Reducing emergency department (ED) computed tomography (CT) utilization in women treated for gynecologic cancers.

OBJECTIVES: The objective of this quality improvement (QI) project was to decrease the rate of low-value computed tomography (CT) imaging in established gynecologic oncology patients presenting to the emergency department (ED). METHODS: This was a cohort study with a before and after design that evaluated implementation of a QI project designed to decrease CT utilization in established gynecologic oncology patients in the ED. The pre-intervention cohort included patients admitted through the ED from 4/1/17 to 5/31/18, while the post-intervention cohort was from 6/1/18 to 5/31/19. The intervention included gynecologic oncology consultation before CT on patients who had imaging within the prior 3 weeks. Details regarding CT, ED length of stay (LOS), and oncologic history were abstracted. The value of CT was determined by consensus from 2 reviewers. Prospective data monitoring evaluated for patient safety. RESULTS: Prior to intervention, there were 129 unique ED encounters in gynecologic oncology patients leading to admission. CT scans were performed in 101 (78.3%) encounters, 57.7% of which were deemed to be of low-value. Following implementation, the CT utilization rate decreased significantly from median monthly rate of 75.2% to 49.1% (p < 0.00001), and the ED LOS decreased from 8.1 to 6.9 h (p = 0.0102). The number of CT scans deemed to be low-value in the post-intervention group decreased to 2 (3.8%). CONCLUSIONS: Implementation of an early consultation policy and imaging guidelines led to a significant decrease in unnecessary CT utilization and shorter ED LOS in gynecologic oncology patients presenting to the ED.

Large acute cerebral hemorrhage presenting with pure alexia.

Alexia (the acquired inability to read) is an uncommon presenting complaint in the emergency department (ED). It is usually associated with a lesion in the brain located within the dominant hemisphere near the parieto-occipital junction, with some involvement of the splenium of the corpus callosum. Our review of the literature revealed multiple distinct causes for the finding of alexia, and a majority of the cases uncovered also involved agraphia (the acquired inability to write) and frequently visual field defects. We present the case of an otherwise healthy 35-year-old white man who arrived at our ED with the chief complaint of having difficulty reading. He was, however, able to write, and he exhibited no defects in his visual fields on gross testing in our ED. The patient was found to have a large, acute, intraparenchymal hemorrhage in the right posterior/inferior parietal cortex, very near the occipital lobe. We present this case, followed by a brief discussion, to heighten awareness of the complaint of alexia with or without agraphia as a possible presenting symptom of intracranial hemorrhage, or ischemic cerebrovascular accident.