Study: Accountability at a glancenew tool may cut unnecessary CT exams in ED

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Emergency physicians at the Hospital of the University of Pennsylvania reduced abdominal CT scans approximately 10 percent after implementing an electronic accountability tool in the EMR and computerized physician order entry (CPOE) systems, according to a study presented May 11 at the annual meeting of the Society for Academic Emergency Medicine.

Abdominal pain represents a challenging diagnostic situation in the ED. A wide range of conditions, ranging from those that can be addressed by over-the-counter medications to life-threatening, may cause abdominal pain. Consequently, ED physicians tend to rely on CT to evaluate these patients, which partially accounts for the surge in CT exams in the U.S.

“We need to be sure about our diagnosis in order to keep patients safe, but we need to balance the risks of giving a test like a CT scan with the chance that the test will truly provide us with information we could not get in some other way with less risk to the patient,” Angela M. Mills, MD, medical director of the Hospital of the University of Pennsylvania (UPenn) in Philadelphia, said in a statement.

In October 2011, the hospital deployed an electronic accountability tool that triggers a series of checks and balances related to abdominal CT orders. It takes less than 20 seconds for physicians to click through the four screens, Mills said in an interview.  

The tool queries physicians about: suspected primary and secondary diagnoses, whether or not the user is the primary provider ordering the study and pre-test probability of the primary diagnosis.

The system does not block orders or offer advice, Mills said. However, residents’ orders for abdominal CT exams have to be approved by attending physicians prior to scanning.

Mills and colleagues compared abdominal CT orders in two UPenn emergency departments from July to Oct. 16, 2011, to those acquired Oct. 17, 2011 to March. The study population included 11,176 patients older than 18 years old. A total of 81 percent of patients presented with a chief complaint of abdominal pain.

Prior to the implementation of the accountability tool, 32.3 percent of these patients underwent abdominal CT. After the tool was deployed, this rate dropped to 28 percent. After researchers adjusted for age, illness severity, disposition and hospital site, they calculated a 10 percent reduction in abdominopelvic CT exams.

Although an unclear diagnosis may prompt admission to the hospital, the rate of admission did not change significantly during the two time periods, according to the researchers.  

Radiology has been heavily involved in phase 2 of the project, which was recently launched, Mills said. The enhanced version of the project leverages Radiance, an internally developed, open-source system that extracts and provides information on a patient’s previous abdominal imaging tests at Penn and cumulative radiation exposure from previous CT scans at Penn. It also allows users to review reports and images from previous abdominal imaging exams, explained Mills.  

Radiance presents the information in a graphic format that emergency physicians can review quickly, Mills said. These features might help to further reduce CT imaging.