in bone only in 11 patients, in adnexa only in five patients, and in adnexa, endometrium, and bone in one patient. In addition, pelvic CT led to the performance of 204 additional radiologic examinations, including 186 pelvic sonographic examinations, and 50 surgical procedures; 215 (84.6%) of these 254 additional examinations and procedures yielded normal, benign, or indeterminate results. CONCLUSION: The routine use of pelvic CT in the evaluation of patients with breast cancer has an extremely low yield and often prompts performance of pelvic sonographic or surgical procedures, the results of which were rarely relevant to cancer therapy.     

Acute appendicitis in childhood: oral contrast does not improve CT diagnosis

Introduction

We compared the diagnostic accuracy of CT performed without and with oral contrast for suspected appendicitis in children.

Methods

In this retrospective cohort study, we reviewed abdomen/pelvis CT scans with IV contrast performed between 2011 and 2015 for suspected appendicitis. Oral contrast was used routinely before August 2013 and eliminated from the CT protocol thereafter. Diagnostic accuracy of CT was compared with operative/pathology reports, and included a 30-day follow-up period for non-surgical patients. For a secondary analysis, the oral contrast group was subdivided into “complete” (contrast extending into the cecum) or “partial” contrast. We also compared groups for CT turnaround time, the frequency of appendiceal perforation and abscess, and the potential influence of a prior appendix ultrasound.

Results

Five hundred fifty-eight patients were included: 51.6% (n =?288) without oral contrast and 48.4% (n =?270) with oral contrast (of which 52% (n =?140/270) had “complete” contrast). There was no difference in diagnostic accuracy between the oral contrast and non-contrast groups (p =?0.903), with sensitivity/specificity of 93.8% (95% CI 84.8–98.3)/98.5% (CI 95.8–99.7) and 94.6% (CI 84.9–98.9)/98.3% (CI 95.7–99.5), respectively. Similarly, there was no difference in accuracy when comparing only “complete” contrast vs. non-contrast groups (p =?0.755). CT turnaround time for the non-contrast group was significantly faster (43.8 ± 37.6 min), on average, than the oral contrast group (137.4 ± 47.5 min).

Conclusion

For children evaluated by CT with IV contrast for suspected appendicitis, administering oral contrast increased wait time by >?90 min, did not reach the cecum in 48% of cases, and did not improve diagnostic accuracy. Oral contrast for pediatric CT appendicitis evaluation is not warranted.

     

An evaluation of the use of oral contrast media in abdominopelvic CT

Objectives

To evaluate the diagnostic efficacy of different oral contrast media (OCM) for abdominopelvic CT examinations performed for follow-up general oncological indications. The objectives were to establish anatomical image quality criteria for abdominopelvic CT; use these criteria to evaluate and compare image quality using positive OCM, neutral OCM and no OCM; and evaluate possible benefits for the medical imaging department.

Methods

Forty-six adult patients attending a follow-up abdominopelvic CT for general oncological indications and who had a previous abdominopelvic CT with positive OCM (n?=?46) were recruited and prospectively placed into either the water (n?=?25) or no OCM (n?=?21) group. Three radiologists performed absolute visual grading analysis (VGA) to assess image quality by grading the fulfilment of 24 anatomical image quality criteria.

Results

Visual grading characteristics (VGC) analysis of the data showed comparable image quality with regards to reproduction of abdominal structures, bowel discrimination, presence of artefacts, and visualization of the amount of intra-abdominal fat for the three OCM protocols.

Conclusion

All three OCM protocols provided similar image quality for follow-up abdominopelvic CT for general oncological indications.

Key Points

? Positive oral contrast media are routinely used for abdominopelvic multidetector computed tomography ? Experimental study comparing image quality using three different oral contrast materials ? Three different oral contrast materials result in comparable CT image quality ? Benefits for patients and medical imaging department     

Radiologist,obstetric patient,and emergency department provider survey: radiologist-patient interaction in the emergency department setting

The aim of this study was to evaluate the feasibility and acceptance of a model of direct interaction between radiologist and patients in the emergency department (ED) setting. The study population was comprised of pregnant patients accrued in a non-consecutive prospective manner from June 2014 to September 2015, who had an obstetrical ultrasound performed in the radiology department of an inner-city tertiary care hospital at the request of the ED. The feasibility and approval of direct communication between radiologist and patient were evaluated by means of a questionnaire presented by an independent observer to the ED provider, patient, and radiologist. The exam enrolled 54 patients. Ultrasound (US) exam results were divided into (31) normal live intrauterine gestation (group 1), (7) abnormal failed intrauterine gestation or ectopic pregnancy (group 2), and (16) indeterminate pregnancies that could not be placed in the former categories and may require a follow-up exam (group 3). Forty-five (83 %) ED providers approved of the radiologist’s direct communication with patients. Fifty (93 %) patients stated a better understanding of the radiologist’s role in their care after than before the interaction. The radiologists found the interaction with patients to be positive in 52 (96 %) cases. Direct communication between radiologist and patient yielded a good acceptance by the radiologist, ED provider, and patient. More importantly, after the encounter, the vast majority of patients reported a better understanding of the radiologist’s role in their care.     

Syncope and head CT scans in the emergency department

Context Patients presenting with syncope to the emergency department (ED) of a community hospital were evaluated. Aim The objective of this study is to examine the use and results of head computerized tomography (CT) scans in patients presenting with syncope to the ED of a community hospital. Settings and design A retrospective chart review of patients presenting with syncope to the emergency room was conducted. Methods and materials We reviewed the charts of patients who presented to the ED over a 6-month period with syncope. When performed, head CT scan findings were noted, and their relationship to the clinical presentation was examined. Results One hundred twenty-eight patients were identified. Forty-four patients had their head CT scans performed. In 1 patient, the CT scan showed evidence of infarction in the posterior circulation. In 19 patients, the head CT scan was normal. Twenty-four patients had abnormal findings unrelated to the ED presentation. Conclusions Head CT scans were commonly used in our series of syncope patients. Abnormal findings pertinent to the syncope were observed in only 1 patient. A prospective study examining yield in a larger series of patients may help define the utility of this neuroimaging modality in syncope.     

Comparison of 2 positive and 1 negative oral contrast media for abdominal CT diagnosis

In a prospective randomised study three groups of 30 patients each were subjected to CT of the entire abdomen. The oral intestinal contrast media used were iodine solution (2%), barium suspension (1.5%) and paraffin emulsion (25%). The results were evaluated according to imaging, artifacts, ability to assess the intestinal wall, taste and side effects. All three contrast media are suitable for marking the gastrointestinal tract; paraffin shows advantages in the upper part of the tract and is the only medium that enables assessment of the wall, while causing the lowest rate of artifacts. Barium has a high acceptance and the best tolerance of all contrast agents.     

Effects of eliminating routine use of oral contrast for computed tomography of the abdomen and pelvis: A pilot study

IntroductionComputed tomography (CT) of the abdomen and pelvis using only intravenous contrast has been shown to have a high degree of accuracy in evaluating abdominal pain. The aim of this study was to determine the effect on time to completion of study, time to radiologist read, and length of stay in the emergency department (ED) of implementing a protocol that stopped the routine use of oral contrast for CT of the abdomen and pelvis.MethodsThis was a single-center, retrospective cohort study. All patients ≥18 years of age who presented to the ED and required a CT of the abdomen and pelvis during the hours 0700–1500 were included. There were two one-month study periods, before and after implementing a protocol that specified oral contrast should only be used for CT scans of the abdomen and pelvis if body mass index <25 kg/m² or age < 30 years, or if there was history of inflammatory bowel disease, gastrointestinal surgery, or suspected bowel malignancy.ResultsDuring the pre- and post-implementation periods, there were 93 and 83 patients, respectively, with mean times to CT completion of 158 min and 135 min, representing a reduction of 23 min (15%). The mean lengths of stay in the pre- and post-implementation periods were 365 min and 336 min, a decrease of 29 min (8%).ConclusionA protocol without the routine use of oral contrast for CT of the abdomen and pelvis can result in improved time to completion and ED length of stay.     

Chest pain in the emergency department: role of multidetector CT

The development of newer generations of multidetector computed tomographic (CT) scanners capable of enabling accurate assessment of the coronary arteries in conjunction with the increasing placement of CT scanners near the emergency department has raised interest in using CT to provide a comprehensive imaging evaluation of patients presenting with acute chest pain. In this article, the authors review the challenges surrounding the current clinical and imaging work-up of chest pain in the emergency room and provide a framework for understanding the potential role of CT.