Improving Throughput, Mythbusting, Radiology, Radiology

Slaying the contrastivorous Radiologasaurus

 

When was the last time you saw a Dinosaur? I encounter one quite regularly. Native to dark rooms, surviving off Starbucks, Dragon dictation, and PO contrast, the radiologasaurus frowns upon “positive dimer” for a reason for chest CT and not providing oral contrast for abdomen/pelvis CT scans.

Two studies from 2012 help slay this oral contrastivore. In the first, 395 abdomen/pelvis scans were obtained, 184 of them with IV only contrast. Studies were aiming to evaluate for SBO, appendicitis, diverticulitis, or perforation. Not surprisingly, length of ED stay, time to admission, time to OR, and time to discharge from ED were all significantly lower in the IV only arm. Rescan rates were 9% vs 8.7% (PO v. No PO). There was one missed appendicitis, and one patient that was read as early appendicitis and for some reason rescanned with PO contrast that still, amazingly, had appendicitis.

An even larger study retrospectively analyzed patients 2 months before and 2 months after eliminating PO contrast from abdomen/pelvis CT. Patients with inflammatory bowel disease, prior gastrointestinal tract-altering surgery, or lean body habitus continued to receive oral contrast, and those that would not have received PO contrast otherwise (ie, looking for kidney stones), were excluded from analysis. 2,001 ED patients (1,014 before and 987 after protocol change) were examined. 617 pre-intervention and 611 post-intervention were eligible for oral contrast and included. Of these, 95 % received oral contrast prior to the intervention and 42 % thereafter. After the intervention, mean ED LOS among oral contrast eligible patients decreased by 97 min, P < 0.001. Mean time from order to CT decreased by 66 min, P < 0.001. No patient with CT negative for acute findings had additional subsequent abdomen/pelvic imaging within 72 hours at the study institution that led to a change in diagnosis. 611 patients over two months, none of which bounced back or had a change in diagnosis without PO contrast that would have otherwise received it.

Further reason to starve the contrastivorous radiologasaurus.

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PMID: 23359477

PMID: 22744764

 

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2 thoughts on “Slaying the contrastivorous Radiologasaurus

  1. Radiologist here.

    Why do you think that we want to have contrast? Certainly, it is not to get paid more. Certainly, it is not to spite our colleagues in the ER. It is purely because, with experience, we know that it is the right way to do an exam. If oral contrast did not improve detectability and improve specificity, it simply wouldn’t be used at all. It makes some of our interpretations (not all) more certain. One important goal is to be as certain of the interpretation as you can be, and when my wife presented with severe non-specific abdominal pain, she definitely got oral and IV. It cost essentially nothing more, and when her exam was negative, there were no lingering doubts in my mind that she might have an unusual cause, such as carcinoid. We all know the value of a good, strong negative test.
    I think it is a good question to ask why there is such intense universal interest in cutting a corner from our ER colleagues. From my observation in the hospitals I practice, it appears to be because hospital administration has threatened their employment status if the TAT is not decreased. I can’t think that the ER physicians have an inherent distaste for oral contrast, and I have seen this sort of pressure in several institutions. Sadly, it has led to our receiving purposely misleading diagnoses (r/o stone for ANY sort of abdominal pain) in order that we not give contrast. The way to insure the most accurate interpretation for you and your patient is to give as much information about that patient’s potential condition as you have (“pain over the right posterior 10th rib after fall”). Playing hide and seek with the radiologist (r/o stone in a patient who you really suspect might have bowel ischemia) will be certain to lower our sensitivity, and perhaps it won’t be detectable statistically without a large number of patients, but avoiding one tragedy would seem to be worthwhile particularly since it would require only appropriate professional communication.
    The distortion of the good practice of medicine by administrative meddling that I sense here reminds me of a situation I have seen in two hospitals in which negative reviews of the service of the ER docs given by drug seeking patients led to the administration pressuring the docs to improve their patient reviews, and thus to the docs freely giving out narcs to the drug seekers. These sorts of of perversion of medical practice by clueless administrators is something that all physicians should refuse to be involved with.
    It appears that we have a common enemy, and the two victims of this enemy (radiology and ER) shooting at one another does not solve the real problem and it doesn’t prevent this happening in other scenarios.

    • Thanks for the comment, appreciate the read. Sorry for the delay in response.

      The two studies above look about 1500 patients combined. There is no difference in rescan rates, and one missed appendicitis – with CT rates having a sensitivity of about 96% ( http://www.ncbi.nlm.nih.gov/pubmed/12200239 ; http://www.journalofsurgicalresearch.com/article/S0022-4804(08)00188-1/abstract), I hesitate to say it was the contrast that made all the difference in that case and more likely that they were due for a miss based on historic sensitivity of CT scanning.

      I agree that intentionally misleading the radiologist is not going to make friends, but to play devil’s advocate, giving a specific concern could lead to anchor bias – ie, the Hidden Gorilla (http://www.ncbi.nlm.nih.gov/pubmed/23863753). IV contrast certainly has its role for mesenteric ischemia and for biliary duct evaluation. Though for nephrolithiasis, pneumoperitoneum, AAA / rupture, pancreatitis, diverticulitis , SBO, or appendicitis, there is good literature that IV contrast adds no value. (http://www.ncbi.nlm.nih.gov/pubmed/16126929)

      While yes, there may be “administrative meddling” to decrease TAT that is financial driven, I do not believe that admin has made a cost/benefit analysis with the understanding that they may harm a few patients a year in order to save XYZ amount of money. They do not want the associated bad press. Rather, there is a bevy of data that suggests increased boarding leads to decreased pain control (http://www.ncbi.nlm.nih.gov/pubmed/18945239), and boarding leads to increased LOS for * everyone * in the ED, even those discharged (http://www.ncbi.nlm.nih.gov/pubmed/22766404). The simple solution would be to add more beds to the ED to hold everyone, however, this actually increases LOS (http://www.ncbi.nlm.nih.gov/pubmed/18783852). Delays in admission (ie, waiting to drink PO contrast), leads to 12% increased inpatient LOS, 11% greater cost. At the study institute, there were 13,460 admissions over a year, resulting in 2,183 days wasted, and $2.1m wasted (http://www.ncbi.nlm.nih.gov/pubmed/20618934). This is more exposure to HAI, and I’m certain the increased cost was at least partially passed on to the patient. Increased boarding leads to increased likelihood of readmission. ED crowding leads to decreased time to antibiotics in febrile neonates (http://www.ncbi.nlm.nih.gov/pubmed/22168202). ED boarding leads to increased mortality (http://www.ncbi.nlm.nih.gov/pubmed/21317786; http://www.ncbi.nlm.nih.gov/pubmed/22168198). The opportunity loss of every 30 minutes of average boarding time equaled the time required to see 3.5 % of the ED’s daily census. (http://www.ncbi.nlm.nih.gov/pubmed/19413166)

      Yes, there is big money at stake in moving patients through the ED. Some of that money gets put back into the patient’s pocket by having a decreased LOS, a potentially smaller hospital bill, and sooner time back to work. Some of that is priceless if you ask the renal colic and migraine patients that have to wait longer to get their pain medication, or the septic neonate with delayed antibiotic treatment. The evidence suggests that it is in the best interest of the patient to decrease TAT, and that it can be done without compromising anyone’s care.

      Cheers, and thanks for reading the blog!
      Patrick

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