Proctoring of New Emergency Radiologists to Promote Clinical Excellence and Ensure Quality of Care.

PURPOSE: The authors' institution provides 24/7 attending radiologist final interpretations for all emergency, urgent, and inpatient studies. As a supplement to the existing emergency radiology faculty, the institution relies on two groups of radiologists to provide final imaging interpretations after hours: radiology fellows (RFs) and newly hired subspecialty radiologists (NRs). For both groups, subspecialty services provide overreads the following day to improve the skills of the staff members and ensure clinical excellence. The purpose of this study was to compare the clinical significance and rate of discrepancies between RFs and NRs. METHODS: A retrospective review of all overreads from July 1, 2012, to June 30, 2015, was performed. Discrepancy rates for RFs and NRs were calculated. Error significance for cases requiring addenda was categorized as follows: acute, likely malignant, indeterminate, unlikely to be of clinical significance, insignificant typographic error, or significant typographic error. RESULTS: In total, 10,796 studies were rechecked, of which 1.9% (n = 205) required addenda, 3.6% (n = 384) were deemed addendum-optional, and 94.5% (n = 10,207) required no comments. There was no significant difference in cases requiring addenda (RFs, 1.7% [119 of 6,847]; NRs, 2.2% [86 of 3,949]; P = .11). Of the 205 cases requiring addenda, 21.0% (n = 43) were deemed to be acute, 4.9% (n = 10) likely malignant, 28.3% (n = 58) indeterminate, 32.7% (n = 67) unlikely to be of clinical significance, and 13.1% (n = 27) secondary to typographic errors (66.7% [n = 18] deemed to be significant). CONCLUSIONS: After-hours coverage with RFs and NRs allows high-quality final, actionable interpretations with low discrepancy rates and no significant difference between both groups for addendum-needed cases. The program strikes a balance between the need for timely interpretations and the need to continually monitor and improve the quality of interpretations through subspecialist feedback.

Emergency physician focused cardiac ultrasound improves diagnosis of ascending aortic dissection.

STUDY OBJECTIVE: Ascending aortic dissection (AAD) is an uncommon, time-sensitive, and deadly diagnosis with a nonspecific presentation. Ascending aortic dissection is associated with aortic dilation, which can be determined by emergency physician focused cardiac ultrasound (EP FOCUS). We seek to determine if patients who receive EP FOCUS have reduced time to diagnosis for AAD. METHODS: We performed a retrospective review of patients treated at 1 of 3 affiliated emergency departments, March 1, 2013, to May 1, 2015, diagnosed as having AAD. All autopsies were reviewed for missed cases. Primary outcome measure was time to diagnosis. Secondary outcomes were time to disposition, misdiagnosis rate, and mortality. RESULTS: Of 386547 ED visits, targeted review of 123 medical records and 194 autopsy reports identified 32 patients for inclusion. Sixteen patients received EP FOCUS and 16 did not. Median time to diagnosis in the EP FOCUS group was 80 (interquartile range [IQR], 46-157) minutes vs 226 (IQR, 109-1449) minutes in the non-EP FOCUS group (P = .023). Misdiagnosis was 0% (0/16) in the EP FOCUS group vs 43.8% (7/16) in the non-EP FOCUS group (P = .028). Mortality, adjusted for do-not-resuscitate status, for EP FOCUS vs non-EP FOCUS was 15.4% vs 37.5% (P = .24). Median rooming time to disposition was 134 (IQR, 101-195) minutes for EP FOCUS vs 205 (IQR, 114-342) minutes for non-EP FOCUS (P = .27). CONCLUSIONS: Patients who receive EP FOCUS are diagnosed faster and misdiagnosed less compared with patients who do not receive EP FOCUS. We recommend assessment of the thoracic aorta be performed routinely during cardiac ultrasound in the emergency department.

Completion CT of Chest, Abdomen, and Pelvis after Acute Head and Cervical Spine Trauma: Incidence of Acute Traumatic Findings in the Setting of Low-Velocity Trauma.

PURPOSE: To determine the frequency of acute traumatic findings in computed tomographic (CT) chest abdomen pelvis (CAP) examinations in patients with acute traumatic head and/or cervical spine injury and no evidence suggesting bodily injury. MATERIALS AND METHODS: After institutional review board approval with a waiver of informed consent was obtained, a HIPAA-compliant retrospective study was performed. A review of the electronic medical records and dictated reports identified patients who met the following criteria: CT-documented acute head and/or cervical spine trauma, CT CAP performed at least 20 minutes after initial brain and/or cervical spine CT, and no evidence of bodily injury at physical examination or on initial plain radiographs. The types of head and/or cervical injury, as well as mechanisms of injury in these patients, were analyzed. The frequency of acute traumatic injury in the CT CAP examinations was also determined, and 95% confidence intervals were calculated. RESULTS: There were 115 patients who met the study criteria (average age, 67.3 years). Sixty-three (54.8%) patients were male. The average injury severity score was 9.3. No patients who met the criteria for this study were found to have an acute traumatic injury to the chest, abdomen, or pelvis. These 115 CT CAP examinations comprised 7.5% (115 of 1530) of all CT CAP examinations performed in the emergency department over the 15-month study period. CONCLUSION: CT CAP examinations rarely if ever reveal acute traumatic injury in patients who have experienced low-velocity trauma and have acute head and/or cervical spine trauma in the absence of evidence of bodily injury.

Reshaping the emergency radiology call experience after the merger of two programs: the Yale experience.

In the summer of 2013, 16 radiology residents from the Hospital of Saint Raphael (HSR) joined the 38 residents of Yale-New Haven Hospital (YNHH) to become a single 54-resident program. This posed a significant challenge given the number of residents and very different call structures of the two institutions. After evaluating the emergency radiology volume at both hospitals, it was determined that implementing YNHH's traditional call system at HSR would increase call by approximately 25 %. In order to negate this increase, the SRC rotation was created at HSR. This Monday-Friday rotation covered by R3s starts at 1 p.m. with afternoon conference. Residents then read cases on a subspecialty service from 2-5 p.m. and then cover the entire hospital until 10 p.m. with a single attending. Because of this rotation, call did not increase for the YNHH residents and third year residents were provided with increased responsibility. For programs not undergoing a merger, call rotations can also be extremely beneficial. These rotations allow third year residents to have more "call-free" weeks prior to the ABR core exam. Also, patient care can be improved, as the shift length for on-call residents is reduced, which has been shown to improve accuracy.

Disclosure of financial conflicts of interest: an evaluation of orthopaedic surgery patients' understanding.

BACKGROUND: Industry and orthopaedic surgeons often partner to develop new technology, which can lead to orthopaedic surgeons having financial conflicts of interest (FCOI). It is essential these FCOI be conveyed clearly to patients. It is unclear, however, whether and to what degree patients understand the ramifications of physician FCOI. QUESTIONS/PURPOSES: We evaluated (1) patients' concerns regarding their surgeon having FCOI or the presence of institutional FCOI, (2) the effect of surgeon FCOI on patients' willingness to have surgery, and (3) patients' understanding of FCOI. METHODS: We asked 101 patients (66% female) receiving total joint arthroplasty from the orthopaedic practices of two surgeons at an academic health center to complete a descriptive, correlational designed survey at their 6-week followup appointment. The data collected included patient demographics, knowledge of FCOI, and the influence of FCOI on patient attitudes toward surgery and their surgeon. RESULTS: A minority of patients (13%) reported discussing FCOI with prior physicians and only 55% agreed or strongly agreed a surgeon should disclose FCOI. Only 15% of patients believed such conflicts would make them less likely to have their surgeon operate on them. Level of education was weakly correlated (Spearman's rho = 0.29) with patient understanding of FCOI. CONCLUSIONS: Overall, patients had a poor understanding of FCOI. Both level of education and previous discussions of FCOI predicted better understanding. This study emphasizes communication of FCOI with patients needs to be enhanced.

Looking beyond the D-dimer.

The D-dimer test ruled out a pulmonary embolism in our patient, but her signs and symptoms suggested that we take another look.