Value of Multidisciplinary Lecture Series in Appropriate Use of Imaging Studies

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Alaina Strickland
5 years ago
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1 Value of Multidisciplinary Lecture Series in Appropriate Use of Imaging Studies

2 Authors: Nathan Kolderman, James Davis, Alexander Copelan, Mina Zaki, Paul Thottakara, Farnoosh Sokhandon The authors have no financial disclosures

3 Purpose There remains a lack of understanding by ordering physicians on what is the optimal imaging study to assess specific pathologies The correct imaging study allows for: Appropriate analysis of the suspected pathology As low as reasonably achievable radiation dose to the patient Reduction of unnecessary health care cost The purpose of the project: Identify areas of misunderstanding among ordering health care professionals at Beaumont Health Provide educational lectures to improve understanding/appropriate ordering of imaging

4 Materials and Methods A lecture series was created in 2010 as part of institutional wide radiation dose reduction program The series was given to various residencies at our institution: Emergency Medicine, Surgery, Internal Medicine, Pediatrics, Family Medicine Each lecture is tailored to the specific specialty s patient demographics with examples as how to handle commonly encountered imaging scenarios Information regarding the differences in imaging protocols is discussed including when/why a protocol would be preferred over another Detailed information regarding the use of contrast media, radiation dose reduction techniques, and imaging during pregnancy. Participants complete a short pretest before the lecture and a short post test after the lecture.

5 Fig 1. Slides from lecture given to Emergency Medicine Residents with focus on Body Imaging Protocols

6 - Neuro&Imaging-Protocols-Pre&test- 1.- A-26-yr-F-construction-worker-presents-to-the-EC-with-penetrating-trauma-to-the-left-eye.- A&O-x3-with-no-focal-neurological-deficits,-no-signs-of-gross-head-trauma-or-other-injury.- What-is-the-most-appropriate-study-to-order?- a.- -MRI-head-with-and-without-gadoliniumb.- -CT-Orbits-with-IV-contrastc.- -CT-Head-without-IV-contrastd.- -CT-Orbits-without-IV-contraste.- -Skull-radiograph yr-M-presents-with-AMS,-found-down-in-nursing-home.-Patient-was-down-forunknown-duration-and-has-had-decreased-urine-output-since-being-found-down.-What-isthe-most-appropriate-study-to-order?- a.- -CT-perfusion-studyb.- -CT-head-with-and-without-IV-contrastc.- -CT-head-without-IV-contrastd.- -CT-angiography- 3.- Concern-for-retropharyngeal-abscess-in-a-dialysis-patient.-What-is-the-appropriate- action?- a.- CT-neck-without-IV-contrastb.- CT-Neck-with-IV-contrast,-limit-contrast-dosec.- CT-neck-with-IV-contrast,-give-IV-hydrationd.- CT-neck-with-IV-contrast,-give-oral-hydration Which-of-the-following-is-the-preferred-pre&medication-protocol-for-patients-with-a-history- of-an-allergic-reaction-to-iodinated-contrast?- a.- -48&hour-steroid-taperb hour-prep-with-steroid-given-at-13,-7,-and-1-hour-and-benadryl-given-at-1-hour- prior-to-study.- c.- -6-hour-prep-with-steroid-given-at-6-and-1-hour-and-benadryl-given-at-5-minutesprior-to-studyd.- Steroid-and-Benadryl-given-immediately-prior-to-study Which-of-the-following-is-not-an-indication-for-CT-head-without-contrast?- a.- -Traumab.- -Evaluate-for-metastasesc.- -Acute-CVA-- d.- Sudden-onset-severe-headache Which-of-the-following-regarding-radiation-is-true?- a.- While-CT-accounts-for-the-majority-of-radiologic-exams-performed,-it-accounts-forless-than-10%-of-radiation-doseb.- There-is-zero-risk-of-cancer-associated-with-CT-examinationsc.- Radiation-exposure-is-effected-by-elevation-and-air-travel--- d.- -MRI-delivers-more-radiation-dose-than-does-CT- Body%Imaging%Protocols%Pre3test% % 1.% %For%a%patient%on%dialysis,%which%of%the%following%precautions%should%be%taken%prior%to%a% CT%study%with%iodinated%contrast?% a.% Limit%the%amount%of%contrast%to%80cc% b.% Do%not%perform%the%examination% c.% Proceed%with%the%study%as%ordered% d.% Give%a%2%L%bolus%of%NS%prior%to%iodinated%contrast% % 2.% In%patients%with%nonspecific%GI%symptoms,%bowel%obstruction,%or%suspicion%for% pyelonephritis,%the%most%appropriate%ct%protocol%would%be:% a.% CT%abdomen%and%pelvis%without% b.% CT%abdomen%and%pelvis%with% c.% CT%abdomen%with%and%without% d.% CT%abdomen%and%pelvis%with%and%without% % 3.% True%of%false:%High%resolution%CT%is%preferred%over%standard%CT%chest%with%contrast%for% evaluation%of%a%lung%mass?% a.% %True% b.% False% % 4.% Which%of%the%following%regarding%radiation%is%TRUE?% a.% %While%CT%accounts%for%the%majority%of%radiological%exams%performed,%it%accounts% for%less%than%10%%radiation%dose% b.% There%is%zero%risk%of%cancer%associated%with%CT%examinations% c.% Radiation%is%thought%to%be%most%damaging%to%the%fetus%in%the%first%trimester% d.% MRI%is%associated%with%a%small%increase%in%risk%of%cancer%over%a%lifetime% % 5.% Which%of%the%following%is%TRUE%regarding%MRI?% a.% MRI%cannot%be%performed%on%a%claustrophobic%patient% b.% Patient%must%be%able%to%hold%their%breath%for%20330%seconds% c.% In%a%15%week%pregnant%patient%with%pelvic%pain%with%nonspecific%findings%on%US,% CT%of%the%pelvis%is%preferred%over%MRI% d.% Titanium%prosthesis%are%a%contraindication%to%MRI% % % % Fig 2a and 2b. Pretest quiz given to Internal Medicine Residents prior to lecture focusing on appropriate ordering of Neuro-imaging (a) and Body Imaging (b).

7 Materials and Methods A printed ordering guide booklet was provided to the participants following lecture Contains all available radiological studies and the appropriate clinical indications A follow-up survey will be sent to the participants 3-4 months after the lectures to assess for: Retention of material Perceived utility of this service Degree to which the lecture changed daily practices.

Index IMAGING ORDERING GUIDE Guide also available on Beaumont doctor online beaumont.

MRA VII. Ultrasound VIII. Ultrasound Guided Procedures IX. Nuclear Medicine X. Nuclear Medicine Consultation and Therapy Services XI. PET Imaging XII. Mammorgraphy Ordering Decision Tree XIII.

Please refer to Section VII of this guide for additional information on radiation safety.

8 Index IMAGING ORDERING GUIDE Guide also available on Beaumont doctor online beaumont.edu/doctor TO SCHEDULE AN EXAM / STAT EXAM Appointment Center: Physician Liaisons and Forms Ordering: I. Imaging at Beaumont II. Choosing CT or MRI III. CT IV. CTA V. MRI VI. MRA VII. Ultrasound VIII. Ultrasound Guided Procedures IX. Nuclear Medicine X. Nuclear Medicine Consultation and Therapy Services XI. PET Imaging XII. Mammorgraphy Ordering Decision Tree XIII. Radiation Safety CT Choosing CT or MRI CT (cont.) This page is intended to assist the ordering physician in choosing the appropriate exam when CT and MRI are both being considered. Please refer to Section VII of this guide for additional information on radiation safety. Area of Concern Head and neck Brain NEUROLOGIC IMAGING Body Part CT MRI Soft tissue neck Paranasal sinuses Face Orbits evaluation of trauma/hemorrhage evaluation of all neck pathology initial sinus evaluation initial evaluation of all pathologies including trauma trauma evaluation or with contrast if MRI contraindicated inflammation, seizures and neoplasm. If MRI contraindicated then a CT head with and without contrast. contraindications for contrast or renal failure initial CT invasive inflammatory process if recommended after initial CT Consider MRI soft tissue face if recommended after initial CT inflammation, neoplasm Area of Concern Abdomen Body Part general Oral IV Reason for Exam Exam to be Ordered Prep Contrast Possible without contrast No CT abdomen and pelvis trast allergies, pre-medication is recommended) policy or contact radiology with questions (CT contrast is to be avoided at least six weeks before treatment and also in the following six weeks. However, please contact the treating nuclear medicine physician with questions at ext ) hematoma or hemorrhage Yes Yes CT abdomen and pelvis with contrast acute massive abdominal-pelvic hemorrhage tumor, sarcoma, melanoma or carcinoid, order dual phase liver) Any other general indication not listed in this guide CPT Code CHOOSING CT OR MRI Appointment Center: Appointment Center: Fig 3. Select images from Imaging Ordering Guide given to residents/ordering providers following lecture series.

9 Results General lack of knowledge regarding appropriate ordering of imaging studies in Internal Medicine, Emergency Medicine, Pediatric and Family Medicine residencies Average pretest score of 61.5% After the lecture, drastic improvement was seen across all groups tested Average posttest score of 86.4%

10 Improvement in scores following lecture Family Med. Emergency Pediatrics Emergency Emergency Med.2016 Med Med (body (neuro (body lecture) lecture) lecture) Pretest % Post test % Internal Medicine Average of Combined Residencies Pretest % Post test %

11 Effect of consecutive lectures Annual lecture series Evaluation of these scores demonstrated poor recall of the material covered, Some participants may have seen the original lecture more than one time, and completed the same pretest and post test on both occasions. Similar pretest scores of ~50% However, the degree of improvement from pretest to post test was substantial Post test score of 64% in year 1 Post test score of 90% in year 2

12 Pre/post Tests Over Consecutive Years Year 1 Pretest % Post test % Year 2

13 Further interest from ordering providers The ordering guide lecture series was initially designed by the Radiology Department at Beaumont Health. Over time, ordering providers began to contact the radiologists associated with this lecture series to give additional lectures associated with appropriate imaging. Conferences Grand Rounds Demonstrates the interest and importance of sufficient knowledge of appropriate imaging by ordering providers

14 Conclusion Providing educational lectures to the clinicians at our institution increases awareness of the appropriate imaging study to order This allows for improved patient care, reduction of unnecessary radiation, and decrease of health care costs The lack of recall from year to year underscores the importance of regularly refreshing our colleagues knowledge on the subject matter Evidence of significant interest of appropriate imaging as demonstrated by several invitations to present at conferences, Grand Rounds, etc. We hope that by continuing to educate ordering physicians on these topics we can ensure ongoing efficacious use of radiology and optimal patient care.

Spine MRI and Spine CT Test Request Tip Sheet

Spine MRI and Spine CT Test Request Tip Sheet Spine MRI and Spine CT With/Without Contrast CT, MRI The study considered best for a specific clinical scenario should be ordered. The second study should be done ONLY if the first study does not provide