PAUL NAGY, PhD
QUALITY MATTERS
Quality Improvement Projects Based in the Emergency Department Ryan W. Woods, MD, MPH, Staci Reintjes, DO, Paul Nagy, PhD INTRODUCTION
The emergency department (ED) is an ideal partner when considering quality projects. Radiology in the ED combines large imaging volumes, tight time constraints, and the need for highly effective communication inherent in obtaining and interpreting diagnostic examinations. Quality improvement projects in the ED have a large impact on patient care and can improve relationships with referring physicians [1,2]. Just as in radiology, residents and attending physicians in the ED are required to conduct continuous quality improvement projects by the ACGME and the American Board of Medical Specialties, respectively. Joint projects are sufficient for both parties and should be actively encouraged. The first step is to designate and receive project buy-in from several ED stakeholders. A good starting point is to look for a physician in the ED who serves as a representative to the hospital in quality matters or is involved in training ED residents in systems-based performance; an ED administrator or patient safety officer in the department can provide guidance on this task. This will ensure that the designated stakeholders have close ties with both IT and nursing in the department, which will facilitate implementation of the project. With any quality improvement project that spans departments, frequent meetings and status updates are needed to update one another on both successes and pitfalls during implementation and review of the project. In this article, we describe 3 quality improvement project starter ideas that can be undertaken in the ED and give specific examples of each type of project using the 4-step
plan-do-study-act cycle for continuous quality improvement [1,3]. PROJECT: REPORT TURNAROUND TIME FOR CASES OF SUSPECTED COMMUNITY-ACQUIRED PNEUMONIA
In the ED, established guidelines exist for the timely performance of chest radiography and administration of antibiotics in suspected communityacquired pneumonia (CAP). Quality improvement projects to improve the performance of chest radiography and report turnaround time could focus on any aspect of the process, including patient transport to and from radiology, expedited performance of the examination, and identification of the study as urgent. An assessment of each stage of the process might elucidate areas for improvement. If slow transport is a problem, processes could be implemented to alert transport staff members more quickly when CAP is suspected. Chest radiographs suspicious for CAP could be prioritized in the radiology information system work list or simply flagged on the requisition form (eg, with colored paper or a prominent stamp) to identify these studies as requiring expedited interpretations and direct communication of results. Report turnaround time is a great choice for a quality improvement project in the ED because it fills many of the criteria of a SMART (specific, measurable, achievable, realistic, and timely) goal. Plan: Increase the percentage of ED CAP studies read within 1 hour to 100% over 6 months from the start of the project after implementing a CAP radiograph identification flag in the radiology information system. Do: Collect data on the number of minutes between obtaining the radiologic study and its final interpretation.
ª 2014 American College of Radiology 1546-1440/14/$36.00 http://dx.doi.org/10.1016/j.jacr.2014.01.002
Study: Identify root causes. Act: If the target is not met, identify potential areas in which time might be saved in the interpretation process or workflow and target those areas for further intervention.
PROJECT: PERFORMANCE OF IMAGING ACCORDING TO ESTABLISHED STANDARDS OF CARE (STROKE)
The American Stroke Association (ASA) has guidelines for the performance of neurologic imaging, particularly nonenhanced CT or MRI, of the brain before the administration of intravenous thrombolytic agents [2,4] in patients with acute stroke. The ASA recommends that patients presenting with symptoms of acute stroke undergo nonenhanced CT or MRI within 25 min of arrival, with complete interpretation within 45 min. EDs have extensive information systems that track patients’ movement from arrival to discharge or admission to the hospital. These data can be combined with the radiology information system by linking the medical record number and/or accession number of an order. Data that need to be collected include the times between patient arrival, evaluation by a physician, ordering and completion of the examination, examination interpretation, and communication of results. By identifying the areas of greatest delay, an intervention can be targeted to very specific areas. For example, if the greatest delay is identified between physician ordering and scan performance, a process can be implemented in which CT or MRI technologists are immediately notified when a stroke-associated CT or MRI study is ordered by an ED physician. Plan: Increase adherence to the ASA’s neurologic imaging guidelines in the ED 423
424 Quality Matters
to 100% 6 months from the start of the project after an intervention aimed at decreasing the time between ED physician ordering and scan performance. Do: Collect data on how often the ASA guidelines are met when performing nonenhanced CT or MRI of the brain in the evaluation of acute stroke. Study: Determine if the compliance with ASA guidelines met the target. Act: Identify root causes. If the target is not met, develop an improved workflow that breaks barriers to decreased ordering to scan performance time.
PROJECT: COMMUNICATION OF INCIDENTAL FINDINGS
The Joint Commission’s National Patient Safety Goals [5] and the National Quality Forum’s Safe Practices [6] list many topics that are relevant to safe radiologic practice, including critical results communication, and are primary targets for quality improvement in the ED. One aspect of critical results communication is the identification, communication, and management of findings incidentally discovered during a radiologic examination. Incidental identification of a pulmonary nodule occurs in approximately 25% to 50% of CT examinations of the chest [7,8] and 40% of CT examinations of the abdomen obtained for research purposes [9]. Identification of incidental findings is important for complete patient care, and not identifying incidental findings exposes radiologists and hospitals to liability [10,11]. By closely working with the ED, radiologists may be able to mitigate adverse outcomes for patients, their ED colleagues, and themselves. The project would require two phases. The first would be for radiology to implement a consistent way to flag ED cases with incidental findings. Consider a flag or text macro to put into the report. The second
phase of the project could take the report flag and trigger an ED physician to review radiologic examination reports before discharge for incidental findings and include a specific area to document both the finding and the recommended follow-up in their information system. Reporting from the systems could track which patients were flagged with incidental findings to ensure that all patients had the information communicated with them before discharge. With both the flagging system created by radiology and this discharge tool created by the ED, a closed communication loop is ensured, along with a system to catch any findings that were overlooked in the fast-paced ED environment.
improvement projects, as this could have a large impact on patient safety and will undoubtedly improve relationships and communication with referring physicians.
Plan: Implement a flagging mechanism and management system for unsuspected pulmonary nodules in the ED within 6 months by creating a system to easily identify thoracic CT studies with incidental nodules that require follow-up.
4. Jauch EC, Saver JL, Adams HP Jr, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44:870-947.
Do: Collect data on the number of incidental pulmonary nodules identified and followed up on ED radiologic examinations. Study: Determine if the number of incidental pulmonary nodules that were appropriately followed up met the target goal. Act: Identify root causes. If the target is not met, develop an improvement plan to further refine how nodules are identified and communicated to ED physicians.
CONCLUSIONS
The ED is an important source of diagnostic and therapeutic radiology examinations and as such is an important target for radiologybased quality and safety improvement projects. In this article, we describe and give 3 examples of quality improvement starter ideas. We encourage radiologists to look to the ED as a source of inspiration when contemplating quality
REFERENCES 1. American Board of Radiology. MOC: Maintenance of Certification: diagnostic radiology: guidelines for PQI projects. Available at: http://www.theabr.org/mocdr-pqiguides. Accessed December 5, 2013. 2. American Stroke Association. Target: Stroke campaign manual. Available at: http://www. strokeassociation.org/idc/groups/heart-public/ @wcm/@hcm/@gwtg/documents/download able/ucm_308277.pdf. Accessed January 27, 2014. 3. Applegate KE. Continuous quality improvement for radiologists. Acad Radiol 2004;11: 155-61.
5. The Joint Commission. 2013 National Patient Safety Goals. Available at: http://www. jointcommission.org/standards_information/ npsgs.aspx. Accessed December 5, 2013. 6. National Quality Forum. Safe Practices for Better Healthcare—2010 update: a consensus report. Available at: http://www.qualityforum. org/WorkArea/linkit.aspx?LinkIdentifier¼id &ItemID¼25689. Accessed January 27, 2014. 7. Wiener RS, Schwartz LM, Woloshin S, Welch HG. Population-based risk for complications after transthoracic needle lung biopsy of a pulmonary nodule: an analysis of discharge records. Ann Intern Med 2011;155:137-44. 8. Welch HG, Schwartz L, Woloshin S. Overdiagnosed: making people sick in the pursuit of health. Boston, Massachusetts: Beacon, 2011:228. 9. Orme NM, Fletcher JG, Siddiki HA, et al. Incidental findings in imaging research: evaluating incidence, benefit, and burden. Arch Intern Med 2010;170:1525-32. 10. Berlin L. How do you solve a problem like incidentalomas? Appl Radiol 2013;42: 10-2. 11. Berlin L. Malpractice and ethical issues in radiology: the incidentaloma. AJR Am J Roentgenol 2013;200:W91.
Ryan W. Woods, MD, MPH, and Paul Nagy, PhD, are from the Department of Radiology, Johns Hopkins University, Baltimore, Maryland. Staci Reintjes, DO, is from the Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland. Paul Nagy, PhD, Johns Hopkins University, Department of Radiology, 600 North Wolfe Street, Baltimore, MD 21287; e-mail: [email protected].
QUALITY MATTERS
Quality Improvement Projects Based in the Emergency Department Ryan W. Woods, MD, MPH, Staci Reintjes, DO, Paul Nagy, PhD INTRODUCTION
The emergency department (ED) is an ideal partner when considering quality projects. Radiology in the ED combines large imaging volumes, tight time constraints, and the need for highly effective communication inherent in obtaining and interpreting diagnostic examinations. Quality improvement projects in the ED have a large impact on patient care and can improve relationships with referring physicians [1,2]. Just as in radiology, residents and attending physicians in the ED are required to conduct continuous quality improvement projects by the ACGME and the American Board of Medical Specialties, respectively. Joint projects are sufficient for both parties and should be actively encouraged. The first step is to designate and receive project buy-in from several ED stakeholders. A good starting point is to look for a physician in the ED who serves as a representative to the hospital in quality matters or is involved in training ED residents in systems-based performance; an ED administrator or patient safety officer in the department can provide guidance on this task. This will ensure that the designated stakeholders have close ties with both IT and nursing in the department, which will facilitate implementation of the project. With any quality improvement project that spans departments, frequent meetings and status updates are needed to update one another on both successes and pitfalls during implementation and review of the project. In this article, we describe 3 quality improvement project starter ideas that can be undertaken in the ED and give specific examples of each type of project using the 4-step
plan-do-study-act cycle for continuous quality improvement [1,3]. PROJECT: REPORT TURNAROUND TIME FOR CASES OF SUSPECTED COMMUNITY-ACQUIRED PNEUMONIA
In the ED, established guidelines exist for the timely performance of chest radiography and administration of antibiotics in suspected communityacquired pneumonia (CAP). Quality improvement projects to improve the performance of chest radiography and report turnaround time could focus on any aspect of the process, including patient transport to and from radiology, expedited performance of the examination, and identification of the study as urgent. An assessment of each stage of the process might elucidate areas for improvement. If slow transport is a problem, processes could be implemented to alert transport staff members more quickly when CAP is suspected. Chest radiographs suspicious for CAP could be prioritized in the radiology information system work list or simply flagged on the requisition form (eg, with colored paper or a prominent stamp) to identify these studies as requiring expedited interpretations and direct communication of results. Report turnaround time is a great choice for a quality improvement project in the ED because it fills many of the criteria of a SMART (specific, measurable, achievable, realistic, and timely) goal. Plan: Increase the percentage of ED CAP studies read within 1 hour to 100% over 6 months from the start of the project after implementing a CAP radiograph identification flag in the radiology information system. Do: Collect data on the number of minutes between obtaining the radiologic study and its final interpretation.
ª 2014 American College of Radiology 1546-1440/14/$36.00 http://dx.doi.org/10.1016/j.jacr.2014.01.002
Study: Identify root causes. Act: If the target is not met, identify potential areas in which time might be saved in the interpretation process or workflow and target those areas for further intervention.
PROJECT: PERFORMANCE OF IMAGING ACCORDING TO ESTABLISHED STANDARDS OF CARE (STROKE)
The American Stroke Association (ASA) has guidelines for the performance of neurologic imaging, particularly nonenhanced CT or MRI, of the brain before the administration of intravenous thrombolytic agents [2,4] in patients with acute stroke. The ASA recommends that patients presenting with symptoms of acute stroke undergo nonenhanced CT or MRI within 25 min of arrival, with complete interpretation within 45 min. EDs have extensive information systems that track patients’ movement from arrival to discharge or admission to the hospital. These data can be combined with the radiology information system by linking the medical record number and/or accession number of an order. Data that need to be collected include the times between patient arrival, evaluation by a physician, ordering and completion of the examination, examination interpretation, and communication of results. By identifying the areas of greatest delay, an intervention can be targeted to very specific areas. For example, if the greatest delay is identified between physician ordering and scan performance, a process can be implemented in which CT or MRI technologists are immediately notified when a stroke-associated CT or MRI study is ordered by an ED physician. Plan: Increase adherence to the ASA’s neurologic imaging guidelines in the ED 423
424 Quality Matters
to 100% 6 months from the start of the project after an intervention aimed at decreasing the time between ED physician ordering and scan performance. Do: Collect data on how often the ASA guidelines are met when performing nonenhanced CT or MRI of the brain in the evaluation of acute stroke. Study: Determine if the compliance with ASA guidelines met the target. Act: Identify root causes. If the target is not met, develop an improved workflow that breaks barriers to decreased ordering to scan performance time.
PROJECT: COMMUNICATION OF INCIDENTAL FINDINGS
The Joint Commission’s National Patient Safety Goals [5] and the National Quality Forum’s Safe Practices [6] list many topics that are relevant to safe radiologic practice, including critical results communication, and are primary targets for quality improvement in the ED. One aspect of critical results communication is the identification, communication, and management of findings incidentally discovered during a radiologic examination. Incidental identification of a pulmonary nodule occurs in approximately 25% to 50% of CT examinations of the chest [7,8] and 40% of CT examinations of the abdomen obtained for research purposes [9]. Identification of incidental findings is important for complete patient care, and not identifying incidental findings exposes radiologists and hospitals to liability [10,11]. By closely working with the ED, radiologists may be able to mitigate adverse outcomes for patients, their ED colleagues, and themselves. The project would require two phases. The first would be for radiology to implement a consistent way to flag ED cases with incidental findings. Consider a flag or text macro to put into the report. The second
phase of the project could take the report flag and trigger an ED physician to review radiologic examination reports before discharge for incidental findings and include a specific area to document both the finding and the recommended follow-up in their information system. Reporting from the systems could track which patients were flagged with incidental findings to ensure that all patients had the information communicated with them before discharge. With both the flagging system created by radiology and this discharge tool created by the ED, a closed communication loop is ensured, along with a system to catch any findings that were overlooked in the fast-paced ED environment.
improvement projects, as this could have a large impact on patient safety and will undoubtedly improve relationships and communication with referring physicians.
Plan: Implement a flagging mechanism and management system for unsuspected pulmonary nodules in the ED within 6 months by creating a system to easily identify thoracic CT studies with incidental nodules that require follow-up.
4. Jauch EC, Saver JL, Adams HP Jr, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44:870-947.
Do: Collect data on the number of incidental pulmonary nodules identified and followed up on ED radiologic examinations. Study: Determine if the number of incidental pulmonary nodules that were appropriately followed up met the target goal. Act: Identify root causes. If the target is not met, develop an improvement plan to further refine how nodules are identified and communicated to ED physicians.
CONCLUSIONS
The ED is an important source of diagnostic and therapeutic radiology examinations and as such is an important target for radiologybased quality and safety improvement projects. In this article, we describe and give 3 examples of quality improvement starter ideas. We encourage radiologists to look to the ED as a source of inspiration when contemplating quality
REFERENCES 1. American Board of Radiology. MOC: Maintenance of Certification: diagnostic radiology: guidelines for PQI projects. Available at: http://www.theabr.org/mocdr-pqiguides. Accessed December 5, 2013. 2. American Stroke Association. Target: Stroke campaign manual. Available at: http://www. strokeassociation.org/idc/groups/heart-public/ @wcm/@hcm/@gwtg/documents/download able/ucm_308277.pdf. Accessed January 27, 2014. 3. Applegate KE. Continuous quality improvement for radiologists. Acad Radiol 2004;11: 155-61.
5. The Joint Commission. 2013 National Patient Safety Goals. Available at: http://www. jointcommission.org/standards_information/ npsgs.aspx. Accessed December 5, 2013. 6. National Quality Forum. Safe Practices for Better Healthcare—2010 update: a consensus report. Available at: http://www.qualityforum. org/WorkArea/linkit.aspx?LinkIdentifier¼id &ItemID¼25689. Accessed January 27, 2014. 7. Wiener RS, Schwartz LM, Woloshin S, Welch HG. Population-based risk for complications after transthoracic needle lung biopsy of a pulmonary nodule: an analysis of discharge records. Ann Intern Med 2011;155:137-44. 8. Welch HG, Schwartz L, Woloshin S. Overdiagnosed: making people sick in the pursuit of health. Boston, Massachusetts: Beacon, 2011:228. 9. Orme NM, Fletcher JG, Siddiki HA, et al. Incidental findings in imaging research: evaluating incidence, benefit, and burden. Arch Intern Med 2010;170:1525-32. 10. Berlin L. How do you solve a problem like incidentalomas? Appl Radiol 2013;42: 10-2. 11. Berlin L. Malpractice and ethical issues in radiology: the incidentaloma. AJR Am J Roentgenol 2013;200:W91.
Ryan W. Woods, MD, MPH, and Paul Nagy, PhD, are from the Department of Radiology, Johns Hopkins University, Baltimore, Maryland. Staci Reintjes, DO, is from the Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland. Paul Nagy, PhD, Johns Hopkins University, Department of Radiology, 600 North Wolfe Street, Baltimore, MD 21287; e-mail: [email protected].
