IT key to reducing redundant, dual-modality chest imaging in the ED

Of 3,627 emergency patients imaged twice for cardiothoracic concerns at two academic medical centers over a five-year period—once with chest x-ray and once with chest CT—50.3 percent were sent to the second modality before the final radiology report on the first was available.

Very close to 10 percent (354 of the 3,627) were imaged in a second modality even before the images of the first were up.

Retrospectively analyzing these and other data, emergency radiologist Tarek Hanna, MD, and colleagues at Emory University in Atlanta suggest that overutilization, inefficiencies and unnecessary radiation doses may abound in U.S. emergency medicine.

They recommend greater deployment of “targeted technology solutions,” such as real-time information tools to clue in ordering physicians and clinical decision support software to guide radiologists, as keys to achieving more appropriate chest imaging in the emergency setting.

Their report is running in the Journal of the American College of Radiology.

During the period under analysis, January 2009 through December 2013, the vast majority of the twice-imaged chests, 94.8 percent, were x-rayed before being CT scanned.

The CT was ordered first in just 43 cases (1.2 percent). In 91 cases (2.5 percent), the exams were ordered at the same time.

In situations of the latter type, the authors theorize, ED doctors may have ordered imaging in both modalities with the expectation that the chest x-ray would come through quickly, speeding the physicians’ ability to rule out various clinical conditions.

They support this theory by noting that some 83.5 percent of cases included concerns about pulmonary embolism—and turnaround time from order entry to exam completion was 45.7 minutes for chest x-ray versus 103.9 minutes for chest CT.

However, in none of their subsets did x-ray results “alter clinical care in a documented way; all these cases still received more-detailed imaging with CCT, and no [x-ray] added information that was not described in the CCT,” they write, noting that this result aligns with prior studies showing that chest x-ray may be unnecessary for many ED patients and can have an acute abnormality rate as low as 2.5 percent.

While calling for better use of information technology to reduce redundant imaging orders, Hanna and colleagues also acknowledge that IT can contribute to the problem.

Such can be the case when, for example, EMR systems allow for automatic ordering of chest x-rays for all patients presenting with chest pain.  

“Ultimately, better electronic medical records and computerized physician order entry system processes, including automated warnings of existing orders for same-body-part imaging, could be harnessed to reduce use of redundant examinations,” the authors write.

A 2011 survey by the Centers for Disease Control and Prevention showed that more than 10 percent of all ED visits are occasioned by acute cardiothoracic symptoms, including chest pain, cough and shortness of breath.