Faculty Bibliography

Background Emergency departments (EDs) rely on advanced imaging such as CT for diagnosis. Owing to increased ED volumes at the authors' institution, CT image acquisition became a significant bottleneck in ED patient throughput. Methods A multidisciplinary team was formed to solve this complex patient flow issue. Lean management principles were leveraged to identify process gaps and institute changes to achieve workflow improvements, remove process wastes, and improve patient throughput in the ED CT scanner. Process metrics such as percentage of CT examinations completed within 120 minutes and monthly median examination turnaround time (TAT) were tracked on a monthly basis. To measure impact, outcome metrics such as time savings from elimination of wasted steps were developed. Interventions Four projects including development of an ideal staffing model, a patient flow worksheet, revision of the CT patient screening form, and examination prioritization efforts were tested. Just-do-it activities such as revision of the CT angiography protocol ordering tool, optimizing scanner utilization, and improving communication and collaboration between the radiology department and ED were also attempted. Results After a phased rollout of changes over 6 months, the percentage of ordered ED CT examinations completed within 120 minutes increased by 10% (61%-71%); however, this improvement was sustained for only 6 weeks. Elimination of process inefficiencies resulted in a monthly median TAT reduction from 90-109 minutes to 82-106 minutes, and approximately 6 weeks (268 hours) of annualized full-time technologist time was saved. Conclusion Lean management tools can be leveraged to solve complex ED CT patient flow issues and reduce TAT. Online supplemental material is available for this article. ^©RSNA, 2021.

Computed tomography (CT) represents one of the largest sources of radiation exposure to the public in the United States. Regulatory requirements now mandate dose tracking for all exams and investigation of dose events that exceed set dose thresholds. Radiology practices are tasked with ensuring quality control and optimizing patient CT exam doses while maintaining diagnostic efficacy. Meeting regulatory requirements necessitates the development of an effective quality program in CT. This review provides a template for accreditation compliant quality control and CT dose optimization. The following paper summarizes a large health system approach for establishing a quality program in CT and discusses successes, challenges, and future needs.

BACKGROUND:Current methods to predict height and growth failure are imprecise. MRI measures of physeal cartilage are promising biomarkers for growth. PURPOSE:In the physis, to assess how 3D MRI volume measurements, and diffusion tensor imaging (DTI) measurements (tract volume and length) correlate with growth parameters and detect differences in growth. We compared patients exposed to cis-retinoic acid, which causes physeal damage and growth failure, with normal subjects. STUDY TYPE:Case-control. POPULATION:Twenty pediatric neuroblastoma survivors treated with cis-retinoic acid and 20 age- and sex-matched controls. FIELD STRENGTH/SEQUENCE:3T; DTI and 3D double-echo steady-state (DESS) sequences. ASSESSMENT:On distal femoral MR studies, physeal 3D volume and DTI tract measurements were calculated and compared to height. STATISTICAL TESTS:We used partial Spearman correlation, analysis of covariance, logistic regression, Wald test, and the intraclass correlation coefficient (ICC). RESULTS:The height percentile correlated most strongly with DTI tract volumes (r = 0.74), followed by mean tract length (r = 0.53) and 3D volume (r = 0.40) (all P < 0.02). Only tract volumes and lengths correlated with annualized growth velocity. Relative to controls, patients showed smaller tract volumes (8.00 cc vs. 13.71 cc, P < 0.01), shorter tract lengths (5.92 mm vs 6.99 mm, P = 0.03), and smaller ratios of 3D cartilage volume to tract length; but no difference (4.51 cc vs 4.85 cc) in 3D MRI volumes. The 10 patients with the lowest height percentiles had smaller tract volumes (5.07 cc vs. 10.93 cc, P < 0.01), but not significantly different 3D MRI volumes. Tract volume is associated with abnormal growth, with an accuracy of 75%. DATA CONCLUSION:DTI tract volume of the physis/metaphysis predicts abnormal growth better than physeal cartilage volumetric measurement and correlates best with height percentile and growth velocity. EVIDENCE LEVEL:2 TECHNICAL EFFICACY: Stage 2 J. Magn. Reson. Imaging 2020;52:544-551.

PURPOSE/OBJECTIVE:The purpose of this study was to determine how often a second-opinion interpretation of interstitial lung disease (ILD) by an academic cardiothoracic radiologist is discordant with the initial interpretation by a nonacademic radiologists and how often the clinical diagnosis determined by multidisciplinary consensus agrees with the initial and second-opinion interpretations. METHODS:This retrospective study included 364 consecutive second-opinion CT examination reports of imaging from nonacademic radiology practices from July 2014 to May 2016. The second-opinion interpretations, provided by seven fellowship-trained cardiothoracic radiologists, were compared with the initial interpretations and the clinical diagnoses determined by multidisciplinary consensus. RESULTS:Two hundred ninety-six consecutive reports met the inclusion criteria, and two hundred had findings of ILD. The initial interpretations lacked specific diagnoses in 41% of reports, but the second-opinion reports lacked specific diagnoses in only 7%. When a diagnosis was provided, the second-opinion diagnosis disagreed with the initial interpretation in 25% of cases. The clinical-consensus diagnosis was concordant with that of the academic radiologists 85% of the time but concordant with the initial interpretation only 44% of the time. The academic radiologists' diagnostic sensitivity was higher than that of the initial radiologists for the four most common diagnoses: usual interstitial pneumonitis (0.91 versus 0.4), sarcoidosis (0.94 versus 0.60), hypersensitivity pneumonitis (0.79 versus 0.17), and nonspecific interstitial pneumonitis (0.72 versus 0.14). CONCLUSIONS:Academic cardiothoracic radiologists were more likely to provide specific diagnoses for ILD, and these diagnoses were more likely to be concordant with the multidisciplinary consensus.

IMPORTANCE:Computed tomography (CT) radiation doses vary across institutions and are often higher than needed. OBJECTIVE:To assess the effectiveness of 2 interventions to reduce radiation doses in patients undergoing CT. DESIGN, SETTING, AND PARTICIPANTS:This randomized clinical trial included 864 080 adults older than 18 years who underwent CT of the abdomen, chest, combined abdomen and chest, or head at 100 facilities in 6 countries from November 1, 2015, to September 21, 2017. Data analysis was performed from October 4, 2017, to December 14, 2018. INTERVENTIONS:Imaging facilities received audit feedback alone comparing radiation-dose metrics with those of other facilities followed by the multicomponent intervention, including audit feedback with targeted suggestions, a 7-week quality improvement collaborative, and best-practice sharing. Facilities were randomly allocated to the time crossing from usual care to the intervention. MAIN OUTCOMES AND MEASURES:Primary outcomes were the proportion of high-dose CT scans and mean effective dose at the facility level. Secondary outcomes were organ doses. Outcomes after interventions were compared with those before interventions using hierarchical generalized linear models adjusting for temporal trends and patient characteristics. RESULTS:Across 100 facilities, 864 080 adults underwent 1 156 657 CT scans. The multicomponent intervention significantly reduced proportions of high-dose CT scans, measured using effective dose. Absolute changes in proportions of high-dose scans were 1.1% to 7.9%, with percentage reductions in the proportion of high-dose scans of 4% to 30% (abdomen: odds ratio [OR], 0.82; 95% CI, 0.77-0.88; P < .001; chest: OR, 0.92; 95% CI, 0.86-0.99; P = .03; combined abdomen and chest: OR, 0.49; 95% CI, 0.41-0.59; P < .001; and head: OR, 0.71; 95% CI, 0.66-0.76; P < .001). Reductions in the proportions of high-dose scans were greater when measured using organ doses. The absolute reduction in the proportion of high-dose scans was 6.0% to 17.2%, reflecting 23% to 58% reductions in the proportions of high-dose scans across anatomical areas. Mean effective doses were significantly reduced after multicomponent intervention for abdomen (6% reduction, P < .001), chest (4%, P < .001), and chest and abdomen (14%, P < .001) CT scans. Larger reductions in mean organ doses were 8% to 43% across anatomical areas. Audit feedback alone reduced the proportions of high-dose scans and mean dose, but reductions in observed dose were smaller. Radiologist's satisfaction with CT image quality was unchanged and high during all periods. CONCLUSIONS AND RELEVANCE:For imaging facilities, detailed feedback on CT radiation dose combined with actionable suggestions and quality improvement education significantly reduced doses, particularly organ doses. Effects of audit feedback alone were modest. TRIAL REGISTRATION:ClinicalTrials.gov Identifier: NCT03000751.

To evaluate differences in fluoroscopy time (FT) for common vascular access and gastrointestinal procedures performed by radiology trainees vs faculty radiologists. Report information was extracted for all 17,966 index fluoroscopy services performed by trainees or faculty, or both from 2 university hospitals over 66 months. Various vascular access procedures (eg, peripherally inserted central catheters [PICCs] and ports) and gastrointestinal fluoroscopy procedures (eg, upper gastrointestinal and contrast enema studies) were specifically targeted. Statistical analysis was performed. FT was recorded in 17,549 of 17,966 reports (98%) The 1393 procedures performed by nonphysician providers or transitional year interns were excluded. Residents, fellows, and faculty were primary operators in 5066, 6489, and 4601 procedures, respectively. Average FT (in seconds) for resident and fellow services, respectively, was less than that of faculty only for PICCs (75 and 101 vs 148, P < 0.01). For all other procedures, average FT of trainee services was greater than that for faculty. This was statistically significant (P < 0.05) for fellows vs faculty port placement (121 vs 87), resident vs faculty small bowel series (130 vs 96), and both resident and fellow vs faculty esophagram procedures (143 and 183 vs 126 ). FT for residents was significantly less than that for fellows only for PICCs (75 vs 101, P < 0.01). For most, but not all, fluoroscopy procedures commonly performed by radiology trainees, FT is greater than that for procedures performed by faculty radiologists. Better awareness and understanding of such differences may aid training programs in developing benchmarks, protocols, and focused teaching in the safe use of fluoroscopy for patients and operators.

Promoting quality and safety research is now essential for radiology as reimbursement is increasingly tied to measures of quality, patient safety, efficiency, and appropriateness of imaging. This article provides an overview of key features necessary to promote successful quality improvement efforts in radiology. Emphasis is given to current trends and future opportunities for directing research. Establishing and maintaining a culture of safety is paramount to organizations wishing to improve patient care. The correct culture must be in place to support quality initiatives and create accountability for patient care. Focused educational curricula are necessary to teach quality and safety-related skills and behaviors to trainees, staff members, and physicians. The increasingly complex healthcare landscape requires that organizations build effective data infrastructures to support quality and safety research. Incident reporting systems designed specifically for medical imaging will benefit quality improvement initiatives by identifying and learning from system errors, enhancing knowledge about safety, and creating safer systems through the implementation of standardized practices and standards. Finally, validated performance measures must be developed to accurately reflect the value of the care we provide for our patients and referring providers. Common metrics used in radiology are reviewed with focus on current and future opportunities for investigation.