Travis Browning

Predictors of adequate ultrasound quality for hepatocellular carcinoma surveillance in patients with cirrhosis.

Abdominal ultrasound fails to detect over one‐fourth of hepatocellular carcinoma (HCC) at an early stage in patients with cirrhosis. Identifying patients in whom ultrasound is of inadequate quality can inform interventions to improve surveillance effectiveness.

Radiology Resident Preliminary Reporting in an Independent Call Environment: Multiyear Assessment of Volume, Timeliness, and Accuracy

PURPOSE The objective of this paper is to assess the volume, accuracy, and timeliness of radiology resident preliminary reports as part of an independent call system. This study seeks to understand the relationship between resident year in training, study modality, and discrepancy rate. METHODS Resident preliminary interpretations on radiographs, ultrasound, CT, and MRI from October 2009 through December 2013 were prospectively scored by faculty on a modified RADPEER scoring system. Discrepancy rates were evaluated based on postgraduate year of the resident and the study modality. Turnaround times for reports were also reviewed. Differences between groups were compared with a chi-square test with a significance level of 0.05. Institutional review board approval was waived as only deidentified data were used in the study. RESULTS A total of 416,413 studies were reported by 93 residents, yielding 135,902 resident scores. The rate of major resident-faculty assessment discrepancies was 1.7%. Discrepancy rates improved with increasing experience, both overall (PGY-3: 1.8%, PGY-4: 1.7%, PGY-5: 1.5%) and for each individual modality. Discrepancy rates were highest for MR (3.7%), followed by CT (2.4%), radiographs (1.4%), and ultrasound (0.6%). Emergency department report turnaround time averaged 31.7 min. The average graduating resident has been scored on 2,746 ± 267 reports during residency. CONCLUSIONS Resident preliminary reports have a low rate of major discrepancies, which improves over 3 years of call-taking experience. Although more complex cross-sectional studies have slightly higher discrepancy rates, discrepancies were still within the range of faculty report variation.

Caudal duplication syndrome: imaging evaluation of a rare entity in an adult patient

Several theories have been put forth to explain the complex yet symmetrical malformations and the myriad of clinical presentations of caudal duplication syndrome. Hereby, reported case is a 28-year-old female, gravida 2 para 2, with congenital caudal malformation who has undergone partial reconstructive surgeries in infancy to connect her 2 colons. She presented with recurrent left lower abdominal pain associated with nausea, vomiting, and subsequent feculent anal discharge. Imaging reveals duplication of the urinary bladder, urethra, and colon with with cloacal malformations and fistulae from the left-sided cloaca, uterus didelphys with separate cervices and vaginal canals, right-sided aortic arch and descending thoracic aorta, and dysraphic midline sacrococcygeal defect. Hydronephrosis of the left kidney with left hydroureter and inflammation of one of the colons were suspected to be the cause of the patient’s acute complaints. She improved symptomatically over the course of her hospitalization stay with conservative treatments. The management for this syndrome is individualized and may include surgical intervention to fuse or excise the duplicated organs.

Implementation of an Online Screening and Check-In Process to Optimize Patient Workflow Before Outpatient MRI Studies

BACKGROUND/SUMMARY OF THE PROBLEM The long examination times in MRI create the need to reduce access time and implement an efficientmodel to reduce patient turnaround time to a minimum [1]. A commonly encountered cause of delay is the screening process, an essential and indispensable step to ensure patient safety and delivery of high-quality care [2,3]. Traditionally, the MRI screening process is completed with a paper questionnaire, which is then scanned into the electronic medical record (EMR) or uploaded to the PACS for documentation purposes. The MRI screening process is commonly completed after patient arrival for an MRI appointment. If a patient reports a positive pertinent history during MRI screening (eg, placement of a medical device or presence of foreign bodies), further investigation is required, for example, obtaining specific information about the make and model of an implanted device before “clearing” the patient [2-6]. This process has several challenges. First,many patients are unaware of the specifics of their implanted device or may not be aware of the need or may simply forget to bring device-specific documentation to their MRI

Quality improvement initiative: enhanced communication of newly identified, suspected GI malignancies with direct critical results messaging to surgical specialist

Purpose To improve timely evaluation and management of newly identified, suspected, gastrointestinal (GI) malignancies discovered on radiologic imaging at a safety-net hospital through direct critical results messaging to surgical specialists. Materials and Methods To address delays in evaluating patients for suspected GI malignancies identified on imaging, an enhanced workflow was created--electronically routed critical results messaging to the ordering provider was supplemented with parallel messaging to the surgical oncology clinic. Messaging data obtained for 10 months pre and post intervention were compared. Using chart reviews, time intervals were recorded to assess the impact on (1) being seen by a specialist, (2) completing a diagnostic workup and (3) initiating definitive management. Results Significant improvements were achieved: (1) patients seen by a specialist increased from 45.9% to 98.0% (p<0.001), with median time decreasing from 35 to 7 days (p<0.001); (2) patients completing a diagnostic workup increased from 77.1% to 93.9% (p<0.05), with median time decreasing from 44 to 18 days (p<0.001); (3) patients with initiation of definitive management increased from 72.1% to 89.8% (p<0.05), with median time decreasing from 62 to 35 days (p<0.05). Further study is needed to assess impact on fragmentation of care and financial implications. Conclusions Direct critical results messaging from the radiologist to the surgical oncologist at a safety-net hospital significantly improves the time to complete a diagnostic workup and initiate definitive management with significantly more patients being seen by a relevant specialist.

Editorial: ultrasound surveillance of hepatocellular carcinoma in the 21st century – authors' reply

modalities compared to ultrasound in most societies. Neither modality is without risk. CT involves significant radiation doses and both CT andMRI require the administration of intravenous contrast for optimum examination which can be associated with significant side effects. Despite its limitations, ultrasound will remain the primary imaging modality for HCC for the foreseeable future. It is therefore crucial to maximise the performance of ultrasound as a screening tool by ensuring it is performed and reported by adequately trained operators; they need to be experienced in hepatobiliary imaging in order to obtain high-quality diagnostic examinations and to minimise the referral rate for CT/MRI imaging surveillance, and the ensuing financial and resource implications associated with this.

A novel use of the discrete templated notes within an electronic health record software to monitor resident supervision

Objective Monitoring the supervision of residents can be a challenging task. We describe our experience with the implementation of a templated note system for documenting procedures with the aim of enabling automated, discrete, and standardized capture of documentation of supervision of residents performing floor-based procedures, with minimal extra effort from the residents. Materials and methods Procedural note templates were designed using the standard existing template within a commercial electronic health record software. Templates for common procedures were created such that residents could document every procedure performed outside of the formal procedural areas. Automated reports were generated and letters were sent to noncompliers. Results A total of 27 045 inpatient non-formal procedural area procedures were recorded from August 2012 to June 2014. Compliance with NoteWriter template usage averaged 86% in the first year and increased to 94.6% in the second year ( P  = .0055). Initially, only 12.5% of residents documented supervision of any form. By the end of the first year, this was above 80%, with the gains maintained into the second year and beyond. Direct supervision was documented to have occurred where required in 62.8% in the first year and increased to 99.8% in the second year ( P  = .0001) after the addition of hard stops. Notification of attendings prior to procedures was documented 100% of the time by September 2013. Letters sent to errant residents decreased from 3.6 to 0.83 per 100 residents per week. Conclusion The templated procedure note system with hard stops and integrated reporting can successfully be used to improve monitoring of resident supervision. This has potential impact on resident education and patient safety.