Importance of clinical decision support system response time monitoring: a case report.

Clinical decision support (CDS) systems are prevalent in electronic health records and drive many safety advantages. However, CDS systems can also cause unintended consequences. Monitoring programs focused on alert firing rates are important to detect anomalies and ensure systems are working as intended. Monitoring efforts do not generally include system load and time to generate decision support, which is becoming increasingly important as more CDS systems rely on external, web-based content and algorithms. We report a case in which a web-based service caused significant increase in the time to generate decision support, in turn leading to marked delays in electronic health record system responsiveness, which could have led to patient safety events. Given this, it is critical to consider adding decision support-time generation to ongoing CDS system monitoring programs.

Current role of lateral cervical spine radiograph: a case report.

We report a case showing the classic features of a Hangman's cervical spine fracture following a motor vehicle collision. Because this injury was not diagnosed at ED presentation, this case also illustrates the select subset of trauma patients for whom the almost obsolete lateral cervical spine radiograph remains an important part of the radiographic trauma series.

Reduced-dose CT: effect on reader evaluation in detection of pulmonary embolism.

OBJECTIVE: The purpose of this study was to evaluate the effect of reduction in radiation dose on CT detection of pulmonary embolism. SUBJECTS AND METHODS: Emergency department patients were evaluated for pulmonary embolism with standard and simulated reduced-dose CT angiography. Simulated lower-dose CT angiograms obtained at 90, 45, 22, and 10 mAs(eff) were reconstructed by mathematical addition of noise to the standard dose (180 mAs(eff)) data from the images of 18 patients with and 20 patients without pulmonary embolism. Four radiologists blinded to the study parameters separately interpreted each CT angiogram. Dose trends for subjective measures (diagnostic certainty, image quality, and perceived technical limitations) were evaluated, test characteristics for the detection of pulmonary embolism were computed, and clot burden was measured. RESULTS: Readers indicated significant reductions in diagnostic certainty (p < 0.02) and image quality (p < 0.02) and an increase in perceived technical limitations (p < 0.01) as the simulated radiation dose was decreased. These subjective measures also showed significant adverse dose trends when the mAs(eff) was reduced (p < 0.001). At reduced radiation doses, the sensitivity and positive predictive value for detection of pulmonary embolism diminished significantly. The sensitivity was 0.94 (lower bound of 0.95 CI, 0.92); specificity, 0.99 (lower bound of 0.95 CI, 0.98); positive predictive value, 0.95 (lower bound of 0.95 CI, 0.92); and negative predictive value, 0.99 (lower bound of 0.95 CI, 0.97). All patients had a low to moderate clot burden. CONCLUSION: Reduction in dose for CT angiography in the detection of pulmonary embolism has a significant adverse effect on readers' subjective assessment of diagnostic confidence and image quality. Detection of pulmonary embolism also decreases as the tube current dose is reduced.

Dedicated CT scanner in an emergency department: quantification of factors that contribute to lack of use.

OBJECTIVE: The purpose of our study was to quantify the factors that contribute to the lack of use of a dedicated CT scanner in the emergency department of our institution and to identify possible changes to reduce scanner idle time. MATERIALS AND METHODS: We designed a data collection form to record consecutive periods of patient scanning and periods between patients when the CT scanner was not in use. The contributing factors for each idle period were identified and logged according to an entry system previously decided in consensus. Data were collected continuously for 11 days. The factors we identified for measurement were no request for scanning, preventive maintenance, equipment failure, technologist unavailable, room cleaning and preparation, patient preparation for abdominal CT, patient undergoing other tests, transportation delays, pending laboratory workup, and miscellaneous factors. The time attributed to the most prevalent factors was also grouped into four 6-hr periods corresponding to our department's shifts. RESULTS: The scanner was idle 73% of the total study time. The chief contributing factors to lack of use were having no patients to scan, patient undergoing preparation, and transportation delays, which accounted for 38.5%, 31%, and 11.7% of the aggregate idle time, respectively. The 6-hr periods of least use were the 7:00 A.M.-1:00 P.M. and the 1:00 A.M.-7:00 A.M. shifts, which accounted for 17% and 19% of idle time, respectively. CONCLUSION: Dedicated emergency department CT scanners can have significant daily periods of consistent lack of use. The idle time can be reduced by identifying patterns of referral time and correcting specific operational delays.