RSNA 2016: Radiology’s patient transfer procedures need review

Radiology departments may benefit from scrutinizing their protocol when transferring trauma patients, according to a Nov. 27 session at RSNA 2016.

Computing the waste in CT

The University of Zurich’s Ricarda Hinzpeter, MD, measured the costs of unnecessary CT scans for transfer patients, finding that University Hospital Zurich was wasting nearly $40,000 a year on CT imaging.

Just under 300 patients were transferred into the hospital’s trauma unit over the course of a year, with 75 referred for additional imaging in the emergency department. Head injury or major trauma were the most commonly cited reasons for ordering imaging, accounting for 80 percent of the referrals.

These over-scanned patients also received a preventable dose of 22 millisieverts per patient, accounting for half of their recommended maximum yearly dose.

“A considerable number of transfer trauma patients undergo repeated and potentially preventable CT scans, adding dose to the patient and costs to the healthcare system,” said Hintzpeter.

The primary culprit? Inadequate CT image data transfer. Whether there’s issues with image quality or it’s simply taking too long, if a patient arrives in the ED without any imaging a surgeon is almost always going to order it.

There is a simple way to eliminate these excess scans: Cut out CT for trauma patients who are injured badly enough to be transferred to the level 1 center. However, assessing the severity of trauma injuries is not an exact science.

“I think the first triage is difficult, and the level of trauma can be underestimated,” said Hinzpeter.

“However, efforts should be made to improve and accelerate the image transfer,” she added.

Transferring radiologists need comment cards

University of Washington Professor of Radiology Jeffrey Robinson, MD, MBA, presented a paper quantifying the rate of discrepancies in over-reads of patients transferred to Harborview Medical Center in downtown Seattle.

Many patients transferred to the hospital have undergone advanced imaging, but the radiologist reports don’t always make it. Some images have a final report, some have a preliminary report, and occasionally there’s no report attached at all.

“This is ported into our hospital’s PACS system which raises the question: Who’s responsible for these exams?,” said Robinson. “Which exams should be over-read?”

Researchers compiled data on all adult CT patients transferred to Harborview in a one-month period, finding 17 percent of patients had major differences between the referrer’s report and the over-read report—inconsistencies that had the potential to change patient management.

“A major discrepancy rate of 17 percent in transfer patients is unacceptably high,” said Robinson.

There were more discrepancies in trauma than non-trauma patients, including many underreported fractures and a liver laceration incorrectly described as a contusion.

“We hypothesize that it may be related to a higher level of experience among emergency radiologists who are more familiar with injury patterns and know where to look for missed injuries,” said Robinson.

However, there was a lower discrepancy rate in neurological exams, which Robinson attributes to the higher frequency of normal head CT—radiologists are simply more used to it. The eventual goal for Harborview is a formal feedback process that involves the referring physicians in the correction process, but the shape that hat might take is unknown as of yet.

“How would you actually provide that feedback—is it an informal call to the outside radiologist or part of the post-transfer report that goes back to the hospital QA committee?” said Robinson. “We haven’t figured it out yet, but it’s on the roadmap.”