Feature: Early a.m. rad shift expedites communication of urgent findings

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Image source: American Journal of Roentgenology

An early morning radiologist shift can expedite the communication of urgent findings and improve patient care, according to a study in this month's Journal of the American College of Radiology. “The Joint Commission and the ACR have emphasized the importance of improved communication, particularly of critical test results, for better patient care,” Rathachai Kaewlai, MD, of Massachusetts General Hospital in Boston, shared with Health Imaging News.

However, many hospitals contend with incomplete coverage for radiography interpretation, particularly during the overnight and early morning hours. “The limited and variable expertise of nonradiologists who may be called on to provide real-time interpretation of off-hours studies raises a concern that critical findings that require immediate management may be overlooked,” wrote Kaewlai and colleagues.

If nonradiologists overlook critical findings on preliminary interpretations, findings such as malposition of tubes and lines or pneumothorax could persist unobserved for more than 12 hours, reported the authors.

Kaewlai and colleagues examined the impact of a 3 a.m. to 11 a.m. radiologist shift on the acquisition and communication of urgent findings on portable overnight critical care chest radiography. The primary aim was to calculate how much earlier urgent findings would be communicated to medical staff members when the radiologist start time was moved to 3 a.m.; the secondary aim was to tabulate the frequency and types of urgent findings in the patient population, explained Kaewlai.

“The radiologist work shift staggering is possible," noted Kaewlai. "This approach helps, in terms of urgent finding communication, which likely raised the standard of patient care. This is another thing that we, as radiologists, can do to help our patients, to ease the pain of our clinical colleagues [from interpreting studies by themselves], to demonstrate our willingness to be a part of patient care team and to help the hospital to do better.”

During the control period from Jan. 1, 2006 to Dec. 31, 2006, daytime radiologists interpreted portable chest x-rays acquired between 5 p.m. and 11 a.m. In the investigational period from Sept. 1 to Dec. 31, 2007, an on-site radiologist working a 3 a.m. to 11 a.m. shift interpreted the studies.

Researchers defined urgent findings as new findings, persistently abnormal findings, or increasingly abnormal findings in one of the following categories: line and tube malpositioning, pneumothorax, pneumomediastinum, abnormal mediastinal and cardiac silhouette, pneumoperitoneum, and possible massive aspiration, wrote Kaewlai. Radiologists communicated urgent findings via phone to an in-house physician or nurse and details were recorded in the radiology report in a standard template.

During the early a.m. study period, 308 of the 6,448 portable radiographic studies contained urgent findings. Tube or line malpositioning accounted for 68.5 percent of urgent findings, and new or increased pneumothorax ranked second at 20.1 percent of urgent findings, reported the researchers.

“If identification and communication of such imaging findings were delayed until a standard shift of radiologists were available, as in the case of many radiology practices, it may not constitute optimal patient care,” wrote Kaewlai. In fact, researchers found that the historical control group communicated urgent findings an average of 7.6 hours after the exam was performed.

The research team excluded six reports and analyzed the remaining 302 from the investigational period and compared them to 156 randomly selected historical control portable chest studies.

“The mean elapsed time from image acquisition to the communication of urgent results was significantly shorter in the study group than in the control group,” wrote Kaewlai. “The early morning shift of radiologists, on average, communicated these findings two hours earlier compared with the historical control group.”

Both radiologists and referring physicians responded positively to the staggered shift. “The acceptance had been very good for both radiologists and referring physicians,” stated Kaewlai. “Staggered shift helped decrease case load in the early morning hours, easing the work of standard-hour morning radiologists. For referring physicians, they much appreciated us letting them know about urgent findings on imaging studies they requested--which was more timely